Reducing short-acting beta-agonist use in asthma: Impact of national incentives on prescribing practices in England and the findings from SENTINEL Plus early adopter sites

Short-acting beta-agonist (SABA) over-use in asthma is harmful for patients and the environment. The Investment and Impact Fund (IIF) 2022/2023 financially rewarded English primary care networks that achieved specific targets, including reducing SABA over-use (RESP-02) and lowering the mean carbon footprint per salbutamol inhaler prescribed (ES-02). SENTINEL Plus is a co-designed quality improvement package that aims to improve asthma outcomes and reduce asthma's environmental impact by addressing SABA over-use. We investigated the impact of (i) the IIF incentives and (ii) SENTINEL Plus implementation on asthma prescribing. Using Openprescribing.net data, we demonstrate that IIF 2022-2023 had no significant impact on the total number of SABA prescribed in England (25,927,252 during 12-months pre- and 25,885,213 12-months post-IIF; 0.16% decrease; p=NS), but lower carbon footprint SABA inhaler use increased (Salamol™ prescribing increased from 5.1% to 19% of SABA prescriptions, p < 0.01). In contrast, SENTINEL Plus sites significantly reduced SABA prescribing post-implementation (5.43% decrease, p < 0.05).

Pharmacological characterization of the selective orexin-1 receptor antagonist JNJ-61393215 in healthy volunteers

BACKGROUND

Up to 40% of patients suffering from anxiety disorders do not benefit from currently available pharmacological treatments. Overactivity of the orexin-1 receptor (OX1R) has been implicated in anxiety- and panic-related states.

AIM & METHODS

We investigated the pharmacokinetics and characterized the pharmacodynamic (PD) profile of the OX1R antagonist JNJ-61393215 using a battery of central nervous system assessments investigating relevant functional domains such as alertness, attention, (visuo)motor coordination, balance, subjective effects and resting-state electroencephalography in a single ascending dose placebo-controlled study in doses from 1 to 90 mg inclusive, assessing PD up to 10 h after dosing, safety and pharmacokinetic in 48 healthy male subjects.

RESULTS

Average time to maximal plasma concentration (T_max) ranged between 1.0 and 2.25 h; average half-life ranged from 13.6 to 24.6 h and average maximum plasma concentration ranged from 1.4 to 136.8 ng/mL in the 1 and 90 mg groups, respectively. JNJ-61393215 did not demonstrate any statistically significant or clinically meaningful effects on any PD endpoint at any dose investigated at T_max nor over the total period up to 10 h post-dose and was well tolerated. The reported somnolence rate was 16.7% (which was attributable to the cohorts receiving 6 mg and higher doses) compared to 12.5% in placebo.

CONCLUSION

This observation is in line with our knowledge about the OX1R in preclinical studies, where only inconsistent and non-dose-dependent changes in electroencephalography or other behavioural measures were observed under non-challenged conditions, potentially exemplifying the need for a challenged subject.

Containment of a Verona Integron-Encoded Metallo-Beta-Lactamase-Producing Pseudomonas aeruginosa Outbreak Associated With an Acute Care Hospital Sink-Tennessee, 2018-2020

Background

Contaminated healthcare facility wastewater plumbing is recognized as a source of carbapenemase-producing organism transmission. In August 2019, the Tennessee Department of Health (TDH) identified a patient colonized with Verona integron-encoded metallo-beta-lactamase-producing carbapenem-resistant Pseudomonas aeruginosa (VIM-CRPA). A record review revealed that 33% (4 of 12) of all reported patients in Tennessee with VIM had history of prior admission to acute care hospital (ACH) A intensive care unit (ICU) Room X, prompting further investigation.

Methods

A case was defined as polymerase chain reaction detection of bla_VIM in a patient with prior admission to ACH A from November 2017 to November 2020. The TDH performed point prevalence surveys, discharge screening, onsite observations, and environmental testing at ACH A. The VIM-CRPA isolates underwent whole-genome sequencing (WGS).

Results

In a screening of 44% (n = 11) of 25 patients admitted to Room X between January and June 2020, we identified 36% (n = 4) colonized with VIM-CRPA, resulting in 8 cases associated with Room X from March 2018 to June 2020. No additional cases were identified in 2 point-prevalence surveys of the ACH A ICU. Samples from the bathroom and handwashing sink drains in Room X grew VIM-CRPA; all available case and environmental isolates were found to be ST253 harboring bla_VIM-1 and to be closely related by WGS. Transmission ended after implementation of intensive water management and infection control interventions.

Conclusions

A single ICU room's contaminated drains were associated with 8 VIM-CRPA cases over a 2-year period. This outbreak highlights the need to include wastewater plumbing in hospital water management plans to mitigate the risk of transmission of antibiotic-resistant organisms to patients.

