Commissioning of a solid tank design for fan-beam optical CT based 3D radiation dosimetry

Objective.Optical computed tomography (CT) is one of the leading modalities for imaging gel dosimeters used in the verification of complex radiotherapy treatments. In previous work, a novel fan-beam optical CT scanner design was proposed that could significantly reduce the volume of the refractive index baths that are commonly found in optical CT systems. Here, the proposed scanner has been manufactured and commissioned.Approach.Image reconstruction is performed through algebraic reconstruction technique and iterated using the fast iterative shrinkage-thresholding algorithm (FISTA) algorithm. Ray tracing for algebraic reconstruction was performed using an in-house developed ray tracing simulator. A set of Sylgard® 184 phantoms were created to commission spatial resolution, geometric deformity, contrast-to-noise ratio (CNR), and scan settings.Main Results.The scanner is capable of a 0.929 mm-1spatial resolution, observed at 200 iterations, although the spatial resolution is highly dependent on the number of iterations. The geometric distortion, measured by scanning a needle phantom with the prototype scanner as well as a conventional x-ray CT was found to be within <0.25 mm. The CNR was found to peak between 65 and 190 occurring between 50 and 100 iterations and was highly dependent on the region chosen for background noise calculation. The proposed scanner is capable of scanning and reading out slices in less than 1 min per slice.Significance.This work displays the viability of a fan-beam optical CT scanner with minimal index matching using ray-traced algebraic reconstruction.

A266 DIET-BASED THERAPIES FOR INTESTINAL DYSFUNCTION INDUCED BY CLOSTRIDIOIDES DIFFICILE INFECTION

Background

Chronic gut dysfunction occurs in up to 25% of patients following antibiotic-treated C. difficile infection (CDI). We developed a humanized mouse model in which germ free mice colonized with microbiota from patients with severe constipation post-CDI developed slow colonic transit, as a result of damage to the Interstitial Cells of Cajal (ICC) network by pro-inflammatory macrophages. Colonic transit, immune activation and the ICC network normalized after fecal microbiota transplantation using samples from healthy mice, as well after treatment with psyllium fiber. Here we explored the long-term effects of psyllium and evaluated the therapeutic potential of pectin and quercetin in this model.

Purpose

1) To investigate the time course of the beneficial effect of psyllium on colonic motility.

2) To explore possible therapeutic properties of flavonoids and pectin.

Method

Germ-free mice were colonized with microbiota from the post-CDI (PCDI) patient or healthy controls (HC). After 3 weeks, the mice were fed for 4-5 weeks with a control diet or diets with 15% psyllium (PSY), 10% pectin (PCT) or 0.05% quercetin (QCT). To evaluate time course of PSY on motility, control diet was administered for 3-weeks following PSY treatment. The bead expulsion test was used to assess colonic motility. Stool samples were collected for microbial profiling, and short and branched-chain fatty acids (SCFA/BCFA) analysis. Macrophages morphology and counts, and ICC network structure were evaluated by immunohistochemistry.

Result(s)

Compared to HC microbiota, colonization with post-CDI microbiota induced slow colonic transit in recipient mice, and this was normalized by PSY (n=13; p=0.02). The benefit of PSY was transient as colonic transit slowed following discontinuation of PSY (p=0.001). The changes in colonic transit were paralleled by switch in macrophages phenotype and damage to the ICC network. Additionally, discontinuation of PSY resulted in a return of microbial diversity (p< 0.001), SCFA/BCFA levels (acetic and propionic acid/ iso-butyric and valeric acid) and specific bacterial species abundances, to values seen in untreated mice colonized with post-CDI microbiota. Microbial analysis predicted potential pathways involved in macrophage polarization, including the synthesis of SCFA/BCFA, degradation of inositol and production of acetylglucosamine.

PCT also normalized slow intestinal transit in mice colonized with post-CDI microbiota (p=0.003), restored phenotype of infiltrating macrophages, and improved the structural integrity of the ICC network. In contrast, QCT failed to improve gut dysfunction in PCDI mice.

Conclusion(s)

Our results suggest that the beneficial effects of psyllium in this model are transient. Dietary pectin, but not quercetin, may also serve as a novel treatment strategy to restore colonic motility and immune homeostasis in humans with severe constipation post-CDI.

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Other

Please indicate your source of funding;

W. Garfield Weston Foundation

Disclosure of Interest

None Declared

A30 EPITHELIAL FUNCTION OF THE CIRCADIAN CLOCK GENE, BMAL1, IS NECESSARY FOR COLONIC REGENERATION

Background

The circadian clock is a self-sustained molecular oscillator which drives 24-hour physiological rhythms. It consists of the genes Bmal1 and Clock that positively regulate Cry and Per, their negative regulators, resulting in a 24-hour transcription/translation feedback loop. Shift work, which causes disruptions to 24-hour physiological rhythms, has been shown to lead to an increased incidence of inflammatory bowel disease (IBD). We have previously established that mice lacking the non-redundant circadian regulator, Bmal1, exhibit more severe colitis compared to controls.

