DeepFocus: fast focus and astigmatism correction for electron microscopy

High-throughput 2D and 3D scanning electron microscopy, which relies on automation and dependable control algorithms, requires high image quality with minimal human intervention. Classical focus and astigmatism correction algorithms attempt to explicitly model image formation and subsequently aberration correction. Such models often require parameter adjustments by experts when deployed to new microscopes, challenging samples, or imaging conditions to prevent unstable convergence, making them hard to use in practice or unreliable. Here, we introduce DeepFocus, a purely data-driven method for aberration correction in scanning electron microscopy. DeepFocus works under very low signal-to-noise ratio conditions, reduces processing times by more than an order of magnitude compared to the state-of-the-art method, rapidly converges within a large aberration range, and is easily recalibrated to different microscopes or challenging samples.

Pathology teaching in different undergraduate medical curricula within and outside the United States: a pilot study

Pathology education is taught using different curricula in the United States (USA) and abroad. We evaluate and compare the hours spent in different forms of pathology teaching such as lectures, team-based learning (TBL), problem-based learning (PBL), and other methods taught in general and systemic pathology amongst different medical schools within the USA and outside the USA. The total number of lecture hours taught in general and systemic pathology combined was greater in outside schools than within the USA (141 h vs 97.8 h, respectively). Three subjects in general pathology and six subjects in systemic pathology had a significantly greater lecture hours in outside medical schools. The greatest difference was the hours spent in labs were longer for both general and systems pathology in schools outside the USA. The overall utilization of PBL in general and systemic pathology teaching combined was much greater outside the USA compared to within the USA (average overall hours PBL - 97.2 outside vs 16.5 in the USA), however, the reverse was observed for using TBL (average overall hours TBL - 59.5 outside vs 84.5 in USA). Average hours used with other methods of teaching was also greater in outside medical schools compared to USA medical schools (80.8 h vs 44 h, respectively). Pathology teaching in both general and systemic pathology has more extensive lecture hours, laboratory hours, PBL, and other methods of teaching pathology in outside medical schools with different curricula than USA medical schools. TBL is utilized more extensively in USA medical schools.

Comparison of the diagnostic yield of transbronchial lung biopsies by forceps and cryoprobe in diffuse parenchymal lung disease

Background

Transbronchial lung cryobiopsy (TBLC) in the diagnosis of diffuse parenchymal lung disease (DPLD) has shown a promising yield in recent times, with low post-procedural mortality and morbidity.

Objectives

To compare the yield of TBLC and conventional transbronchial forceps lung biopsy (TBLB).

Methods

A prospective study was carried out in patients with DPLD over a period of 1 year in a tertiary respiratory care institute in New Delhi, India. All 87 patients enrolled underwent both TBLB and TBLC. The procedures were performed in the bronchoscopy suite under conscious sedation and local anaesthesia, with an attempt to take a minimum of three biopsy specimens by conventional TBLB followed by TBLC. A 1.9 mm cryoprobe with a freezing time of 4 - 5 seconds was used. An Arndt endobronchial blocker was used to control bleeding along with locally administered medications.

Results

TBLB and TBLC led to a definitive diagnosis in 27 (31.0%) and 69 (79.3%) cases, respectively. The commonest diagnoses were hypersensitivity pneumonitis, sarcoidosis and pulmonary tuberculosis. TBLC led to additional diagnoses in 42 cases (48.3%). Pneumothorax was observed in 12 cases (13.8%), and moderate bleeding occurred in 63 (72.4%). There were no procedure-related deaths.

Conclusion

TBLC had a better diagnostic yield than conventional TBLB in DPLD. It has the potential to become a safe day-care procedure in a resource-limited setting, if certain precautions are taken.

Study synopsis

What the study adds. Compared with transbronchial forceps lung biopsy, transbronchial lung cryobiopsy (TBLC) led to additional diagnoses in 42 (48.3%) of 87 patients with clinicoradiological features of diffuse parenchymal lung disease. Pneumothorax was observed in 12 cases (13.8%) and moderate bleeding in 63 (72.4%). TBLC without rigid bronchoscopy or advanced airway devices under conscious sedation had a good diagnostic yield with an acceptable adverse events profile.Implications of the findings. TBLC under conscious sedation is not resource intensive and can be carried out in settings with limited resources.

Multi-ancestry genome-wide analysis identifies shared genetic effects and common genetic variants for self-reported sleep duration

Both short (≤6 h per night) and long sleep duration (≥9 h per night) are associated with increased risk of chronic diseases. Despite evidence linking habitual sleep duration and risk of disease, the genetic determinants of sleep duration in the general population are poorly understood, especially outside of European (EUR) populations. Here, we report that a polygenic score of 78 European ancestry sleep duration single-nucleotide polymorphisms (SNPs) is associated with sleep duration in an African (n = 7288; P = 0.003), an East Asian (n = 13 618; P = 6 × 10-4) and a South Asian (n = 7485; P = 0.025) genetic ancestry cohort, but not in a Hispanic/Latino cohort (n = 8726; P = 0.71). Furthermore, in a pan-ancestry (N = 483 235) meta-analysis of genome-wide association studies (GWAS) for habitual sleep duration, 73 loci are associated with genome-wide statistical significance. Follow-up of five loci (near HACD2, COG5, PRR12, SH3RF1 and KCNQ5) identified expression-quantitative trait loci for PRR12 and COG5 in brain tissues and pleiotropic associations with cardiovascular and neuropsychiatric traits. Overall, our results suggest that the genetic basis of sleep duration is at least partially shared across diverse ancestry groups.

