Methylprednisolone in severe COVID-19 with acute respiratory distress syndrome - less is more?

INTRODUCTION

Corticosteroids, particularly methylprednisolone, are part of the treatment for severe COVID-19 with acute respiratory distress syndrome (ARDS). In this study, we aimed to compare the mortalities of patients treated with higher versus lower doses of methylprednisolone. Secondary outcomes included oxygenation, need for mechanical ventilation, length of stay in intensive care unit (ICU), secondary infection, improvement of PaO2/FiO2 (PF) ratio, and inflammatory response as expressed by C-reactive protein (CRP).

MATERIALS AND METHODS

A retrospective cohort study conducted at Sarawak General Hospital from 1st June to 30th September 2021. Patients who received intravenous methylprednisolone for severe COVID-19 in the ICU were identified and divided into two groups: higher dose (cumulative dose more than 10 mg per kg) and lower dose (cumulative dose less than 10 mg per kg).

RESULTS

Out of a total of 165 patients, 40 (24.2%) patients received higher dose methylprednisolone. There was no significant difference in socio-demographic characteristics (age, gender, body mass index), COVID-19 vaccination status, laboratory parameters (lymphocyte count, CRP, lactate dehydrogenase, D-dimer), or usage of immunomodulator therapy between the groups. Overall mortality was 23.6%. Mortality in the higher dose group was twice as high compared to lower dose group (37.5% versus 19.2%) (OR 3.79, 95% CI 1.24-11.59, p<0.05). In addition, the higher dose cohort developed more secondary infections (87.5%) and had longer stays in ICU (median 11 days, IQR 8- 15). No significant difference was found between both cohorts in terms of CRP reduction, improvement of PF ratio, or the need for mechanical ventilation post methylprednisolone.

CONCLUSION

In this study, the use of higher dose methylprednisolone in COVID-19 with ARDS was not associated with better clinical outcomes. A lower dose of methylprednisolone might be sufficient in treating severe COVID-19 with ARDS.

Whole genome and transcriptome analysis enhances precision cancer treatment options

BACKGROUND

Recent advances are enabling delivery of precision genomic medicine to cancer clinics. While the majority of approaches profile panels of selected genes or hotspot regions, comprehensive data provided by whole genome and transcriptome sequencing and analysis (WGTA) presents an opportunity to align a much larger proportion of patients to therapies.

PATIENTS AND METHODS

Samples from 570 patients with advanced or metastatic cancer of diverse types enrolled in the Personalized OncoGenomics (POG) program underwent WGTA. DNA-based data, including mutations, copy number, and mutation signatures, were combined with RNA-based data, including gene expression and fusions, to generate comprehensive WGTA profiles. A multidisciplinary molecular tumour board used WGTA profiles to identify and prioritize clinically actionable alterations and inform therapy. Patient responses to WGTA-informed therapies were collected.

RESULTS

Clinically actionable targets were identified for 83% of patients, 37% of whom received WGTA-informed treatments. RNA expression data were particularly informative, contributing to 67% of WGTA-informed treatments; 25% of treatments were informed by RNA expression alone. Of a total 248 WGTA-informed treatments, 46% resulted in clinical benefit. RNA expression data were comparable to DNA-based mutation and copy number data in aligning to clinically beneficial treatments. Genome signatures also guided therapeutics including platinum, PARP inhibitors, and immunotherapies. Patients accessed WGTA-informed treatments through clinical trials (19%), off-label use (35%), and as standard therapies (46%) including those which would not otherwise have been the next choice of therapy, demonstrating the utility of genomic information to direct use of chemotherapies as well as targeted therapies.

CONCLUSIONS

Integrating RNA expression and genome data illuminated treatment options that resulted in 46% of treated patients experiencing positive clinical benefit, supporting the use of comprehensive WGTA profiling in clinical cancer care.

CLINICAL TRIAL NUMBER

NCT02155621.

Fluctuations in quality of life and immune responses during intravenous immunoglobulin infusion cycles

Despite adequate infection prophylaxis, variation in self-reported quality of life (QOL) throughout the intravenous immunoglobulin (IVIG) infusion cycle is a widely reported but infrequently studied phenomenon. To better understand this phenomenon, subjects with humoral immunodeficiency receiving replacement doses of IVIG were studied over 3 infusion cycles. Questionnaire data from 6 time points spread over 3 IVIG infusions cycles (infusion day and 7 days after each infusion) were collected in conjunction with monitoring the blood for number of regulatory T-cells (Treg) and levels of 40 secreted analytes: primarily cytokines, chemokines, and growth factors. At day 7, self-reported well-being increased, and self-reported fatigue decreased, reflecting an overall improvement in QOL 7 days after infusion. Over the same period, percentage of Treg cells in the blood increased (p<0.01). Multiple inflammatory chemokine and cytokine levels increased in the blood by 1 hour after infusion (CCL4 (MIP-1b), CCL3 (MIP-1a), CCL2 (MCP-1), TNF-α, granzyme B, IL-10, IL-1RA, IL-8, IL-6, GM-CSF, and IFN- γ). The largest changes in analytes occurred in subjects initiated on IVIG during the study. A significant decrease in IL-25 (IL-17E) following infusion was seen in most intervals among subjects already receiving regular infusions prior to study entry. These findings reveal several short-term effects of IVIG given in replacement doses to patients with humoral immunodeficiency: QOL consistently improves in the first week of infusion, levels of a collection of monocyte-associated cytokines increase immediately after infusion whereas IL-25 levels decrease, and Treg levels increase. Moreover, patients that are new to IVIG experience more significant fluctuations in cytokine levels than those receiving it regularly.