Opportunities, approaches and challenges to the engagement of citizens in filling small water body data gaps

Monitoring the condition (water quality, biodiversity, hydromorphology) of small water bodies presents a challenge for the relevant authorities in terms of time and resources (labour and financial) due to the extensive length of the stream network or the sheer number of small standing water bodies. Citizen science can help address information gaps, but the effort required should not be underestimated if such projects are to generate reliable and sustained data collection. The overall aim of this paper is to propose a framework for operationalisation of citizen science targeting collection of data from small water bodies. We first consider the data gaps and the elements (water chemistry, ecology, hydromorphology) to be addressed, in order to define where citizen science could best make an impact. We review examples of tools and methods that are appropriate for small water bodies, based on experience from a selection of freshwater citizen science projects, and the support that is needed for effective and sustained small water body projects across Europe.

Burn Registries State of Affairs: A Scoping review

Registry science allows for the interpretation of disease-specific patient data from secondary databases. It can be utilized to understand disease and injury, answer research questions, and engender benchmarking of quality-of-care indicators. Numerous burn registries exist globally, however, their contributions to burn care have not been summarized. The objective of this study is to characterize the available literature on burn registries. The authors conducted a scoping review, having registered the protocol a priori. A thorough search of the English literature, including grey literature, was carried out. Publications of all study designs were eligible for inclusion provided they utilized, analyzed, and/or critiqued data from a burn registry. Three hundred twenty studies were included, encompassing 16 existing burn registries. The most frequently used registries for peer-reviewed publications were the American Burn Association Burn Registry, Burn Model System National Database, and the Burns Registry of Australia and New Zealand. The main limitations of existing registries are the inclusion of patients admitted to burn centers only, deficient capture of outpatient and long-term outcome data, lack of data standardization across registries, and the paucity of studies on burn prevention and quality improvement methodology. Registries are an invaluable source of information for research, delivery of care planning, and benchmarking of processes and outcomes. Efforts should be made to stimulate other jurisdictions to build burn registries and for existing registries to be improved through data linkage with administrative databases, and by standardizing one international minimum dataset, in order to maximize the potential of registry science in burn care.

POS0244 ASSOCIATION OF PROTEINASE 3 GENE (PRTN3) Val119Ile POLYMORPHISM (SNP rs351111) WITH RISK OF RELAPSE AMONG HOMOZYGOUS PATIENTS WITH PR3 ANCA-ASSOCIATED VASCULITIS

Background

The frequency of the proteinase 3 gene (PRTN3) polymorphisms in patients with ANCA-associated vasculitis (AAV) is not well characterized. We hypothesize that PRTN3 gene polymorphisms induce allosteric changes in PR3 conformation which may alter its interaction with ligands and PR3-ANCA during inflammation with potential implications for disease presentation and clinical outcomes.

Objectives

To analyze the association of PRTN3 Val119Ile polymorphism (SNP rs351111) with risk of relapse risk among homozygous patients with PR3 ANCA-associated vasculitis.

Methods

DNA variant calling for SNP rs351111 (chr.19:844020, c.355G>A) in PRTN3 gene assessed the allelic frequency in patients with PR3-AAV included in the Rituximab versus Cyclophosphamide (RAVE) trial. This was followed by RNA-seq variant calling to characterize the mRNA expression. We compared clinical presentation and outcomes between patients homozygous for PR3-Ile119 or PR3-Val119.

Results

Serum samples for DNA calling were available in 188 of the 197 patients with AAV in the RAVE cohort. 75 PR3-AAV patients had the allelic variant: 13 patients were homozygous for PR3-Ile119 and 62 patients were heterozygous PR3-Val119Ile with an allele frequency threshold of 29.3 – 55.1% of reads (Figure 1A and 1B). RNA-seq was available for 89 patients and the mRNA corresponding to the allelic variant was found in 35 PR3-AAV patients: 13 patients were homozygous for PR3-Ile119 and 22 patients were heterozygous PR3-Val119Ile with an allele frequency threshold of 11.1 – 62.8% of reads (Figure 1A and 1C). The agreement between the DNA calling results and the mRNA expression of the 86 patients that overlapped was 100%. We found an additional homozygous patient for PR3-Val119 in which blood was not available for DNA calling. We compared the clinical presentation and outcomes of 74 patients with PR3-AAV: 13 homozygous for PR3-Ile119 and 51 homozygous for PR3-Val119 (Table 1). The frequency of severe flares at 18 months in homozygous PR3-Ile119 was ≥ 2x higher when compared with homozygous PR3-Val119 (46.2% vs. 19.6%, p=0.048). We found no differences in clinical presentation.

Figure 1.

RAVE trial population distribution according to the zygosity status for PRTN3 gene (PR3 and MPO-ANCA patients) and DNA or RNA variant calling (panel A). Allelic frequency for rs351111, chr.19:844020 (c.355G>A) in PRTN3 among patients with AAV (PR3 and MPO-ANCA) in the DNA (panel B) and RNA (panel C) variant calling.