[Pharmacological importance of novel spiro derivatives against human pathogenic fungi]

Human mycoses have become a threat to health world-wide. Unfortunately there are only a limited number of antimycotic drugs in use. In the present study, antifungal activity of earlier synthesized spiro-1,4-dihydropyridines (1,4-DHPs) was investigated. The antifungal activity of spiro-1,4-DHPs compounds were screened against Aspergillus flavus, A. fumigatus, and Candida albicans by using Disc Diffusion and Modified Microdilution method. Among six spiro-1,4-DHPs compounds tested all of them showed stronger antifungal activity possibly through inhibiting the synthesis of chitin in cell wall against A. flavus, A. fumigatus, and C. albicans as compared to fluconazole, a standard antifungal drug. The combination of compounds showed that the synthesized compounds had synergistic, additive effects as compared to currently used drugs as an antifungal agent. These results indicated that these designed compounds were potential chitin synthase inhibitors and had excellent antimycotic activity for the treatment of fungal infections.

Faculty-or senior resident-led SNAPPS for postgraduate teaching in pediatrics

This was an educational intervention on postgraduates using SNAPPS (Summarize narrow, analyze, probe, plan, self-directed learning) showing comparable median (interquartile range) satisfaction scores with faculty or senior residents as 4 (3,5) and 4 (4, 4.25); respectively, P = 0.79. Further training of senior residents in medical education will enable them to participate efficiently and actively in postgraduate teaching.

Digital Pathology, A Cognitively Efficient Teaching Strategy: Current Application and a Glimpse into Future

Introduction/Objective

If pathology education is to be efficacious, it must embrace the ramifications of cognitive load of the learners, to optimize the capacity of the working memory. When undergraduate students commence their learning of pathology, they encounter a heap of new data and classifications. Simplifying these intricate systems into assimilable subschemas and items is key for effective transfer of knowledge. The minimization of the profundity of intrinsic cognitive load is essential, considering that its impact on pathology beginners is often left unaccounted, both in active learning as well as in traditional methods of instruction. In today’s digital generation, digital pathology plays a key role by intertwining disease morphology with clinical presentation and fortifying its pathophysiologic basis. We designed a teaching methodology utilizing digital pathology to evaluate its effect on cognitive load.

Methods/Case Report

Active learning was implemented online using digital pathology, molecular pathology, and laboratory data in case-based setting with question-answer sessions. In small groups, students were encouraged to analyze digital pathology slides with the help of annotations and identify areas of histopathological significance. They utilized this information further to make an accurate diagnosis and answer corresponding questions, with access to answers available later, complemented with algorithms and concept maps. A 14-item structured questionnaire was delivered afterwards to evaluate the efficacy and popularity of the exercise.

Results (if a Case Study enter NA)

End-of-term examination results showed that learners developed higher-order comprehension skills along with a greater potential in interpreting histopathological data towards solving case studies. Feedback revealed a higher degree of overall satisfaction and increased ability to retain information.

Conclusion

Digital transformation of pathology education provides the kind of framework where learning happens naturally - developing in small boosts of progress until expertise is achieved, and students appreciate the value of the ‘learned thing’ along with the real utility of that knowledge. The innovative approach utilizing digitization and integration offers the opportunity of decrement in intrinsic cognitive load by invoking students to build better, reliable, long-lasting, supportable and inclusive schemata while correlating the relevant incoming information with previously stabilized knowledge and consolidating the entirety of understanding.

Development of a patient decision aid for discharge planning of hospitalized patients with stroke

Background

Patient involvement in discharge planning of patients with stroke can be accomplished by providing personalized outcome information and promoting shared decision-making. The aim of this study was to develop a patient decision aid (PtDA) for discharge planning of hospitalized patients with stroke.

Methods

A convergent mixed methods design was used, starting with needs assessments among patients with stroke and health care professionals (HCPs). Results of these assessments were used to develop the PtDA with integrated outcome information in several co-creation sessions. Subsequently, acceptability and usability were tested to optimize the PtDA. Development was guided by the International Patient Decision Aids Standards (IPDAS) criteria.

Results

In total, 74 patients and 111 HCPs participated in this study. A three-component PtDA was developed, consisting of:

1) a printed consultation sheet to introduce the options for discharge destinations, containing information that can be specified for each individual patient;

2) an online information and deliberation tool to support patient education and clarification of patient values, containing an integrated “patients-like-me” model with outcome information about discharge destinations;

3) a summary sheet to support actual decision-making during consultation, containing the patient’s values and preferences concerning discharge planning.

In the acceptability test, all qualifying and certifying IPDAS criteria were fulfilled. The usability test showed that patients and HCPs highly appreciated the PtDA with integrated outcome information.

Conclusions

The developed PtDA was found acceptable and usable by patients and HCPs and is currently under investigation in a clinical trial to determine its effectiveness.

Experiences with information provision and preferences for decision making of patients with acute stroke

OBJECTIVE

The aim of this study was to gain insight into experiences of patients with acute stroke regarding information provision and their preferred involvement in decision-making processes during the initial period of hospitalisation.

METHODS

A sequential explanatory design was used in two independent cohorts of patients with stroke, starting with a survey after discharge from hospital (cohort 1) followed by observations and structured interviews during hospitalisation (cohort 2). Quantitative data were analysed descriptively.

RESULTS

In total, 72 patients participated in this study (52 in cohort 1 and 20 in cohort 2). During hospitalisation, the majority of the patients were educated about acute stroke and their treatment. Approximately half of the patients preferred to have an active role in the decision-making process, whereas only 21% reported to be actively involved. In cohort 2, 60% of the patients considered themselves capable to carefully consider treatment options.