Purpose

This study aims to investigate the epithelial function of Bmal1 in colonic regeneration during colitis.

Method

In order to assess the cell-specific role of the clock, we tested the regenerative effects of Bmal1 in intestinal epithelial tissue using Vil^+/+;Bmal1^flox/flox (control) and Vil^Cre/+;Bmal1^flox/flox (conditional mutant) mice. Dextran Sulfate Sodium (DSS) was applied to induce acute colitis. Disease progression was evaluated during colitis and during recovery upon removal of DSS treatment. We hypothesized that the absence of a functional circadian clock disrupts effective proliferation and regeneration of intestinal epithelial cells during colitis remission.

Result(s)

Vil^+/+;Bmal1^flox/flox control and Vil^Cre/+;Bmal1^flox/flox conditional mutant mice exhibit no significant differences in disease severity or tissue histopathology during colitis. However, after the removal of DSS, Vil^Cre/+;Bmal1^flox/flox conditional mutants show increased total lesions and overall inflammation, decreased crypt density as well as a higher propensity of hyperplastic crypts in the tissue. Regenerative ability of the colon is decreased in conditional mutants: phosphorylated-histone H3 and Ki67 show persistent increases in mitosis and overall proliferation near ulcerated lesions. This suggests that, while controls complete the regenerative response, conditional mutants fail to recover from colitis and show inefficient regeneration when Bmal1 is disrupted in intestinal epithelial cells.

Conclusion(s)

Our results support a critical role for Bmal1 in intestinal epithelial cells during post-colitis regeneration and recovery.

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CIHR, Other

Please indicate your source of funding;

OGS, Crohn's & Colitis Canada

Disclosure of Interest

None Declared

A62 IDENTIFICATION OF SPECIFIC COLONIC DEEP MUSCLE LAYER MACROPHAGES SUBSETS BY THE CD64 (FCΓRI) MARKER

Background

Although intestinal muscle layer macrophages have been suggested to play an important role in the colonic transit by interacting with the myenteric plexus neurons, they have not been fully characterized. CD64 (FcγRI) is one of the most generally used markers for intestinal macrophages, but several studies suggested existence of a subpopulation of macrophages that lack CD64. In addition, the muscle layer macrophage subsets currently identified are considered to be same in the small intestine and colon, although this has not been formally tested.

Purpose

In this study, we aim to identify and characterize the subsets of muscle layer macrophages by CD64 marker. We hypothesize that colon specific CD64-macrophages have a different role from CD64+ conventional macrophages.

Method

The muscle layers of small intestine (ileum) and colon were separated from SPF mice and cells from each muscle layer were analyzed by flow cytometry and fluorescent staining. The muscle layer macrophages were gated withCD45+, F4/80+, CD11b+ and Ly6c-, and analyzed with CD64 and MHCⅡmarkers by flow cytometry. In additional experiments, fluorescent staining with CD64 and F4/80 was assessed in whole-mount tissue of the separated muscle layer.

Result(s)

Within the macrophage population from the colon muscle layer, we found not only CD64+ cells, a conventional marker of macrophage, but also CD64- cell population (CD45+, F4/80+, CD11b+, Ly6c-). However, in the small intestine, this CD64- cell population was barely detectable. In addition, colonic CD64+ cells had mostly high expression of MHCⅡ marker, while CD64- cells had low expression of MHCⅡ. A similar pattern was found when we examined intestinal and colonic tissues by immunofluorescent staining.

Conclusion(s)

We identified a colon-specific CD64- subset of macrophage in muscle layer. Additional experiments are needed to characterize their immunomodulatory properties.

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None

Disclosure of Interest

None Declared

CLIINICAL PRACTICE

A45 FIBER-FREE DIET REDUCES BACTEROIDES ABUNDANCE AND PREVENTS MUCUS DEGRADATION IN MICE COLONIZED WITH MICROBIOTA FROM PATIENTS WITH GENERALIZED ANXIETY DISORDER

Background

Generalized anxiety disorder (GAD) is a debilitating condition with a lifetime prevalence of 4-7% worldwide. We have previously found that compared to healthy controls, GAD patients had lower reported fiber intake, increased gastrointestinal symptoms; and enrichment of Bacteroides genus as well as carbohydrate metabolism pathways (as determined by PICRUSt2, correlated to Bacteroides abundance). Bacteroides are known for its ability to degrade a wide variety of host polysaccharides, such as the intestinal mucus, which could lead to local and systemic inflammation. In this regard, GAD patients had higher C-reactive protein (CRP) compared to healthy controls (p=0.049).

Purpose

To investigate whether a fiber-free diet could decrease Bacteroides abundance and prevent damage of the mucus layer reducing anxiety-behavior in mice with GAD microbiota.