Cardiovascular diseases among diffuse large B-cell lymphoma long-term survivors in Asia: a multistate model study

BACKGROUND

We modeled the clinical course of a cohort of diffuse large B-cell lymphoma (DLBCL) patients with no prior cardiovascular diseases (CVDs) using a multistate modeling framework.

PATIENTS AND METHODS

Data on 2600 patients with DLBCL diagnosed between 2000 and 2018 and had received chemotherapy with or without radiotherapy were obtained from a population-wide electronic health database of Hong Kong. We used the Markov illness-death model to quantify the impact of doxorubicin and various risk factors (therapeutic exposure, demographic, comorbidities, cardiovascular risk factors, and lifestyle factors which included smoking) on the clinical course of DLBCL (transitions into incident CVD, lymphoma death, and other causes of death).

RESULTS

A total of 613 (23.6%) and 230 (8.8%) of 2600 subjects died of lymphoma and developed incident CVD, respectively. Median follow-up was 7.0 years (interquartile range 3.8-10.8 years). Older ages [hazard ratio (HR) for >75 versus ≤60 years 1.88; 95% confidence interval (CI) 1.25-2.82 and HR for 61-75 versus ≤60 years 1.60; 95% CI 1.12-2.30], hypertension (HR 4.92; 95% CI 2.61-9.26), diabetes (HR 1.43; 95% CI 1.09-1.87), and baseline use of aspirin (HR 5.30; 95% CI 3.93-7.16) were associated with an increased risk of incident CVD. In a subgroup of anticipated higher-risk patients (aged 61-75 years, smoked, had diabetes, and received doxorubicin), we found that they remained on average 7.9 (95% CI 7.2-8.8) years in the DLBCL state and 0.1 (95% CI 0.0-0.4) years in the CVD state, if they could be followed up for 10 years. The brief time in the CVD state is consistent with the high chance of death in patients who developed CVD. Other causes of death have overtaken DLBCL-related death after about 5 years.

CONCLUSIONS

In this Asian population-based cohort, we found that incident CVDs can occur soon after DLBCL treatment and continued to occur throughout survivorship. Clinicians are advised to balance the risks and benefits of treatment choices to minimize the risk of CVD.

Immune-based mutation classification enables neoantigen prioritization and immune feature discovery in cancer immunotherapy

Genetic mutations lead to the production of mutated proteins from which peptides are presented to T cells as cancer neoantigens. Evidence suggests that T cells that target neoantigens are the main mediators of effective cancer immunotherapies. Although algorithms have been used to predict neoantigens, only a minority are immunogenic. The factors that influence neoantigen immunogenicity are not completely understood. Here, we classified human neoantigen/neopeptide data into three categories based on their TCR-pMHC binding events. We observed a conservative mutant orientation of the anchor residue from immunogenic neoantigens which we termed the “NP” rule. By integrating this rule with an existing prediction algorithm, we found improved performance in neoantigen prioritization. To better understand this rule, we solved several neoantigen/MHC structures. These structures showed that neoantigens that follow this rule not only increase peptide-MHC binding affinity but also create new TCR-binding features. These molecular insights highlight the value of immune-based classification in neoantigen studies and may enable the design of more effective cancer immunotherapies.

Chronic Urticaria in Children: an Update on Diagnosis and Treatment

PURPOSE OF REVIEW

Both adults and children are frequently affected by symptoms of itchy urticarial lesions that cause considerable distress and impact nearly all their daily activities. A comprehensive history is critical to identify the etiology in patients who have chronic spontaneous urticaria (CSU) (those with symptoms for > 6 weeks) and is more important than extensive laboratory serum tests. Unfortunately, most of the current treatment guidelines have been based on data from adult studies since there is rare data on children. These treatment algorithms have been subsequently used to extrapolate treatments for children.

RECENT FINDINGS

Current treatment regiments do not achieve complete success in all patients, neither adults nor children. As the pathophysiology of chronic urticaria slowly becomes defined, novel therapies are being tested which target these individual molecular pathways to treat those that continue to experience symptoms. Future studies are required to establish the natural history, risks/benefits and efficacy of current medications, and biologics used to treat CSU in children.

Diagnostic yield of medical thoracoscopy in exudative pleural effusions in a region with high tuberculosis burden

INTRODUCTION

Pleural effusion is frequently encountered in respiratory medicine. However, despite thorough assessment including closed pleural biopsy, the cause of around 20% of pleural effusions remains undetermined. Medical thoracoscopy (MT) is the investigation of choice in these circumstances especially if malignancy is suspected. The aim of this study is to evaluate the diagnostic yield of MT in exudative pleural effusions in a single center from East Malaysia.

METHODS

Retrospective chart review of all adult patients who underwent MT for undiagnosed exudative pleural effusion in a 24-month duration.

RESULTS

Our cohort comprised of 209 patients with a median age of 61 years old (IQR 48.5-69.5). There were 92 (44%) patients with malignant pleural effusion (MPE) and 117 (56%) benign effusions; which included 85 tuberculous pleural effusion (TBE) and 32 cases of non-tuberculous exudative pleural effusion. Conclusive pathological diagnosis was made in 79.4% of the cases. For diagnosis of MPE, MT had a sensitivity of 89.1% (95% CI 80.4-94.3), specificity of 100% (95% CI 96.0-100.0), and positive predictive value (PPV) of 100% (95% CI 94.4-100) and negative predictive value (NPV) of 92.1% (95% CI 85.6-95.9). For TBE, MT had a sensitivity of 90.5% (95% CI 81.8-95.6), specificity of 100% (95% CI 96.3- 100.0) PPV of 100% (95% CI 94.1-100) and NPV of 93.9% (95% CI 88.0-97.2). Overall complication rate was 3.3%.