CONCLUSIONS

Active involvement in the acute decision-making process is preferred by approximately half of the patients with acute stroke and most of them consider themselves capable of doing so. However, they experience a limited degree of actual involvement.

PRACTICE IMPLICATIONS

Physicians can facilitate patient engagement by explicitly emphasising when a decision has to be made in which the patient's opinion is important.

Utility of colon allograft biopsies in surveillance of patients with small intestinal transplantation – A systematic study of 129 biopsies

Introduction/Objective

A segment of right colon is sometimes included with small intestinal allografts to preserve the ileocecal valve and maintain water reabsorption. We correlated pathological findings of colon allograft biopsies obtained during surveillance colonoscopies with clinical, endoscopic, and microbiologic findings.

Methods/Case Report

All colon allograft biopsies from surveillance colonoscopies over a 3-year period were reviewed for crypt apoptotic activity, cryptitis, lamina propria inflammation, ulceration, and crypt architectural distortion. Clinical and endoscopic findings, and positive cultures a week before and after the biopsies were recorded.

Results (if a Case Study enter NA)

There were 129 colon biopsies from 29 patients; 98 were histologically normal, whereas 28 showed rare apoptoses (n=14), focal cryptitis (n=8), increased intraepithelial lymphocytes (n=2), moderate acute rejection (n=1), and crypt architectural distortion (n=2). Of these 29 patients, 8 had abnormal endoscopic findings, 21 were normal. Out of 8 patients with abnormal endoscopic exams, 50% had normal histology on biopsy. Twenty-one biopsies were associated with positive cultures in the blood (n=5), urine (n=16) or wound, peritoneal, stool (n=6); 3 had abnormal endoscopies, and 4, abnormal histology. One patient with C.difficle toxin had normal endoscopy and focal cryptitis, whereas another with CMV DNA in blood showed endoscopically congested mucosa and rare apoptoses on biopsy. Of 12 biopsies (7 patients) with abnormal endoscopic findings, (erythema, congestion, ulceration), 4 biopsies had no pathologic findings, 8 had rare apoptosis, and one each had focal cryptitis and chronic colitis. Paired small intestinal biopsies were present with 59 biopsies; 10 showed rare apoptosis and 2, focal cryptitis. Of 70 without paired small intestinal biopsies, there were 5 with rare apoptotic bodies, 5 with focal cryptitis, and 2 with crypt architectural distortion.

Conclusion

The correlation of histologic, endoscopic, and microbiologic findings in colonic allograft surveillance biopsies is inconsistent. Colon allograft biopsies have limited utility in the follow-up of patients, particularly in absence of paired small intestinal biopsies.

Using digital pathology in competency based case scenarios as an efficient pathology learning platform

Introduction/Objective

Case-based learning has been utilized for implementation in learning pathological and clinical features of diseases in an integrated, facile manner for some time now. We applied certain novel technological advances to improve case-based learning - short clinical vignettes describing all pertinent pathologic features with the help of digital pathology images - including both negative and positive findings. The clinical cases combined with digital pathological and radiological images and labs were uploaded on Moodle platform for student access, to be followed later by an online interactive discussion via Zoom.

Methods/Case Report

Clinical cases meticulously woven with digital pathological and radiological images and labs were centralized on 3 fundamental competencies – disease processes, systemic pathology and diagnostic & therapeutic pathology. This was followed by corresponding Q-A session using the “breakout room” feature of Zoom to form a differential diagnosis, reach a final diagnosis and discuss appropriate management options. Students exited the breakout rooms after individual groupwork to return to the main Zoom session for final discussion. Novel web- based tools, social media assistance, and other online resources were utilized to enhance the online learning experience.

Results (if a Case Study enter NA)

Student feedback confirmed that our online instructional methodology was incredibly stimulatory, particularly in topics that were difficult to grasp using traditional pedagogical methods. Summative and formative assessments indicated performance gain, enhanced motivation, improved critical thinking and evolved ability to solve clinical cases. Drawbacks included irregular student participation, lack of face-to-face interaction, network issues and time differences.

Conclusion

Our pathology pedagogy provides flexibility and self-directed learning skills, while simultaneously covering the geographical limitations. This not only helps students in developing critical clinical reasoning, but also enables them to acquire life-long learning and problem-solving skills. The technique proved to be a powerful educational tool that facilitated an interactive learning experience beyond the classroom setting, with integration of multidisciplinary aspects in learning Pathology. Additionally, the communication competency was also covered during case discussion among students, promoting literary, verbal and team-working capabilities.

Porto-Sinusoidal Vascular Disease and Focal Nodular Hyperplasia-like Nodules in a Patient with Neurofibromatosis and Non-Cirrhotic Portal Hypertension

Introduction/Objective

Non-cirrhotic portal hypertension (NCPH) is uncommon. The underlying pathophysiology appears to lie at the level of intrahepatic portal veins and sinusoids, hence the term “porto-sinusoidal vascular disease” (PSVD). We report a rare case of PSVD with focal nodular hyperplasia (FNH)-like nodules in a patient with neurofibromatosis type 2 (NF2).