Method

Two germ-free NIH Swiss mouse breeding pairs were colonized with GAD microbiota using patients’ stool samples and kept on either fiber-free or 10 % inulin (fiber) diet. Offspring were weaned at week 3 and psychometric tests were performed at 10 weeks of age. After sacrifice, samples for histology (mucus layer thickness determination), blood (CRP ELISA determination) and stool (Illumina 16S rRNA gene sequencing) were collected. The microbiota data was analyzed following the pipelines of dada2 and by mean comparisons, correlation, AncomBC using R software (v.1.2.1335). Multiple comparison results were corrected allowing 5% of FDR.

Result(s)

Beta diversity analysis showed that parent and offspring’s (n=24 fiber-supplemented and n=14 fiber-free groups) microbiota was similar to the GAD donor. The most differentially abundant bacterial taxon was Bacteroides uniformis, which was decreased in the fiber-free group (p.adj= 0.003). Furthermore, fiber-free diet reduced the overall Bacteroides abundance by half compared to the donor and fiber-supplemented mice group. This led to a thickening (p.adj=0.027) of the mucus layer, increasing from 30 µm (fiber-supplemented diet) to 60 µm in the fiber-free diet group. B. uniformis was negatively correlated to the mucus layer thickness (R= -0.81; p.adj=0.26), although not statistically significant, likely due to a low n number (n=4). We only found a statistical trend for higher CRP levels and anxiety-like behavior in the fiber-supplemented group. This might be because fiber supplementation has several beneficial effects that can counteract the proposed increase in anxiety-like behavior fromBacteroides. Despite that, we found a significant correlation between B. uniformis and time mice spent in the dark (indicative of anxiety-like behavior) in the light preference test.

Conclusion(s)

Our data suggests that Bacteroides abundance, specifically Bacteroides uniformis, contributes to the degradation of the mucus layer and potentially triggers low grade gut inflammation and anxiety-like behavior.

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CIHR

Disclosure of Interest

None Declared

A19 INVESTIGATING MECHANISMS THAT DRIVE SYMPTOMS IN IRRITABLE BOWEL SYNDROME PATIENTS WITH PERCEIVED GLUTEN SENSITIVITY

Background

Patients with irritable bowel syndrome (IBS) often report gastrointestinal symptoms after consuming wheat and gluten-containing foods. It is, however, unclear whether gluten is the main driver of symptoms, as other immunogenic peptides, such as amylase trypsin inhibitors (ATI), poorly digestible fiber (inulin, part of FODMAP) or even the nocebo effect may contribute to symptom generation.

Purpose

To evaluate whether whole wheat containing ATIs and/or purified gluten trigger gastrointestinal symptoms compared to nocebo in patients with IBS adopting a gluten-free diet (GFD).

Method

We conducted a double-blind, randomized, nocebo-controlled crossover study in adult IBS patients (Rome IV criteria) who previously perceived improvement of symptoms while on a GFD. The study was approved by the Hamilton Research Ethics Board (HiREB #4367). Participants were challenged for 7 days with whole wheat, purified gluten, and nocebo (gluten-free flour) added to low FODMAP cereal bars. Each challenge was followed by a 2-week washout. Patients remained on a GFD throughout the study, diet adherence was assessed by a dietitian and stool gluten immunogenic peptides (GIP; Biomedal). Gastrointestinal symptoms were assessed by IBS Symptom Severity Score (IBS-SSS); increases >50 points were considered a significant worsening. Blood samples were collected to assess immune markers and celiac (HLA DQ2, DQ8 and DQ7) genotype. Statistical comparisons used Friedman rank sum tests and paired Wilcoxon signed rank tests.

Result(s)

Twenty-nine IBS patients (27 female, mean age=42, SD=14.4 years) were enrolled in the study; 1 dropped. Similar proportions of patients reacted symptomatically to wheat (11/28, 39.3%), gluten (10/28, 35.7%) and nocebo (8/28, 28.6%). However, there was an overall significant increase in IBS symptoms after wheat (+39.5 on IBS-SSS; p=0.030) but not after gluten (+27.5; p=0.051) or nocebo (+5.5; p=0.236) challenges (Figure 1). Ten participants experienced IBS-SSS symptoms >175 during baseline and did not worsen further during the challenges. TNF-α trended from 1.35 pg/mL after nocebo, 1.47 pg/mL after gluten, to 1.57 pg/mL after wheat; however, this was not significant. Baseline adherence to a GFD was rated excellent in 19 (68%), good in 6 (21%), and fair in 3 (11%) participants. Median GIP levels were 0.584 µg/g after wheat, 0.432 µg/g after gluten, and 0.095 µg/g after nocebo; p<0.0001. Celiac predisposition genes were present in 19/24 participants (10/24 had DQ2, 2/24 had DQ8, and 9/24 had DQ7).