CONCLUSIONS

MT showed excellent sensitivity and specificity in the diagnosis of exudative pleural effusion in this region. It reduces empirical therapy by providing histological evidence of disease when initial non-invasive investigations were inconclusive.

Measurement of Azimuthal Anisotropy of Muons from Charm and Bottom Hadrons in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

The elliptic flow of muons from the decay of charm and bottom hadrons is measured in pp collisions at sqrt[s]=13  TeV using a data sample with an integrated luminosity of 150  pb^{-1} recorded by the ATLAS detector at the LHC. The muons from heavy-flavor decay are separated from light-hadron decay muons using momentum imbalance between the tracking and muon spectrometers. The heavy-flavor decay muons are further separated into those from charm decay and those from bottom decay using the distance-of-closest-approach to the collision vertex. The measurement is performed for muons in the transverse momentum range 4-7 GeV and pseudorapidity range |η|<2.4. A significant nonzero elliptic anisotropy coefficient v_{2} is observed for muons from charm decays, while the v_{2} value for muons from bottom decays is consistent with zero within uncertainties.

Search for Magnetic Monopoles and Stable High-Electric-Charge Objects in 13 Tev Proton-Proton Collisions with the ATLAS Detector

A search for magnetic monopoles and high-electric-charge objects is presented using 34.4  fb^{-1} of 13 TeV pp collision data collected by the ATLAS detector at the LHC during 2015 and 2016. The considered signature is based upon high ionization in the transition radiation tracker of the inner detector associated with a pencil-shape energy deposit in the electromagnetic calorimeter. The data were collected by a dedicated trigger based on the tracker high-threshold hit capability. The results are interpreted in models of Drell-Yan pair production of stable particles with two spin hypotheses (0 and 1/2) and masses ranging from 200 to 4000 GeV. The search improves by approximately a factor of 5 the constraints on the direct production of magnetic monopoles carrying one or two Dirac magnetic charges and stable objects with electric charge in the range 20≤|z|≤60 and extends the charge range to 60<|z|≤100.

Febrile neutropenia and its associated hospitalization in breast cancer patients on docetaxel-containing regimen: A retrospective cohort study on duration of prophylactic GCSF administration

PURPOSE

To compare febrile neutropenia (FN) incidence and hospitalization among breast cancer patients on docetaxel with no granulocyte colony-stimulating factors (GCSF) primary prophylaxis (PP), 4/5-day PP, or 7-day PP.

METHODS

We identified 3916 breast cancer patients using docetaxel-cyclophosphamide (TC), doxorubicin-cyclophosphamide then docetaxel (AC-T), fluorouracil-epirubicin-cyclophosphamide then docetaxel (FEC-T), docetaxel-carboplatin-trastuzumab (TJH), or docetaxel-doxorubicin-cyclophosphamide (TAC) from a hospital pharmacy dispensing database in Hong Kong between 2014 and 2016. Patients were offered GCSF within 5 days since administering docetaxel. Outcomes included FN incidence, time to first hospitalization, hospitalization rate, and duration.

RESULTS

In TC regimen, FN incidence (with odds ratio, OR) of patients with no PP, 4/5-day PP, and 7-day PP was 21.69%, 7.95% (OR 0.31, p < 0.001), and 5.33% (OR 0.20, p < 0.001), respectively. In TJH regimen, FN incidence of patients with no PP, 4/5-day PP, and 7-day PP was 38.26%, 8.33% (OR 0.15, p < 0.001), and 8.57% (OR 0.15, p < 0.001), respectively. FN incidence of patients on AC-T regimen with no PP and 4/5-day PP was 20.93% and 6.84%, respectively (OR 0.28, p = 0.005); with FEC-T regimen, the incidence was 9.91% and 4.77%, respectively (OR 0.46, p = 0.035). Only 3.27% FN cases were not hospitalized. Mean (±standard deviation, SD) time to first hospitalization was 8.21 ± 2.44 days. Mean (±SD) duration of hospitalization for patients with no PP, 4/5-day PP, and 7-day PP was 4.66 ± 2.60, 4.37 ± 2.85, and 5.12 ± 2.97 days, respectively.

CONCLUSION

GCSF prophylaxis in breast cancer patients on docetaxel could reduce FN incidence and hospitalization. 4/5-day PP demonstrated similar efficacy to 7-day PP with superior saving benefits on healthcare expenditure.

Advances in aeroallergen immunotherapy

PURPOSE OF REVIEW

Allergic rhinoconjunctivitis is the most common manifestation of allergic disease. This break in the normal natural function of the immune system to ignore harmless molecules such as pollen and pet dander to now aggressively react has lead to a substantial disease burden that is not always recognized and adequately treated.

RECENT FINDINGS

Individual molecular component testing may increase the predictive value of blood sIgE and clinical symptoms. Defining the most symptoms inducing allergenic protein has led to advances in peptide-based allergen immunotherapy. There have been steady consistent reports that allergy immunotherapy for children with symptomatic allergic rhinitis prevents the onset of asthma.