Methods/Case Report

A 57-year-old male with NF2 and type 2 diabetes, presented with a large variceal bleed requiring blood transfusion and subsequent transjugular intrahepatic portosystemic shunt (TIPS). Imaging showed a nodular liver, presumed to be cirrhosis due to non-alcoholic liver disease. Liver biopsy was not done. Thereafter, he had several episodes of hepatic encephalopathy and TIPS was downsized to prevent recurrences. The patient required liver transplantation for intractable portal hypertension and severe hepatic encephalopathy; his liver synthetic function was near normal and MELD was 11. Portal vein was patent. The explanted liver was micronodular, soft and weighed 946 grams. Unencapsulated nodules, a few mm to 1 cm in size, were present. Microscopically, there was diffuse nodularity in the absence of bridging fibrosis. Thin, incomplete curvilinear fibrous septa were present. There were aberrant veins, hypervascular portal tracts, herniated portal veins and rare occluded portal veins. Trichrome and reticulin stains confirmed architectural abnormalities including nodularity, lack of bridging fibrosis and approximation of portal tracts. Immunohistochemistry for glutamine synthetase accentuated architectural distortion and revealed nodules with FNH-like geographic areas of staining.

Results (if a Case Study enter NA)

NA

Conclusion

This is a rare case of NCPH due to PSVD in a patient with NF2. Microscopy suggested incomplete septal cirrhosis (ISC), a pattern associated with both PSVD and regression of fibrosis in a cirrhotic liver. Isolated portal hypertension without loss of synthetic function favors primary PSVD over regression of fibrosis. FNH-like nodules are consistent with regenerative changes caused by localized abnormalities of blood flow.

Rare presentation of primary hepatic marginal zone B-cell lymphoma and membranous glomerulopathy in a 3-year-old boy

Introduction/Objective

Primary hepatic marginal zone B-cell lymphoma (MZL) is a rare entity that has been described with chronic inflammatory disorders such as chronic viral hepatitides B and C and primary biliary cholangitis. We report MZL in a 3-year-old African-American boy that was discovered incidentally at autopsy.

Methods/Case Report

The patient first came to medical attention at 9-months of age with bilateral periorbital edema that progressed to generalized edema of the[PL1] face, extremities, and abdomen. Laboratory testing showed nephrotic syndrome with massive proteinuria (50-60 g/day). A percutaneous renal biopsy specimen showed membranous glomerulopathy with PLA2R detected by immunofluorescence, and granular IgG deposition along tubular basement membranes. Serum was negative for anti-PLA2R antibodies. The patient suffered recurrent upper respiratory tract infections requiring several intensive care hospitalizations. At 3 years of age, he was transported unresponsive and pulseless to the emergency department where he was pronounced dead. A brother with the infantile nephrotic syndrome had died from sepsis at 2 years of age. Suspicion of abuse led to an autopsy by the medical examiner, who discovered nodular masses in the right and left liver lobes, which histologically showed a serpiginous infiltrate of small B-lymphocytes positive for CD20, CD43 admixed with plasmacytoid cells with kappa light chain restriction. There were no extrahepatic tumors. Transmission electron microscopy of glomeruli showed membranous glomerulopathy. Kidneys showed dense reactive interstitial lymphocytic infiltrate with germinal centers

Results (if a Case Study enter NA)

NA

Conclusion

To our knowledge, this is the first reported case of MZL presenting in a pediatric patient with membranous glomerulopathy. Both diagnoses are associated with autoimmune diseases and persistent, chronic inflammation. Recurrent infections in this patient suggest an immunoregulatory disorder, setting the stage for chronic inflammation, as seen in the kidney, with progression to MZL in the liver.

Innovating With the Times: Pathology Education in Context of Physician Burnout

Introduction/Objective

Learning a boundless volume of information, preparing for multiple exams, and getting involved in several other academic activities are just a few things that the current medical students need to tackle in a finite duration. While these challenges encourage learners to be their best, and prepare them for their careers as future physicians, they can also result in a largely unnoticed issue — burnout. Curricular reform targeted at developing skills to mitigate burnout is the need of the hour. To combat this issue in the pathology classroom, we used our tried and tested strategy of algorithms in combination with fun activities, particularly keyword mnemonics, to evaluate the impact on reducing burnout in medical students.

Methods

Lectures were delivered and recorded for students of semester 4 and 5, and sample algorithms and mnemonics were included. We also used pathophysiology case sessions comprising clinical vignettes and questions. Students were divided into small groups to solve questions and had to frame their own algorithms and mnemonics to help them. The method’s effectiveness was assessed using performance in past and current exams. Feedback was performed to gauge students’ perceptions

Results

Feedback evaluation showed that 86% of students indicated that algorithms and mnemonics not only strengthened the rote memory but also helped lessen the stress during exam preparation. 59% of students expressed that teamwork made it easier and fun to work. Almost 11% felt that mnemonics should be included as part of new lectures but they found it difficult and ineffective to make their own. Further assessment will be performed to analyze the strategy’s impact on burnout.

Conclusion

Classroom traditions that encourage shared problem-solving and decision-making leads to reduced burnout rates among medical students, with the added benefit of enhanced retention of complicated material and improved clinical correlation capabilities. The relationship between stress and memory is well-documented, and feedback revealed that this technique helped alleviate negative stress on the students. Our project underlines the essence of research studies to minimize burnout in medical students, for design and development of future interventions to prevent burnout at the outset in the training of future physicians.

Risk of pre-eclampsia in patients with a maternal genetic predisposition to common medical conditions: a case-control study

OBJECTIVE

To assess whether women with a genetic predisposition to medical conditions known to increase pre-eclampsia risk have an increased risk of pre-eclampsia in pregnancy.

DESIGN

Case-control study.

SETTING AND POPULATION

Pre-eclampsia cases (n = 498) and controls (n = 1864) in women of European ancestry from five US sites genotyped on a cardiovascular gene-centric array.