Image

Conclusion(s)

IBS patients self-reporting wheat or gluten sensitivity had worse symptoms after whole wheat, but not purified gluten or nocebo challenge. However, similar proportions of IBS patients reacted to each intervention, suggesting that central mechanisms play an important role in symptom genesis. Furthermore, one third of patients had high symptoms during a GFD and did not react to wheat or gluten challenges, suggesting that other mechanisms are driving their IBS symptoms.

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CIHR, Other

Please indicate your source of funding;

Society for the Study of Celiac Disease (Nestle); Canadian Digestive Health Foundation

Disclosure of Interest

None Declared

A265 TEMPORAL DYNAMICS OF SYMPTOMS AND GUT MICROBIOTA IN EPISODES OF IRRITABLE BOWEL SYNDROME

Background

Irritable bowel syndrome (IBS) is a disorder of gut-brain axis that manifests with chronic abdominal pain, altered bowel habits, and frequent psychiatric comorbidities. Despite mounting evidence showing gut microbiota composition and associated metabolites being altered in IBS, the mechanisms by which they drive the symptoms are unclear. We have previously shown that several IBS symptoms co-occur, that their severity vary among IBS subtypes (10.1093/jcag/gwab049.050), and that several bacterial taxa are differentially modulated during periods of symptom flares and remission. Here we investigate whether the changes in gut microbiome and bacterial metabolites are linked to symptom occurrence and severity.

Purpose

To investigate temporal associations of IBS symptoms with gut microbiota profiles and metabolites.

Method

16S rRNA gene sequencing was performed on stool samples of 28 IBS patients (IBS-D n=20, IBS-C n=8) and 10 healthy controls (HC), collected weekly over a period of 25 weeks, during which gut and mood symptoms were recorded (total of 950 samples). Correlations between principal ordinates obtained from symptom scores and microbiota beta diversity were studied using Procrustes analysis in R. Metabolomics was performed by Mass Spectrometry and analysed using MetaboAnalyst 5.0. Statistical significance was set at p<0.05.

Result(s)

Significant correlation was found between the symptom scores and microbiota beta diversity ordinates over time in 7 patients (5 IBS-D and 2 IBS-C subjects) out of 28 IBS patients. Metabolomics performed on samples selected based on Procrustes analysis and symptom severity scores of individual subjects showed that several pathways are altered in IBS patients (both subtypes) compared to HC, including primary bile acid biosynthesis, beta alanine metabolism, pyrimidine and histidine metabolism. Furthermore, during symptom flares, ornithine, citrulline and gluconic acid vary in IBS-D, while amino acids cysteine, methionine, threonine, and glycine vary in IBS-C subjects.

Conclusion(s)

Our results suggest that IBS symptoms and changes in gut microbiota composition and metabolites must be studied in conjunction, in order to understand the mechanisms underlying IBS pathophysiology. We found that same pathways are altered in IBS subjects irrespective of their subtype, suggestive of a basal metabolic shift in IBS patients. This shift may make them sensitive to further gut microbial modulation of carbohydrate and protein metabolism in IBS-D and IBS-C subjects, respectively, leading to symptom flares. Further analyses are needed to investigate these metabolites and associated bacteria, as they can help identifying subsets of patients with specific disease mechanisms. This will be a steppingstone in moving away from symptom-based subtyping towards mechanism-based grouping and developing effective treatment strategies accordingly.

Disclosure of Interest

None Declared

A53 FECAL BIOACTIVE PHOSPHOLIPIDS AS TRIGGERS OF INTESTINAL HYPERSENSITIVITY IN IRRITABLE BOWEL SYNDROME

Background

Chronic abdominal pain is the most common complaint of patients with gastrointestinal disorders. Its treatment is of limited efficacy as the pathophysiology is poorly understood. The gut microbiome has been shown to affect host physiology, including the neural system function, and growing evidence suggests that it plays an important role in pain perception. Gut microbiota produces a large variety of molecules that can regulate pain perception, such as histamine or bioactive lipids. Phospholipid mediators (PLM) are signaling molecules linked to neurogenic pain as by-products of inflammatory processes in mammals. But it is unknown whether bacteria can produce PLM and whether they play any role in visceral hyperalgesia.

Purpose

To investigate whether PLM are present in stool of patients with chronic abdominal pain, and whether they have potential to induce visceral hypersensitivity.

Method

Stool samples from 27 patients with irritable bowel syndrome (IBS) were collected both during periods of severe and minimal/no pain. The fecal concentration of two PLM (lipid A and lipid B) was determined by ELISA. The passage of lipid A and lipid B through the intestinal barrier was determined ex vivo using Ussing chambers and in vivo by their intracolonic instillation, and their levels assessed in the serosal compartment and the serum, respectively, by ELISA. We used primary cultures of sensory neurons from the dorsal root ganglia (DRG) of conventional mice (SPF) to study the neuronal activation in vitro. Calcium mobilization in DRG sensory neurons was measured by an inverted fluorescence microscope using a fluorescent probe Fluo-4 (1mM) after stimulation with different concentration of lipid A or lipid B. Visceral sensitivity in vivo after intracolonic instillation of combined lipids A and B was evaluated by colorectal distension.