SUMMARY

Allergy immunotherapy is an effective disease-modulating treatment that alters the underlying immune dysfunction which is a currently underutilized therapy especially as it is likely effective in preventing the onset of asthma in children, at least in the short term.

Keeping Allergen Names Clear and Defined

The World Health Organization/International Union of Immunological Societies (WHO/IUIS) Allergen Nomenclature Sub-Committee was established in 1986 by leading allergists to standardize names given to proteins that cause IgE-mediated reactions in humans. The Sub-Committee's objective is to assign unique names to allergens based on a critical analysis of confidentially submitted biochemical and clinical data from researchers, often prior to publication to preserve consistency. The Sub-Committee maintains and revises the database as the understanding of allergens evolves. This report summarizes recent developments that led to updates in classification of cockroach group 1 and 5 allergens to animal as well as environmental and occupational allergens. Interestingly, routes, doses, and frequency of exposure often affects allergenicity as does the biochemical properties of the proteins and similarity to self and other proteins. Information required by the Sub-Committee now is more extensive than previously as technology has improved. Identification of new allergens requires identification of the amino acid sequence and physical characteristics of the protein as well as demonstration of IgE binding from subjects verified by described clinical histories, proof of the presence of the protein in relevant exposure substances, and demonstration of biological activity (skin prick tests, activation of basophils, or mast cells). Names are assigned based on taxonomy with the abbreviation of genus and species and assignment of a number, which reflects the priority of discovery, but more often now, the relationships with homologous proteins in related species.

Observation of Electroweak Production of a Same-Sign W Boson Pair in Association with Two Jets in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

This Letter presents the observation and measurement of electroweak production of a same-sign W boson pair in association with two jets using 36.1  fb^{-1} of proton-proton collision data recorded at a center-of-mass energy of sqrt[s]=13  TeV by the ATLAS detector at the Large Hadron Collider. The analysis is performed in the detector fiducial phase-space region, defined by the presence of two same-sign leptons, electron or muon, and at least two jets with a large invariant mass and rapidity difference. A total of 122 candidate events are observed for a background expectation of 69±7 events, corresponding to an observed signal significance of 6.5 standard deviations. The measured fiducial signal cross section is σ^{fid}=2.89_{-0.48}^{+0.51}(stat)_{-0.28}^{+0.29}(syst)  fb.

Structural characteristics of lipocalin allergens: Crystal structure of the immunogenic dog allergen Can f 6

Lipocalins represent the most important protein family of the mammalian respiratory allergens. Four of the seven named dog allergens are lipocalins: Can f 1, Can f 2, Can f 4, and Can f 6. We present the structure of Can f 6 along with data on the biophysical and biological activity of this protein in comparison with other animal lipocalins. The Can f 6 structure displays the classic lipocalin calyx-shaped ligand binding cavity within a central β-barrel similar to other lipocalins. Despite low sequence identity between the different dog lipocalin proteins, there is a high degree of structural similarity. On the other hand, Can f 6 has a similar primary sequence to cat, horse, mouse lipocalins as well as a structure that may underlie their cross reactivity. Interestingly, the entrance to the ligand binding pocket is capped by a His instead of the usually seen Tyr that may help select its natural ligand binding partner. Our highly pure recombinant Can f 6 is able to bind to human IgE (hIgE) demonstrating biological antigenicity.

Observation of Light-by-Light Scattering in Ultraperipheral Pb+Pb Collisions with the ATLAS Detector

This Letter describes the observation of the light-by-light scattering process, γγ→γγ, in Pb+Pb collisions at sqrt[s_{NN}]=5.02  TeV. The analysis is conducted using a data sample corresponding to an integrated luminosity of 1.73  nb^{-1}, collected in November 2018 by the ATLAS experiment at the LHC. Light-by-light scattering candidates are selected in events with two photons produced exclusively, each with transverse energy E_{T}^{γ}>3  GeV and pseudorapidity |η_{γ}|<2.4, diphoton invariant mass above 6 GeV, and small diphoton transverse momentum and acoplanarity. After applying all selection criteria, 59 candidate events are observed for a background expectation of 12±3 events. The observed excess of events over the expected background has a significance of 8.2 standard deviations. The measured fiducial cross section is 78±13(stat)±7(syst)±3(lumi)  nb.

Comparison of Fragmentation Functions for Jets Dominated by Light Quarks and Gluons from pp and Pb+Pb Collisions in ATLAS

Charged-particle fragmentation functions for jets azimuthally balanced by a high-transverse-momentum, prompt, isolated photon are measured in 25  pb^{-1} of pp and 0.49  nb^{-1} of Pb+Pb collision data at 5.02 TeV per nucleon pair recorded with the ATLAS detector at the Large Hadron Collider. The measurements are compared to predictions of Monte Carlo generators and to measurements of inclusively selected jets. In pp collisions, a different jet fragmentation function in photon-tagged events from that in inclusive jet events arises from the difference in fragmentation between light quarks and gluons. The ratios of the fragmentation functions in Pb+Pb events to that in pp events are used to explore the parton color-charge dependence of jet quenching in the hot medium. In relatively peripheral collisions, fragmentation functions exhibit a similar modification pattern for photon-tagged and inclusive jets. However, photon-tagged jets are observed to have larger modifications than inclusive jets in central Pb+Pb events.