METHODS

Significant single-nucleotide polymorphisms (SNPs) from 21 traits in seven disease categories (cardiovascular, inflammatory/autoimmune, insulin resistance, liver, obesity, renal and thrombophilia) with published genome-wide association studies (GWAS) were used to create a genetic instrument for each trait. Multivariable logistic regression was used to test the association of each continuous scaled genetic instrument with pre-eclampsia. Odds of pre-eclampsia were compared across quartiles of the genetic instrument and evaluated for significance.

MAIN OUTCOME MEASURES

Genetic predisposition to medical conditions and relationship with pre-eclampsia.

RESULTS

An increasing burden of risk alleles for elevated diastolic blood pressure (DBP) and increased body mass index (BMI) were associated with an increased risk of pre-eclampsia (DBP, overall OR 1.11, 95% CI 1.01-1.21, P = 0.025; BMI, OR 1.10, 95% CI 1.00-1.20, P = 0.042), whereas alleles associated with elevated alkaline phosphatase (ALP) were protective (OR 0.89, 95% CI 0.82-0.97, P = 0.008), driven primarily by pleiotropic effects of variants in the FADS gene region. The effect of DBP genetic loci was even greater in early-onset pre-eclampsia cases (at <34 weeks of gestation, OR 1.30, 95% CI 1.08-1.56, P = 0.005). For other traits, there was no evidence of an association.

CONCLUSIONS

These results suggest that the underlying genetic architecture of pre-eclampsia may be shared with other disorders, specifically hypertension and obesity.

TWEETABLE ABSTRACT

A genetic predisposition to increased diastolic blood pressure and obesity increases the risk of pre-eclampsia.

1164 Prospective Associations Between Sleep Duration, Variability and Timing and Diseases from an Electronic Health Record Biobank in 24,065 Individuals

Introduction

Implementation of electronic health records (EHR) across healthcare systems linking clinical to survey data has enabled systematic assessments of longitudinal relationships between sleep traits and diseases classified by PheWAS codes where ICD-9/10 codes are collapsed to categories based on clinical similarity. In the Partners Biobank, a hospital-based virtual cohort from Mass General Brigham in greater Boston, MA, we aimed to assess associations between sleep traits and incident diseases.

Methods

Self-reported weekday/weekend bed and wake times from a survey at consent were used to derive sleep traits. Incident diseases were defined as two incident PheWAS codes on separate dates ≥1y after consent. Cox proportional hazards models compared short (&lt;7h) and long (≥9h) sleep duration, with 7-8h (referent group), adjusted for age, gender, race/ethnicity, and employment status, then further adjusted for BMI. Similarly, sleep midpoint (midpoint between weekend wake/bed times), sleep debt (difference in weekend/weekday sleep duration), and social jetlag (difference in weekend/weekday sleep midpoint) were assessed.

Results

The analytical sample consisted of 24,065 adults (mean sleep duration =8.12h) seeking regular care with sleep data. Participants had a total of 7,513,649 ICD codes of which incident 323,946 ICD codes mapped to 137,137 PheWAS codes. Over a median follow-up of 2.73 years (interquartile range: 1.82-3.98), participants sleeping &lt;7h had a significantly higher risk of incident Acute pain [hazard ratio(95% confidence interval)=1.46(1.2-1.78)], Tobacco use disorder [1.42(1.18-1.71)], Sciatica [1.72(1.3-2.27)], and Edema [1.69(1.25-2.28)]. Each additional hour of later sleep midpoint and increased sleep debt and social jetlag associated with higher risk of incident Major depressive disorder [midpoint:1.30(1.14-1.49); debt:1.23(1.09-1.38); jetlag:1.54(1.27-1.84)]. Associations retained significance upon further adjustment for BMI, except for Edema, and no other associations were observed at the Bonferroni threshold (P=0.0125).

Conclusion

Our findings in a large hospital-based virtual cohort support unique inter-relationships between sleep duration/timing on somatic, behavioral, and mental health outcomes.

Support

H.S.D. and R.S. are supported by NIDDK grant R01DK107859. B.C. is supported by K01-HL135405-01. S.R. and R.S. are partially supported by R35 NHLBI HL 135816.

0259 Shiftworkers are at Increased Risk of Developing Chronic Pain and Opioid Use Disorders: A Study of 116,000 UK Biobank Participants Over a Decade

Introduction

In the current epidemic of opioid-related deaths, and widespread use of opioids to treat chronic pain, there is a pressing need to understand the underlying risk factors that contribute to such devastating conditions. Shiftwork has been associated with adverse health outcomes. We tested whether shiftwork during middle age is linked to the development of chronic pain and opioid misuse.

Methods

We studied 116,474 participants in active employment between 2006–2010 (mean age 57±8; range 37–71) from the UK Biobank, who have been followed for up to 10 years until 2017. We included participants who were free from all forms of self-reported pain, and were not taking opioid medications at baseline. Chronic pain and opioid use disorder diagnoses were determined using hospitalization records and diagnostic coding from ICD-10. Multivariate logistic regression models were performed to examine the associations of shiftwork status (yes/no) and nightshift frequency (none/occasional/permanent) and with incident chronic pain and/or opioid use disorder during follow-up. Models were adjusted for demographics, education, Townsend deprivation index, major confounders (BMI, diabetes, bone fractures/injuries, operations, peripheral vascular disease, joint/inflammatory diseases, cancer, standing/manual labor at work) and covariates (smoking, alcohol, high cholesterol, depression/anxiety, and cardiovascular diseases).