Result(s)

The concentration of lipid A (p=0.001) and lipid B (p=0.002) in stool was significantly higher in IBS patients when experiencing severe abdominal pain compared to periods of minimal pain. The concentration of lipid A (p=0.03; p=0.07) and lipid B (p=0.018; p=0.018) in the serosal compartment and in the serum, respectively, was higher compared to the control condition. The percentage of neurons responding to lipid A or lipid B was significantly higher compared to the control condition, at all tested concentrations. Finally, combined lipid A and lipid B induced visceral hypersensitivity within 10 minutes (p=0.0433) and 90 minutes (p=0.0020) after intracolonic instillation.

Conclusion(s)

Our data suggest that PLM can be found in stool of patients with abdominal pain, that they cross the colonic barrier and increase visceral sensitivity. Further studies are needed to ascertain whether gut bacteria produce these PLM and investigate the precise mechanisms by which PLM induce hyperalgesia.

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CIHR, Other

Please indicate your source of funding;

Weston Family Foundation

Disclosure of Interest

None Declared

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

User Characteristics of Unique Men's Health Website

Introduction

Covid-19 has helped drive all forms of medicine away from traditional brick and mortar medical interactions. Given the availability of online services to obtain treatments for ED, we developed a website to facilitate patient education, triage and men's health appointment scheduling.

Objective

We sought to assess characteristics of men who utilized a novel website to treat their ED.

Methods

We report on 50 patients who ultimately booked and attended appointments (video or in person) for erectile dysfunction. Patients found our website through our institution's main informational ED pages or through youtube links from our men's health video playlist library. Patients create an institutional account and are then asked a series of MD created questions designed to streamline patient triage and complete the majority of chart documentation ahead of the appointment. Patients are then sent videos relevant to their condition and future appointment options.

Results

2300 users investigated the ED portion of the website with 1.8% of patients ultimately following through with an appointment. 13% of patients who explored the ED portion of the site created a user account that allows a questionnaire to be taken. 90% of men who began the ED questionnaire completed with a mean time of 11 minutes. 52% of men offered an appointment based on their responses completed the patient scheduling form. 71% of traffic was on mobile devices with 29% on desktop/tablet. Site use by time of day is shown in figure 1. Mean age of patients was 53. 92% of patients had ED that occurred > 6 months. Mean SHIM score was 8.2 (IQR 4-12). 80% of participants had both desire and opportunity for sexual activity, 20% did not meet both criteria and thus SHIM scores were less valid for these men. Of the users 28% had never tried pde5s, 32% had partial success with pde5s, 24% could not tolerate or afford pde5s and 42% had unsatisfactory results with pde5s. PDE5 naïve patients were seen by an internal medicine MD specializing in men's health, 10 were seen by surgeons as they requested IPPs and the rest were seen by a combination of men's health APPS and urology attendings for second line treatments and penile doppler. Interestingly, 66% of men were interested in undergoing penile doppler to better understand the etiology of their ED. Hypertension (40%) and diabetes (22%) were the most common medical comorbidities. 36% of the cohort had a strong family history of cardiac disease.

Conclusions

Men with ED can be effectively triaged through a website application. Most men with pde5 refractory ED wish to pursue penile doppler. The majority of patients seen had watched educational video material ahead of time, facilitating a more sophisticated and streamlined patient interaction.

Disclosure

No

HIV cure research in the time of COVID-19 - Antiretroviral therapy treatment interruption trials: A discussion paper

This discussion paper addresses the safety of HIV cure studies, particularly those involving stopping antiretroviral therapy, known as an analytic treatment interruption (ATI) in the context of the SARS-CoV-2 pandemic. More than 30 studies listed on ClinicalTrials.gov include an ATI and many others were planned to begin over the next 12 months but most were halted due to the COVID-19 pandemic. We consider the ethics, risks and practical considerations to be taken into account before re-opening HIV cure clinical trials, noting the specific risks of ATI in the context of circulating SARS-CoV-2.