Combination of Searches for Invisible Higgs Boson Decays with the ATLAS Experiment

Dark matter particles, if sufficiently light, may be produced in decays of the Higgs boson. This Letter presents a statistical combination of searches for H→invisible decays where H is produced according to the standard model via vector boson fusion, Z(ℓℓ)H, and W/Z(had)H, all performed with the ATLAS detector using 36.1  fb^{-1} of pp collisions at a center-of-mass energy of sqrt[s]=13  TeV at the LHC. In combination with the results at sqrt[s]=7 and 8 TeV, an exclusion limit on the H→invisible branching ratio of 0.26(0.17_{-0.05}^{+0.07}) at 95% confidence level is observed (expected).

Search for the Production of a Long-Lived Neutral Particle Decaying within the ATLAS Hadronic Calorimeter in Association with a Z Boson from pp Collisions at sqrt[s]=13 TeV

This Letter presents a search for the production of a long-lived neutral particle (Z_{d}) decaying within the ATLAS hadronic calorimeter, in association with a standard model (SM) Z boson produced via an intermediate scalar boson, where Z→ℓ^{+}ℓ^{-} (ℓ=e, μ). The data used were collected by the ATLAS detector during 2015 and 2016 pp collisions with a center-of-mass energy of sqrt[s]=13  TeV at the Large Hadron Collider and correspond to an integrated luminosity of 36.1±0.8  fb^{-1}. No significant excess of events is observed above the expected background. Limits on the production cross section of the scalar boson times its decay branching fraction into the long-lived neutral particle are derived as a function of the mass of the intermediate scalar boson, the mass of the long-lived neutral particle, and its cτ from a few centimeters to one hundred meters. In the case that the intermediate scalar boson is the SM Higgs boson, its decay branching fraction to a long-lived neutral particle with a cτ approximately between 0.1 and 7 m is excluded with a 95% confidence level up to 10% for m_{Z_{d}} between 5 and 15 GeV.

Colon carcinoma with endobronchial metastasis masquerading as bronchial asthma causing ball valve effect

Malignant central airway obstruction (CAO) with ball valve effect (BVE) in the lung is rare. We discuss a case of metastatic colon cancer who presented with asthma like symptoms which thoracic computed tomography and bronchoscopy revealed an intraluminal tumour obstructing the left main bronchus in a ball valve manner. Airway patency was restored urgently with immediate alleviation of symptoms. This illustrates the importance of recognizing subtle features of central airway obstruction to allow expedition of appropriate investigations and therapy.

Combination of the Searches for Pair-Produced Vectorlike Partners of the Third-Generation Quarks at sqrt[s]=13 TeV with the ATLAS Detector

A combination of the searches for pair-produced vectorlike partners of the top and bottom quarks in various decay channels (T→Zt/Wb/Ht, B→Zb/Wt/Hb) is performed using 36.1  fb^{-1} of pp collision data at sqrt[s]=13  TeV with the ATLAS detector at the Large Hadron Collider. The observed data are found to be in good agreement with the standard model background prediction in all individual searches. Therefore, combined 95% confidence-level upper limits are set on the production cross section for a range of vectorlike quark scenarios, significantly improving upon the reach of the individual searches. Model-independent limits are set assuming the vectorlike quarks decay to standard model particles. A singlet T is excluded for masses below 1.31 TeV and a singlet B is excluded for masses below 1.22 TeV. Assuming a weak isospin (T,B) doublet and |V_{Tb}|≪|V_{tB}|, T and B masses below 1.37 TeV are excluded.

Observation of Centrality-Dependent Acoplanarity for Muon Pairs Produced via Two-Photon Scattering in Pb+Pb Collisions at sqrt[s_{NN}]=5.02 TeV with the ATLAS Detector

This Letter presents a measurement of γγ→μ^{+}μ^{-} production in Pb+Pb collisions recorded by the ATLAS detector at the Large Hadron Collider at sqrt[s_{NN}]=5.02  TeV with an integrated luminosity of 0.49  nb^{-1}. The azimuthal angle and transverse momentum correlations between the muons are measured as a function of collision centrality. The muon pairs are produced from γγ through the interaction of the large electromagnetic fields of the nuclei. The contribution from background sources of muon pairs is removed using a template fit method. In peripheral collisions, the muons exhibit a strong back-to-back correlation consistent with previous measurements of muon pair production in ultraperipheral collisions. The angular correlations are observed to broaden significantly in central collisions. The modifications are qualitatively consistent with rescattering of the muons while passing through the hot matter produced in the collision.

Search for Resonant and Nonresonant Higgs Boson Pair Production in the bb[over ¯]τ^{+}τ^{-} Decay Channel in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

A search for resonant and nonresonant pair production of Higgs bosons in the bb[over ¯]τ^{+}τ^{-} final state is presented. The search uses 36.1  fb^{-1} of pp collision data with sqrt[s]=13  TeV recorded by the ATLAS experiment at the LHC in 2015 and 2016. Decays of the τ-lepton pairs with at least one τ lepton decaying to final states with hadrons and a neutrino are considered. No significant excess above the expected background is observed in the data. The cross-section times branching ratio for nonresonant Higgs boson pair production is constrained to be less than 30.9 fb, 12.7 times the standard model expectation, at 95% confidence level. The data are also analyzed to probe resonant Higgs boson pair production, constraining a model with an extended Higgs sector based on two doublets and a Randall-Sundrum bulk graviton model. Upper limits are placed on the resonant Higgs boson pair production cross-section times branching ratio, excluding resonances X in the mass range 305  GeV<m_{X}<402  GeV in the simplified hMSSM minimal supersymmetric model for tanβ=2 and excluding bulk Randall-Sundrum gravitons G_{KK} in the mass range 325  GeV<m_{G_{KK}}<885  GeV for k/M[over ¯]_{Pl}=1.