Results

In total, 190 (1.6/1,000) developed chronic pain or opioid use disorders. Shiftworkers (n=17,673) saw a 1.5-fold increased risk (OR 1.56, 95% CI: 1.08–2.24, p=0.01) relative to day workers. Within shiftworkers, those who reported occasional nightshift work (n=3,966) were most vulnerable (OR 1.57, 95% CI: 1.06–2.34, p=0.02). Results remained similar after adjusting for baseline sleep duration, chronotype and insomnia.

Conclusion

Shiftwork, and in particular rotating nightshift work is associated with increased risk for developing chronic pain and opioid use disorders. Replication is required to confirm the findings and to examine underlying mechanisms.

Support

This work was supported by NIH grants T32GM007592, RF1AG064312, and RF1AG059867.

Thinking, Creating, Innovating: Utilizing Algorithms in PBL Setup to Enhance Pathology Education

Objectives

Exponential development in the depth and breadth of information in pathology has been challenging for the learners, because the pressure it creates to move quickly beyond content knowledge, to critical analysis, and to the process of applying pathophysiological concepts to clinical scenarios creates cognitive dissonance that impairs near-term performance and long-term retention. We propose an instructional approach where well-organized information is amalgamated with radiological imaging, immunohistochemistry, and molecular pathology, in the form of executable computer programs, to help students categorize the material and retain it as a way to activate multiple sensory systems.

Methods

A demonstration to convey a basic setup of Java to the students was delivered by IT support in the beginning of the semester. PowerPoint presentations on selective systemic pathology topics were used as an in-class vehicle by the large groups to learn, and by the small groups as a tool to create and design computer algorithms with essential checklists in select pathophysiology topics, like solid tumors. Data comprising gross and microscopic histopathological findings, pathophysiology, and differential diagnoses, woven into correlated clinical vignettes, were then provided to small groups, who worked in a PBL setup using patient cases and the already designed computer algorithms, to present their diagnoses. Continuous faculty assessment of student performance was done.

Results

Overall data analysis of block exams revealed that the mean scores were considerably higher for participants, compared to the average results of nonparticipant batches in the same exam. These participants reported better retention and development of significantly higher levels of interest in the subject.

Conclusion

Our preliminary experience suggests that our new instructional methodology can revitalize pathology education by aligning it better with medical students’ inherent enthusiasm for learning and retention. We will continue developing the computational pathology model in various clinicopathological topics as an undergraduate pathology education strategy.

The unique composition of Indian gut microbiome, gene catalogue, and associated fecal metabolome deciphered using multi-omics approaches

BACKGROUND

Metagenomic studies carried out in the past decade have led to an enhanced understanding of the gut microbiome in human health; however, the Indian gut microbiome has not been well explored. We analyzed the gut microbiome of 110 healthy individuals from two distinct locations (North-Central and Southern) in India using multi-omics approaches, including 16S rRNA gene amplicon sequencing, whole-genome shotgun metagenomic sequencing, and metabolomic profiling of fecal and serum samples.

RESULTS

The gene catalogue established in this study emphasizes the uniqueness of the Indian gut microbiome in comparison to other populations. The gut microbiome of the cohort from North-Central India, which was primarily consuming a plant-based diet, was found to be associated with Prevotella and also showed an enrichment of branched chain amino acid (BCAA) and lipopolysaccharide biosynthesis pathways. In contrast, the gut microbiome of the cohort from Southern India, which was consuming an omnivorous diet, showed associations with Bacteroides, Ruminococcus, and Faecalibacterium and had an enrichment of short chain fatty acid biosynthesis pathway and BCAA transporters. This corroborated well with the metabolomics results, which showed higher concentration of BCAAs in the serum metabolome of the North-Central cohort and an association with Prevotella. In contrast, the concentration of BCAAs was found to be higher in the fecal metabolome of the Southern-India cohort and showed a positive correlation with the higher abundance of BCAA transporters.

CONCLUSIONS

The study reveals the unique composition of the Indian gut microbiome, establishes the Indian gut microbial gene catalogue, and compares it with the gut microbiome of other populations. The functional associations revealed using metagenomic and metabolomic approaches provide novel insights on the gut-microbe-metabolic axis, which will be useful for future epidemiological and translational researches.

Association between fibrinogen and fibrinogen γ' and atherosclerotic plaque morphology and composition in symptomatic carotid artery stenosis: Plaque-At-RISK study

INTRODUCTION

Von Willebrand Factor (VWF), ADAMTS13, fibrinogen and fibrinogen γ' are associated with an increased risk of ischemic stroke. Carotid atherosclerosis is an important risk factor for ischemic stroke. Characteristics of the vulnerable plaque; intraplaque hemorrhage (IPH), plaque ulceration and lipid-rich necrotic core (LRNC) can be visualized with imaging techniques. Since atherosclerosis might attribute to the association between coagulation factors and ischemic stroke risk, the aim of this study is to investigate the association between coagulation factors and atherosclerotic plaque characteristics in more detail.

MATERIALS AND METHODS

In 182 patients of the Plaque-At-RISK study (prospective multicenter cohort study) with a recent transient ischemic attack (TIA) or ischemic stroke and a symptomatic mild-to-moderate carotid artery stenosis, we measured VWF antigen (VWF:Ag), ADAMTS13 activity, fibrinogen (Clauss), and fibrinogen γ'. Presence of plaque ulceration, IPH volume and LRNC volume were determined by Multidetector-Row Computed Tomography (MDCTA, n = 160) and Magnetic Resonance Imaging (MRI, n = 172). Linear regression analysis was used to assess the association between imaging biomarkers and coagulation factors.