12 Artificial insemination and embryo transfer results in ewes during a long daylength period

Sheep are polyestrous, short-day breeders (∼11h of daylength), and exhibit oestrus approximately every 16–17 days during the breeding season, usually in late September to late December in the Northern Hemisphere. Progressive sheep producers often use assisted reproductive techniques such as laparoscopic AI and ovarian hyper-stimulation, embryo collection, and embryo transfer (ET) to increase genetic gain, and strive to have early December lambs to target specific show markets, which dictates AI or ET during the late summer. This field trial compared pregnancy rates following AI or ET in July and August (∼14h of daylength) in southwest Virginia (36–38′12″ N). Ewes (AI, n=83; ET recipients, n=33) were synchronized using a modified Ovsynch protocol involving intravaginal progesterone implants for 14 days, prostaglandin F2α (intramuscular) 48h before expected oestrus, and PG600 (IM) and gonadotrophin-releasing hormone (intramuscular) 52 to 54h and 16h before AI, respectively. Ewes were subjected to AI (frozen/thawed semen) regardless of whether they displayed signs of oestrus, and ewes selected as embryo recipients were subjected to a similar protocol but instead received 1 or 2 embryos (based upon the number of viable embryos produced per embryo donor) 6 days following the AI of the embryo donors. Ovarian hyper-stimulation of the embryo donors (n=13) was enabled by twice-daily FSH injections [totalling 350–455IU of Folltropin V (10–13mL)] for the 4 days before AI. Six days following AI, embryos were recovered surgically from the embryo donors (n=13) and yielded an average (±s.e.m.) of 6.6±1.2 total ova, 4.7±1.1 transferable quality embryos, and 1.9±0.8 unfertilized ova per collection. Pregnancy was detected using transrectal ultrasonography at ∼30 days of gestation and the pregnancy rates were analysed using Chi-squared. There was a tendency (P=0.092) for more pregnancies to be established following ET (22/33; 66%) compared with AI (41/83; 49%). There was no statistical relationship between AI ewes or ET recipient ewes that became pregnant relative to whether they displayed signs of oestrus or not. Embryo transfer was a more successful approach to produce pregnancies in ewes compared with AI during long daylength periods in this field trial. Further, ova from hyper-stimulated embryo donor ewes experienced a very high fertilization rate. Future studies will evaluate the ova capability directly via laparoscopic aspiration of ovarian follicles and IVF and evaluation of hyper- and non-hyper-stimulated follicular waves (using transrectal ultrasonography) and endocrine dynamics during different long and short daylength periods. Extending the opportunity to generate embryos and offspring regardless of daylength will assist aggressive sheep producers in reaching their reproductive, financial, and genetic goals.

Optimization of solid tank design for fan-beam optical CT based 3D radiation dosimetry

Optical computed tomography (CT) is one of the leading modalities for imaging gel dosimeters for 3D radiation dosimetry. There exist multiple scanner designs that have showcased excellent 3D dose verification capabilities of optical CT gel dosimetry. However, due to multiple experimental and reconstruction based factors there is currently no single scanner that has become a preferred standard. A significant challenge with setup and maintenance can be attributed to maintaining a large refractive index bath (1-15 l). In this work, a prototype solid 'tank' optical CT scanner is proposed that minimizes the volume of refractive index bath to between 10 and 35 ml. A ray-path simulator was created to optimize the design such that the solid tank geometry maximizes light collection across the detector array, maximizes the volume of the dosimeter scanned, and maximizes the collected signal dynamic range. An objective function was created to score possible geometries, and was optimized to find a local maximum geometry score from a set of possible design parameters. The design parameters optimized include the block length x _bl , bore position x _bc , fan-laser position x _lp , lens block face semi-major axis length x _ma , and the lens block face eccentricity x _be . For the proposed design it was found that each of these parameters can have a significant effect on the signal collection efficacy within the scanner. Simulations scores are specific to the attenuation characteristics and refractive index of a simulated dosimeter. It was found that for a FlexyDos3D dosimeter, the ideal values for each of the five variables were: x _bl = 314 mm, x _bc = 6.5 mm, x _lp = 50 mm, x _ma = 66 mm, and x _be = 0. In addition, a ClearView^™ dosimeter was found to have ideal values at: x _bl = 204 mm, x _bc = 13 mm, x _lp = 58 mm, x _ma = 69 mm, and x _be = 0. The ray simulator can also be used for further design and testing of new, unique and purpose-built optical CT geometries.

2019 update of the European AIDS Clinical Society Guidelines for treatment of people living with HIV version 10.0

BACKGROUND

The European AIDS Clinical Society (EACS) Guidelines cover key aspects of HIV management with major updates every two years.

GUIDELINE HIGHLIGHTS

The 2019 Guidelines were extended with a new section focusing on drug-drug interactions and other prescribing issues in people living with HIV (PLWH). The recommendations for treatment-naïve PLWH were updated with four preferred regimens favouring unboosted integrase inhibitors. A two-drug regimen with dolutegravir and lamivudine, and a three-drug regimen including doravirine were also added to the recommended initial regimens. Lower thresholds for hypertension were expanded to all PLWH and for cardiovascular disease prevention, the 10-year predicted risk threshold for consideration of antiretroviral therapy (ART) modification was lowered from 20% to 10%. Frailty and obesity were added as new topics. It was specified to use urine albumin to creatinine ratio to screen for glomerular disease and urine protein to creatinine ratio for tubular diseases, and thresholds were streamlined with the Kidney Disease: Improving Global Outcomes (KDIGO) recommendations. Hepatitis C virus (HCV) treatment recommendations were split into preferred and alternative treatment options. The algorithm for management of recently acquired HCV infection was updated and includes recommendations for early chronic infection management. Treatment of resistant tuberculosis (TB) was streamlined with the World Health Organization (WHO) recommendations, and new tables on immune reconstitution inflammatory syndrome, on when to start ART in the presence of opportunistic infections and on TB drug dosing were included.