Probing the Quantum Interference between Singly and Doubly Resonant Top-Quark Production in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

This Letter presents a normalized differential cross-section measurement in a fiducial phase-space region where interference effects between top-quark pair production and associated production of a single top quark with a W boson and a b-quark are significant. Events with exactly two leptons (ee, μμ, or eμ) and two b-tagged jets that satisfy a multiparticle invariant mass requirement are selected from 36.1  fb^{-1} of proton-proton collision data taken at sqrt[s]=13  TeV with the ATLAS detector at the LHC in 2015 and 2016. The results are compared with predictions from simulations using various strategies for the interference. The standard prescriptions for interference modeling are significantly different from each other but are within 2σ of the data. State-of-the-art predictions that naturally incorporate interference effects provide the best description of the data in the measured region of phase space most sensitive to these effects. These results provide an important constraint on interference models and will guide future model development and tuning.

Measurement of the Soft-Drop Jet Mass in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

Jet substructure observables have significantly extended the search program for physics beyond the standard model at the Large Hadron Collider. The state-of-the-art tools have been motivated by theoretical calculations, but there has never been a direct comparison between data and calculations of jet substructure observables that are accurate beyond leading-logarithm approximation. Such observables are significant not only for probing the collinear regime of QCD that is largely unexplored at a hadron collider, but also for improving the understanding of jet substructure properties that are used in many studies at the Large Hadron Collider. This Letter documents a measurement of the first jet substructure quantity at a hadron collider to be calculated at next-to-next-to-leading-logarithm accuracy. The normalized, differential cross section is measured as a function of log_{10}ρ^{2}, where ρ is the ratio of the soft-drop mass to the ungroomed jet transverse momentum. This quantity is measured in dijet events from 32.9  fb^{-1} of sqrt[s]=13  TeV proton-proton collisions recorded by the ATLAS detector. The data are unfolded to correct for detector effects and compared to precise QCD calculations and leading-logarithm particle-level Monte Carlo simulations.

Search for Low-Mass Dijet Resonances Using Trigger-Level Jets with the ATLAS Detector in pp Collisions at sqrt[s]=13 TeV

Searches for dijet resonances with sub-TeV masses using the ATLAS detector at the Large Hadron Collider can be statistically limited by the bandwidth available to inclusive single-jet triggers, whose data-collection rates at low transverse momentum are much lower than the rate from standard model multijet production. This Letter describes a new search for dijet resonances where this limitation is overcome by recording only the event information calculated by the jet trigger algorithms, thereby allowing much higher event rates with reduced storage needs. The search targets low-mass dijet resonances in the range 450-1800 GeV. The analyzed data set has an integrated luminosity of up to 29.3  fb^{-1} and was recorded at a center-of-mass energy of 13 TeV. No excesses are found; limits are set on Gaussian-shaped contributions to the dijet mass distribution from new particles and on a model of dark-matter particles with axial-vector couplings to quarks.

Search for the Decay of the Higgs Boson to Charm Quarks with the ATLAS Experiment

A direct search for the standard model Higgs boson decaying to a pair of charm quarks is presented. Associated production of the Higgs and Z bosons, in the decay mode ZH→ℓ^{+}ℓ^{-}cc[over ¯] is studied. A data set with an integrated luminosity of 36.1  fb^{-1} of pp collisions at sqrt[s]=13TeV recorded by the ATLAS experiment at the LHC is used. The H→cc[over ¯] signature is identified using charm-tagging algorithms. The observed (expected) upper limit on σ(pp→ZH)×B(H→cc[over ¯]) is 2.7 (3.9_{-1.1}^{+2.1}) pb at the 95% confidence level for a Higgs boson mass of 125 GeV, while the standard model value is 26 fb.

Search for a Structure in the B_{s}^{0}π^{±} Invariant Mass Spectrum with the ATLAS Experiment

A search for the narrow structure, X(5568), reported by the D0 Collaboration in the decay sequence X→B_{s}^{0}π^{±}, B_{s}^{0}→J/ψϕ, is presented. The analysis is based on a data sample recorded with the ATLAS detector at the LHC corresponding to 4.9  fb^{-1} of pp collisions at 7 TeV and 19.5  fb^{-1} at 8 TeV. No significant signal was found. Upper limits on the number of signal events, with properties corresponding to those reported by D0, and on the X production rate relative to B_{s}^{0} mesons, ρ_{X}, were determined at 95% confidence level. The results are N(X)<382 and ρ_{X}<0.015 for B_{s}^{0} mesons with transverse momenta above 10 GeV, and N(X)<356 and ρ_{X}<0.016 for transverse momenta above 15 GeV. Limits are also set for potential B_{s}^{0}π^{±} resonances in the mass range 5550 to 5700 MeV.

Search for High-Mass Resonances Decaying to τν in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

A search for high-mass resonances decaying to τν using proton-proton collisions at sqrt[s]=13  TeV produced by the Large Hadron Collider is presented. Only τ-lepton decays with hadrons in the final state are considered. The data were recorded with the ATLAS detector and correspond to an integrated luminosity of 36.1  fb^{-1}. No statistically significant excess above the standard model expectation is observed; model-independent upper limits are set on the visible τν production cross section. Heavy W^{'} bosons with masses less than 3.7 TeV in the sequential standard model and masses less than 2.2-3.8 TeV depending on the coupling in the nonuniversal G(221) model are excluded at the 95% credibility level.