RESULTS

VWF:Ag or ADAMTS13 levels were not significantly associated with plaque ulceration, IPH and LRNC. We found an inverse association between fibrinogen and fibrinogen γ' and IPH volume (B = -23.40 mm³/g/L, p = 0.01 and B = -161.73 mm³/g/L, p = 0.01) and between fibrinogen and fibrinogen γ' and LRNC volume (B = -38.89 mm³ g/L, p < 0.01 and B = -227.06 mm³ g/L, p = 0.01). Additional adjustments for C-reactive protein (CRP) did not change the results.

CONCLUSIONS

Fibrinogen and fibrinogen γ' are inversely associated with IPH volume and LRNC volume, independent of inflammation.

CLINICAL TRIAL REGISTRATION

clinicaltrials.govNCT01208025.

Autosomal Dominant Polycystic Kidney Disease: Presence of Hypomorphic Alleles in PKD1 Gene

Autosomal dominant polycystic kidney disease is characterized by multiple cysts in both kidneys manifesting in adult life. In general, the disorder is caused by a pathogenic variant in one allele of PKD1 or PKD2 genes, while the other allele is normal. Pathogenic variants in both the alleles are rare and have variable phenotypes, from lethal or perinatal presentation to a mild form in later adulthood, depending on the type of variant. Here, we describe a proband with two variants (p.Thr1773Ile and p.Ala1871Thr in trans) in PKD1 gene, who presented with disease at age 24 years. Both the parents and one brother had a variant in one allele, the other being wild type only and had normal ultrasound findings. Segregation studies suggest that both the variants may act as “hypomorphic” or “incompletely penetrant” alleles and acting together resulted in haploinsufficiency of protein PC1 in renal cells, leading to cystogenesis in the proband. The consequences of the presence of two hypomorphic variants have been poorly documented in literature. We reviewed the few published cases having two hypomorphic variants and the data conform to the conclusions that we reached by study of the family described. It is emphasized that to resolve the significance of suspected hypomorphic variants, segregation studies in the parents and siblings are essential.

Spectrum of hemostatic disorders in Indian females presenting with bleeding manifestations

INTRODUCTION

Hemostatic disorders are often missed in women with bleeding particularly menorrhagia. Preexisting hemostatic disorders are now known as common risk factor for postpartum hemorrhage and prolonged bleeding in puerperium. Females with bleeding complaints constitute an important population referred to hematology clinic. Hence, we aim to evaluate the type and frequency of hemostatic disorders among females presenting with bleeding in a tertiary care hospital and a basic hemostatic laboratory.

METHODS

Three-year data were retrospectively analyzed for 200 females with various bleeding complaints. Due to resource constraints, a hemostatic workup was done with prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen assay, clot solubility test, mixing studies, specific factor assays, platelet function test, and von Willebrand factor antigen level.

RESULTS

A total of 200 females were investigated to identify the cause of their bleeding. Thirty-five of 200 (17.5%) females were found with an underlying bleeding disorder. Of these 35 females, 65.7% presented with bleeding from more than 1 site. Most common bleeding manifestation was spontaneous bruising in 18 of 35 (51.4%) patients followed by petechiae (48.6%). Inherited bleeding disorders were noted in majority. The most common inherited bleeding disorder identified was von Willebrand disease (VWD) in 34.3% females. Second most common disorder was Glanzmann's thrombasthenia accounting for 22.8%. Rare coagulation factor deficiency, such as factors VII, X, and XIII deficiencies, was noted. Three cases revealed acquired causes of coagulation defects.

CONCLUSION

Underlying hemostatic defects should be searched for in women with unexplained bleeding complaints. This will not only help in diagnosis but also in proper management for future hemostatic challenges.

A Patient Centered Decision Making Dialysis Access Algorithm

Much controversy surrounds the establishment of proper planning, placement and management (the best practice pattern) of dialysis access. These include the dialysis type and modality selection, timing of access placement and who places the access. The lack of and the difficulty of performing randomized studies with multiple confounding factors, in an extremely heterogeneous and rapidly changing ESRD population demographics, only partly explains the dialysis access conundrum. Add to this the rapidly developing and competing technologies, the wide spectrum of the professional experience, bias and socio-economic forces to make the ESRD problems as multivariate and complex as life itself.

This overview describes a dialysis access algorithm approach to the patient needing renal replacement therapy, considering long-term improved patient outcome as the ultimate objective.

Duplex Ultrasound Evaluation for Dialysis access Selection and Maintenance: A Practical Guide

Detailed case directed history and examination is the mainstay of dialysis access modality selection, ie site and type of access, as well as for maintenance of dialysis access for longevity. As a logical step following history and physical examination, duplex ultrasound evaluation (DUE) is the most cost effective and non-invasive screening tool for evaluation for access placement and for assessment of an established access. Pre-operative vascular mapping allows selection of the optimal dialysis access modality and site. In established accesses, duplex ultrasound testing will diagnose the majority of vascular access complications and direct proper surgical or interventional radiology management. This review outlines a practical decision-making algorithm using DUE for choosing and managing the dialysis access.

Entropion Uveae: Early Sphincter Atrophy, Signposting Primary Angle Closure Glaucoma?

PURPOSE

An easily recognized clinical marker for early changes of primary angle closure glaucoma (PACG) or eyes predisposed to angle closure is important so that timely laser iridotomy can prevent morbidity. Pupillary ruff changes, specifically appearance of entropion uveae (EU), are frequent in eyes with PACG.

METHODS

Pupillary ruff was examined under magnification and EU, if present, was graded and correlated with gonioscopic grading and presence of peripheral anterior synechiae (PAS) in consecutive patients with primary open angle glaucoma (POAG), non-glaucomatous controls, and PACG of the subacute, acute, chronic symptomatic, and creeping angle closure glaucoma subgroups.