CONCLUSIONS

The EACS Guidelines underwent major revisions of all sections in 2019. They are available in four different formats including a new interactive web-based version and are translated into Chinese, French, German, Japanese, Portuguese, Russian and Spanish.

Geometric Variations of Modular Head-Stem Taper Junctions of Total Hip Replacements

Taper degradation in Total Hip Replacements (THR) has been identified as a clinical concern, and the degradation occurring at these interfaces has received increased interest in recent years. Wear and corrosion products produced at the taper junction are associated with adverse local tissue responses, leading to early failure and revision surgery. Retrieval and in-vitro studies have found that variations in taper design affect degradation. However, there is a lack of consistent understanding within the literature of what makes a good taper interface. Previous studies assessed different design variations using their global parameters assuming a perfect cone such as: taper length, cone angle and diameters. This study assessed geometrical variations of as-manufactured head and stem tapers and any local deviations from their geometry. The purpose of this study was to provide a greater insight into possible engagement, a key performance influencing parameter predicted by Morse taper connection theory. This was achieved by taking measurements of twelve different commercially available male tapers and six female tapers using a coordinate measurement machine (CMM). The results suggested that engagement is specific to a particular head-stem couple. This is subject to both their micro-scale deviations, superimposed on their macro-scale differences. Differences in cone angles between female and male tapers from the same manufacturer was found to create a predominately proximal contact. However, distally mismatched couples are present in some metal-on-metal head-stem couples. On a local scale, different deviation patterns were observed from the geometry which appeared to be linked to the manufacturing process. Future work will look at using this measurement methodology to fully characterise an optimal modular taper junction for a THR prosthesis.

Application of the NIA-AA Research Framework: Towards a Biological Definition of Alzheimer's Disease Using Cerebrospinal Fluid Biomarkers in the AIBL Study

BACKGROUND

The National Institute on Aging and Alzheimer's Association (NIA-AA) have proposed a new Research Framework: Towards a biological definition of Alzheimer's disease, which uses a three-biomarker construct: Aß-amyloid, tau and neurodegeneration AT(N), to generate a biomarker based definition of Alzheimer's disease.

OBJECTIVES

To stratify AIBL participants using the new NIA-AA Research Framework using cerebrospinal fluid (CSF) biomarkers. To evaluate the clinical and cognitive profiles of the different groups resultant from the AT(N) stratification. To compare the findings to those that result from stratification using two-biomarker construct criteria (AT and/or A(N)).

DESIGN

Individuals were classified as being positive or negative for each of the A, T, and (N) categories and then assigned to the appropriate AT(N) combinatorial group: A-T-(N)-; A+T-(N)-; A+T+(N)-; A+T-(N)+; A+T+(N)+; A-T+(N)-; A-T-(N)+; A-T+(N)+. In line with the NIA-AA research framework, these eight AT(N) groups were then collapsed into four main groups of interest (normal AD biomarkers, AD pathologic change, AD and non-AD pathologic change) and the respective clinical and cognitive trajectories over 4.5 years for each group were assessed. In two sensitivity analyses the methods were replicated after assigning individuals to four groups based on being positive or negative for AT biomarkers as well as A(N) biomarkers.

SETTING

Two study centers in Melbourne (Victoria) and Perth (Western Australia), Australia recruited MCI individuals and individuals with AD from primary care physicians or tertiary memory disorder clinics. Cognitively healthy, elderly NCs were recruited through advertisement or via spouses of participants in the study.

PARTICIPANTS

One-hundred and forty NC, 33 MCI participants, and 27 participants with AD from the AIBL study who had undergone CSF evaluation using Elecsys® assays. INTERVENTION (if any): Not applicable.

MEASUREMENTS

Three CSF biomarkers, namely amyloid β1-42, phosphorylated tau181, and total tau, were measured to provide the AT(N) classifications. Clinical and cognitive trajectories were evaluated using the AIBL Preclinical Alzheimer Cognitive Composite (AIBL-PACC), a verbal episodic memory composite, an executive function composite, California Verbal Learning Test - Second Edition; Long-Delay Free Recall, Mini-Mental State Examination, and Clinical Dementia Rating Sum of Boxes scores.

RESULTS

Thirty-eight percent of the elderly NCs had no evidence of abnormal AD biomarkers, whereas 33% had biomarker levels consistent with AD or AD pathologic change, and 29% had evidence of non-AD biomarker change. Among NC participants, those with biomarker evidence of AD pathology tended to perform worse on cognitive outcome assessments than other biomarker groups. Approximately three in four participants with MCI or AD had biomarker levels consistent with the research framework's definition of AD or AD pathologic change. For MCI participants, a decrease in AIBL-PACC scores was observed with increasing abnormal biomarkers; and increased abnormal biomarkers were also associated with increased rates of decline across some cognitive measures.