Dog and Cat Allergies: Current State of Diagnostic Approaches and Challenges

Allergies to dogs and cats affect 10%-20% of the population worldwide and is a growing public health concern as these rates increase. Given the prevalence of detectable dog and cat allergens even in households without pets, there is a critical need to accurately diagnose and treat patients to reduce morbidity and mortality from exposure. The ability to diagnose cat sensitization is good, in contrast to dogs. Component resolved diagnostics of sensitization to individual allergenic proteins will dramatically improve diagnosis. This review focuses on the current state of knowledge regarding allergies to dogs and cats, recent advances, therapies such as subcutaneous immunotherapy, and discusses important areas to improve diagnosis and therapy.

Search for Heavy Higgs Bosons A/H Decaying to a Top Quark Pair in pp Collisions at sqrt[s]=8 TeV with the ATLAS Detector

A search for heavy pseudoscalar (A) and scalar (H) Higgs bosons decaying into a top quark pair (tt[over ¯]) has been performed with 20.3  fb^{-1} of proton-proton collision data collected by the ATLAS experiment at the Large Hadron Collider at a center-of-mass energy sqrt[s]=8  TeV. Interference effects between the signal process and standard model tt[over ¯] production, which are expected to distort the signal shape from a single peak to a peak-dip structure, are taken into account. No significant deviation from the standard model prediction is observed in the tt[over ¯] invariant mass spectrum in final states with an electron or muon, large missing transverse momentum, and at least four jets. The results are interpreted within the context of a type-II two-Higgs-doublet model. Exclusion limits on the signal strength are derived as a function of the mass m_{A/H} and the ratio of the vacuum expectation values of the two Higgs fields, tanβ, for m_{A/H}>500  GeV.

Search for Dark Matter Produced in Association with a Higgs Boson Decaying to bb[over ¯] Using 36 fb^{-1} of pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

Several extensions of the standard model predict associated production of dark-matter particles with a Higgs boson. Such processes are searched for in final states with missing transverse momentum and a Higgs boson decaying to a bb[over ¯] pair with the ATLAS detector using 36.1  fb^{-1} of pp collisions at a center-of-mass energy of 13 TeV at the LHC. The observed data are in agreement with the standard model predictions and limits are placed on the associated production of dark-matter particles and a Higgs boson.

Search for the Dimuon Decay of the Higgs Boson in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

A search for the dimuon decay of the Higgs boson was performed using data corresponding to an integrated luminosity of 36.1  fb^{-1} collected with the ATLAS detector in pp collisions at sqrt[s]=13  TeV at the Large Hadron Collider. No significant excess is observed above the expected background. The observed (expected) upper limit on the cross section times branching ratio is 3.0 (3.1) times the Standard Model prediction at the 95% confidence level for a Higgs boson mass of 125 GeV. When combined with the pp collision data at sqrt[s]=7  TeV and sqrt[s]=8  TeV, the observed (expected) upper limit is 2.8 (2.9) times the Standard Model prediction.

Search for triboson [Formula: see text] production in pp collisions at [Formula: see text] [Formula: see text] with the ATLAS detector

This paper reports a search for triboson [Formula: see text] production in two decay channels ([Formula: see text] and [Formula: see text] with [Formula: see text]) in proton-proton collision data corresponding to an integrated luminosity of 20.3 [Formula: see text] at a centre-of-mass energy of 8 [Formula: see text] with the ATLAS detector at the Large Hadron Collider. Events with exactly three charged leptons, or two leptons with the same electric charge in association with two jets, are selected. The total number of events observed in data is consistent with the Standard Model (SM) predictions. The observed 95% confidence level upper limit on the SM [Formula: see text] production cross section is found to be 730 fb with an expected limit of 560 fb in the absence of SM [Formula: see text] production. Limits are also set on WWWW anomalous quartic gauge couplings.

Measurement of the Inelastic Proton-Proton Cross Section at sqrt[s]=13 TeV with the ATLAS Detector at the LHC

This Letter presents a measurement of the inelastic proton-proton cross section using 60  μb^{-1} of pp collisions at a center-of-mass energy sqrt[s] of 13 TeV with the ATLAS detector at the LHC. Inelastic interactions are selected using rings of plastic scintillators in the forward region (2.07<|η|<3.86) of the detector. A cross section of 68.1±1.4  mb is measured in the fiducial region ξ=M_{X}^{2}/s>10^{-6}, where M_{X} is the larger invariant mass of the two hadronic systems separated by the largest rapidity gap in the event. In this ξ range the scintillators are highly efficient. For diffractive events this corresponds to cases where at least one proton dissociates to a system with M_{X}>13  GeV. The measured cross section is compared with a range of theoretical predictions. When extrapolated to the full phase space, a cross section of 78.1±2.9  mb is measured, consistent with the inelastic cross section increasing with center-of-mass energy.

Search for Higgs and Z Boson Decays to ϕγ with the ATLAS Detector

A search for the decays of the Higgs and Z bosons to a ϕ meson and a photon is performed with a pp collision data sample corresponding to an integrated luminosity of 2.7  fb^{-1} collected at sqrt[s]=13  TeV with the ATLAS detector at the LHC. No significant excess of events is observed above the background, and 95% confidence level upper limits on the branching fractions of the Higgs and Z boson decays to ϕγ of 1.4×10^{-3} and 8.3×10^{-6}, respectively, are obtained.