RESULTS

No POAG eye had an abnormal pupillary ruff. A total of 86.7% of subacute PACG eyes and all eyes with acute and chronic PACG showed some grade of EU. Iridocorneal synechiae were more significantly correlated with EU than goniosynechiae (p<0.001). Meridian of iridocorneal but not iridotrabecular synechiae could be correlated with the meridian of EU. In age-matched patients EU was only present in eyes with steep iris configuration, with significant correlation with narrow angles and goniosynechiae. In the detection of PACG the presence of EU Grade I was 94.9% sensitive and 98.2% specific for PACG eyes compared to the gonioscopic picture of angle closure in occludable angles. Its positive predictive value was 91.4%.

CONCLUSIONS

EU shows significant correlation with narrow angles, steep iris configuration, and PAS. Kinking of radial iris arteries during angle closure probably causes temporary ischemia, especially of end arteries supplying area of the pupil and sphincter pupillae. EU emerges as an easily observed, objective marker for PACG.

Molecular Response to Imatinib and Its Correlation with mRNA Expression Levels of Imatinib Influx Transporter (OCT1) in Indian Chronic Myeloid Leukemia Patients

Background and objectives:

Imatinib mesylate is approved for the treatment of Chronic Myeloid Leukemia (CML). About 20% of patients with CML do not respond to treatment with Imatinib either initially or because of acquired resistance. In addition to mutated BCR-ABL1 kinase, the organic cation transporter1 (OCT1, encoded by SLC22A1) has been considered to contribute to Imatinib resistance in patients with chronic myeloid leukemia (CML). OCT1 has been reported to be the main influx transporter involved in Imatinib uptake into CML cells. To date, only a few studies have been reported on involvement of influx transporters in development of Imatinib resistance. Therefore this study was aimed to determine the expression level of Imatinib uptake transporter (OCT1) in CML patients and to correlate this level with molecular response.

Methods:

One hundred fifty eight patients on Imatinib were considered for gene expression analysis study for OCT1 gene. Total RNA was extracted from peripheral blood mononuclear cells. Complementary DNAs (cDNAs) were synthesized and Real Time Polymerase Chain Reaction (RQ-PCR) was performed.

Results:

High OCT1 expression was present in 81 (51.8%) patients and low OCT1 expression was in 77 (48.7%) patients. Low Sokal risk score group have a significantly high OCT1 expression (p=0.048). The rate of molecular response was higher in those with high OCT1 expression than in those with low OCT1 expression (p=0.05). Both event-free survival and median overall survival were significantly shorter in patients with low OCT1 expressions when compared to the patients with high OCT1 expression (p=0.03 and p=0.05).

Conclusions:

Our findings demonstrated that the mRNA expression level of OCT1 was significantly correlated with molecular response in CML patients. Based on these findings, present study believes that the pre-therapeutic higher expression of OCT1 may help to predict response to imatinib therapy in CML patients.

Characterizing sleep spindles in 11,630 individuals from the National Sleep Research Resource

Sleep spindles are characteristic electroencephalogram (EEG) signatures of stage 2 non-rapid eye movement sleep. Implicated in sleep regulation and cognitive functioning, spindles may represent heritable biomarkers of neuropsychiatric disease. Here we characterize spindles in 11,630 individuals aged 4 to 97 years, as a prelude to future genetic studies. Spindle properties are highly reliable but exhibit distinct developmental trajectories. Across the night, we observe complex patterns of age- and frequency-dependent dynamics, including signatures of circadian modulation. We identify previously unappreciated correlates of spindle activity, including confounding by body mass index mediated by cardiac interference in the EEG. After taking account of these confounds, genetic factors significantly contribute to spindle and spectral sleep traits. Finally, we consider topographical differences and critical measurement issues. Taken together, our findings will lead to an increased understanding of the genetic architecture of sleep spindles and their relation to behavioural and health outcomes, including neuropsychiatric disorders.

Sleep patterns vary and are associated with health and disease. Here Purcell et al characterize sleep spindle activity in 11,630 individuals and describe age-related changes, genetic influences, and possible confounding effects, serving as a resource for further understanding the physiology of sleep.

Higher rate of central nervous system involvement by flow cytometry than morphology in acute lymphoblastic leukemia

INTRODUCTION

Central nervous system (CNS) involvement in acute lymphoblastic leukemia (ALL) is diagnosed traditionally by cytopathology (CP) of the cerebrospinal fluid (CSF). Role of flow cytometry (FC) to diagnose CNS involvement has not been extensively investigated.

METHODS

We aimed to detect CNS involvement in 42 ALL patients (33 B-ALL, nine T-ALL) at diagnosis by FC and comparing it with CP and to correlate it with known risk factors for CNS disease like Lactate dehydrogenase (LDH). A receiver operating characteristic curve was used to determine the cutoff of LDH to predict CSF involvement. For the analysis of categorical/quantitative variables, Fisher's exact test was used. For the analysis of continuous variables, Mann-Whitney test was used. A P value of <.05 was taken as significant.

RESULTS

CP and FC were positive in five (11.9%) and 11 patients (26.14%) respectively with FC detecting a significantly higher level of involvement (P=.001). All CP-positive cases were FC positive. A LDH value of >472 U/L had a sensitivity of 61% and specificity of 62.5% for diagnosis of CSF involvement by FC.

CONCLUSIONS

CSF FC detects CNS disease in ALL patients at diagnosis at a rate double than CP alone and is statistically associated with an elevated LDH level. It should be incorporated in the evaluation of CSF to detect CNS involvement.