CONCLUSIONS

Increasing biomarker abnormality appears to be associated with worse cognitive trajectories. The implementation of biomarker classifications could help better characterize prognosis in clinical practice and identify those at-risk individuals more likely to clinically progress, for their inclusion in future therapeutic trials.

Investigating Conceptual Models for the Relationship Between Depression and Condomless Sex Among Gay, Bisexual, and Other Men Who have Sex with Men: Using Structural Equation Modelling to Assess Mediation

The aim of this study is to investigate five hypothesized mechanisms of causation between depression and condomless sex with ≥ 2 partners (CLS2+) among gay, bisexual, and other men who have sex with men (GBMSM), involving alternative roles of self-efficacy for sexual safety and recreational drug use. Data were from the AURAH cross-sectional study of 1340 GBMSM attending genitourinary medicine clinics in England (2013–2014). Structural equation modelling (SEM) was used to investigate which conceptual model was more consistent with the data. Twelve percent of men reported depression (PHQ-9 ≥ 10) and 32% reported CLS2+ in the past 3 months. AURAH data were more consistent with the model in which depression was considered to lead to CLS2+ indirectly via low self-efficacy for sexual safety (indirect Beta = 0.158; p < 0.001) as well as indirectly via higher levels of recreational drug use (indirect Beta = 0.158; p < 0.001). SEM assists in understanding the relationship between depression and CLS among GBMSM.

Considering the Role of Adaptive Evolution in Models of the Ocean and Climate System

Numerical models have been highly successful in simulating global carbon and nutrient cycles in today's ocean, together with observed spatial and temporal patterns of chlorophyll and plankton biomass at the surface. With this success has come some confidence in projecting the century-scale response to continuing anthropogenic warming. There is also increasing interest in using such models to understand the role of plankton ecosystems in past oceans. However, today's marine environment is the product of billions of years of continual evolution-a process that continues today. In this paper, we address the questions of whether an assumption of species invariance is sufficient, and if not, under what circumstances current model projections might break down. To do this, we first identify the key timescales and questions asked of models. We then review how current marine ecosystem models work and what alternative approaches are available to account for evolution. We argue that for timescales of climate change overlapping with evolutionary timescales, accounting for evolution may to lead to very different projected outcomes regarding the timescales of ecosystem response and associated global biogeochemical cycling. This is particularly the case for past extinction events but may also be true in the future, depending on the eventual degree of anthropogenic disruption. The discipline of building new numerical models that incorporate evolution is also hugely beneficial in itself, as it forces us to question what we know about adaptive evolution, irrespective of its quantitative role in any specific event or environmental changes.

Protocol of a two arm randomised, multi-centre, 12-month controlled trial: evaluating the impact of a Cognitive Behavioural Therapy (CBT)-based intervention Supporting UPtake and Adherence to antiretrovirals (SUPA) in adults with HIV

Background

Delay to start antiretroviral therapy (ART) and nonadherence compromise the health and wellbeing of people living with HIV (PLWH), raise the cost of care and increase risk of transmission to sexual partners. To date, interventions to improve adherence to ART have had limited success, perhaps because they have failed to systematically elicit and address both perceptual and practical barriers to adherence. The primary aim of this study is to determine the efficacy of the Supporting UPtake and Adherence (SUPA) intervention.

Methods

This study comprises 2 phases. Phase 1 is an observational cohort study, in which PLWH who are ART naïve and recommended to take ART by their clinician complete a questionnaire assessing their beliefs about ART over 12 months. Phase 2 is a randomised controlled trial (RCT) nested within the observational cohort study to investigate the effectiveness of the SUPA intervention on adherence to ART. PLWH at risk of nonadherence (based on their beliefs about ART) will be recruited and randomised 1:1 to the intervention (SUPA intervention + usual care) and control (usual care) arms. The SUPA intervention involves 4 tailored treatment support sessions delivered by a Research Nurse utilising a collaborative Cognitive Behavioural Therapy (CBT) and Motivational Interviewing (MI) approach. Sessions are tailored to individual needs and preferences based on the individual patient’s perceptions and practical barriers to ART. An animation series and intervention manual have been developed to communicate a rationale for the personal necessity for ART and illustrate concerns and potential solutions. The primary outcome is adherence to ART measured using Medication Event Monitoring System (MEMS). Three hundred seventy-two patients will be sufficient to detect a 15% difference in adherence with 80% power and an alpha of 0.05. Costs will be compared between intervention and control groups. Costs will be combined with the primary outcome in cost-effectiveness analyses. Quality adjusted life-years (QALYs) will also be estimated over the follow-up period and used in the analyses.

Discussion

The findings will enable patients, healthcare providers and policy makers to make informed decisions about the value of the SUPA intervention.

Trial registration

The trial was retrospectively registered 21/02/2014, ISRCTN35514212.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6893-z) contains supplementary material, which is available to authorized users.