Measurement of the ZZ Production Cross Section in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

The ZZ production cross section in proton-proton collisions at 13 TeV center-of-mass energy is measured using 3.2  fb^{-1} of data recorded with the ATLAS detector at the Large Hadron Collider. The considered Z boson candidates decay to an electron or muon pair of mass 66-116 GeV. The cross section is measured in a fiducial phase space reflecting the detector acceptance. It is also extrapolated to a total phase space for Z bosons in the same mass range and of all decay modes, giving 16.7_{-2.0}^{+2.2}(stat)+0.9/-0.7(syst)+1.0/-0.7(lumi)  pb. The results agree with standard model predictions.

Primary Immunodeficiency Masquerading as Allergic Disease

Primary immune deficiencies (PIDs) are an uncommon heterogeneous group of diseases that result from fundamental defects in the proteins and cells that enable specific immune responses. Common allergic reactions (eczema, allergic rhinitis, asthma, and food allergies) are exaggerated immune responses that may be manifestations of an underlying PID. Early diagnosis and treatment has significant bearing on outcome. Immune suppression with systemic corticosteroids in these immune compromised individuals can lead to life threatening dissemination of infections.

Transnasal penetrating intracranial injury with a chopstick

We report the first case of a transnasal penetrating intracranial injury in Hong Kong by a chopstick. A 49-year-old man attempted suicide by inserting a wooden chopstick into his left nose and then pulled it out. The chopstick caused a transnasal penetrating brain injury, confirmed by contrast magnetic resonance imaging of the brain. He was managed conservatively. Later he developed meningitis without a brain abscess and was prescribed antibiotics for 6 weeks. He enjoyed a good neurological recovery. This case illustrates that clinician should have a high index of suspicion for penetrating intracranial injury due to a nasally inserted foreign body, even though it had already been removed. In such cases moreover, brain magnetic resonance imaging is the imaging modality of choice, as it can delineate the path of penetration far better than plain computed tomography.

Malignancies after kidney transplantation: Hong Kong renal registry

Manystudies have shown that kidney transplant recipients have a higher incidence of cancers when compared with general population. However, most data on the posttransplant malignancies (PTM) are derived from Western literature and large population-based studies are rare. There is also lack of information about the posttransplant cancer-specific mortality rate. We conducted a population-based study of 4895 kidney transplants between 1972 and 2011, with data from the Hong Kong Renal Registry. Patterns of cancer incidence and mortality in our kidney transplant recipients were compared with those of the general population using standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) respectively. With 40 246 person-years of follow-up, 299 PTM was diagnosed. The SIR of all cancers was 2.94 (female 3.58 and male 2.58). Non-Hodgkin lymphoma (NHL), kidney, and bladder cancers had the highest SIRs. The overall SMR was 2.3 (female 3.4 and male 1.7) and the highest SMR was NHL. The patterns of PTM differ among countries. Increases in cancer incidence can now translate into similar increases in cancer mortality. NHL is important in our kidney transplant recipients. Strategies in cancer screening in selected patient groups are needed to improve transplant outcomes.

BAG3-related myofibrillar myopathy in a Chinese family

In contrast to the usual slow disease progression in myofibrillar myopathies, patients with Bag3opathy often have a rapidly progressive and more severe phenotype with a worse prognosis. We describe a Chinese patient, born to non-consanguineous parents, who first presented at age 6 with clumsy walking and difficult climbing staircase. With a history of restrictive lung disease previously diagnosed as asthma, she progressed rapidly with proximal myopathy, rigid spine and bilateral tightening of the Achilles tendons requiring surgical elongation. Hypertrophic cardiomyopathy with restrictive physiology was shown by echocardiogram. Moreover, prolonged QT interval was also noted in the patient. Family history was unremarkable yet her father was incidentally found to have prolonged QT interval. Mutation analysis with genomic DNA of the proband showed heterozygous de novo known mutation c.626C>T (p.Pro209Leu) and a germline variation c.772C>T (p.Arg258Trp) in BAG3. Her father was found to be a carrier of c.772C>T. Muscle biopsy findings were suggestive of myofibrillar myopathy on light microscopy and ultrastructural studies. To our knowledge, this is the first Chinese case of Bag3opathy so far reported.

The analgesic efficacy of continuous wound instillation with ropivacaine after open hepatic surgery

The analgesic efficacy of continuous local anaesthetic wound instillation after open hepatic surgery was evaluated. Forty-eight patients scheduled for elective liver surgery were assigned to receive either ropivacaine 0.25% or saline infusion at 4 ml.h(-1) for 68 h via two multi-orifice indwelling catheters placed within the musculo-fascial layer before skin closure; plasma ropivacaine concentrations were measured during the infusion. Supplemental analgesia was provided by intravenous patient-controlled analgesia morphine. Patients in the ropivacaine group had decreased mean (SD) total morphine consumption (58 (30) mg vs 86 (44) mg, p = 0.01) and less pain at rest as well as after spirometry at 4, 12, 24, 48 and 72 h postoperatively (p < 0.01). Forced vital capacity was reduced postoperatively in both groups, but the reduction was greater in the saline group at 12 and 24 h (p = 0.03). The mean plasma concentration of ropivacaine increased to 2.05 (0.78) μg.ml(-1) at the point when the infusion was terminated.