Table 1.

Outcomes of patients with PR3-ANCA according with PRTN3 zygosity.

PR3-ANCA (n=64)Homozygous PR3-Val119(n=51)HomozygousPR3-Ile119(n=13)p-value Remission, n (%)45 (88.2)13 (100)0.194 Complete remission, n (%)36 (70.6)10 (76.9)0.650 Any flare 18 months, n (%)30 (58.8)7 (53.8)0.746 Severe Relapse* 18 months, n (%)10 (19.6)6 (46.2)0.048

* Relapse was considered “Severe” if Birmingham Vasculitis Activity Score for Wegener’s Granulomatosis (BVAS/WG) > 3 or one major item as per the RAVE trial definition.

Abbreviations: ANCA - anti-neutrophil cytoplasmic antibody; Ile – isoleucine; n- number; PR3 - proteinase 3; Val - valine.

Conclusion

In patients with PR3-AAV the presence of PRTN3 Val119Ile polymorphism was associated with higher frequency of severe relapse. Further studies are necessary to understand the association of this observation with the risk of severe relapse.

References

[1]Stone JH et al N Engl J Med 2010; 363:221-232

Disclosure of Interests

None declared

569 Burn Registries State of Affairs: A Scoping Review

Introduction

Registry science applies observational study designs to interpret large secondary databases. It can be utilized to understand disease and injury, answer research questions, inform regulatory decision making, and engender benchmarking of quality-of-care indicators. Numerous burn registries exist globally, however their contributions to the science of burn epidemiology, care and treatment have not been summarized. The objective of this study is to characterize the available literature on burn registries.

Methods

We conducted a scoping review, having registered the protocol a priori. A comprehensive literature search across several databases, including the grey literature, was carried out. Studies of all methodological designs were included provided they utilized, analyzed, and/or critiqued burn registry data. Pilot projects from registries in development were included as well. Studies involving non-burn specific registries or registries from a single burn centre were excluded.

Results

Two hundred and sixty-eight studies were included, encompassing 16 existing burn registries. Although registry science has been used to investigate burn care since 1970, the majority of studies were published after 2007. Most studies utilized the American Burn Association Burn Registry or one of its previous versions (75.7%) and the Burns Registry of Australia and New Zealand (10.4%). Main limitations of existing registries are the inclusion of patients admitted to burn centres only, deficient capture of outpatient and long-term outcome data, and lack of data standardization across registries.

Conclusions

Registries are an invaluable source of data for research, delivery of care planning, and benchmarking of processes and outcomes. Efforts should be made to stimulate other jurisdictions to build and maintain burn registries, to incorporate data linkage from administrative and other secondary databases, and to standardize data collection, in order to maximize the potential of registry science in burn care.

Cook Like A Boss: An effective co-created multidisciplinary approach to improving children's cooking competence

Cooking interventions are emphasised as promising methods for changing children's food-related preferences, attitudes and behaviours. However, criticisms remain, including relatively weak intervention designs; lack of validated tools, and limited underpinning theory. Therefore, this research aimed to assess the effectiveness of a theory-driven co-created children's cooking intervention with underpinning rationale for the content, using a validated measure. 'Cook Like A Boss' was a one week, controlled cooking camp style intervention. Thirty two children aged 10-12 years participated. The intervention was developed using the Cook-Ed model for planning, implementing and evaluating cooking programs and was underpinned by Social Learning theory and Experiential Learning theory. The intervention content was developed in a co-creation process with the research team, a chef and the children. The underlying developmental skills required for the recipes were assessed to ensure they were age-appropriate. Children completed pre and post measurements including perceived cooking competence. Process evaluations were also gathered. There was a significant increase in perceived cooking competence after the intervention (P < 0.05) and a significant difference between the intervention and control group (P < 0.001). Additionally, process evaluations found the intervention to have high fidelity and dose received and that it was received extremely positively. The 'Cook Like A Boss' children's cooking camp was an effective multidisciplinary co-created intervention with a vulnerable group, e.g. children, guided by a model and underpinned by theory. The content was developed to ensure it was age-appropriate and achievable for the children. This approach could act as a template for future children's cooking interventions.

Clinical Informatics Training During Emergency Medicine Residency: The University of Michigan Experience

Clinical informatics (CI) is a rich field with longstanding ties to resident education in many clinical specialties, although a historic gap persists in emergency medicine. To address this gap, we developed a CI track to facilitate advanced training for senior residents at our 4-year emergency medicine residency. We piloted an affordable project-based approach with strong ties to operational leadership at our institution and describe specific projects and their outcomes. Given the relatively low cost, departmental benefit, and unique educational value, we believe that our model is generalizable to many emergency medicine residencies. We present a pathway to defining a formal curriculum using Kern's framework.

460 THE IMPACT OF THE BONE MDT: EXPLORING CHANGES IN BONE PROTECTION DECISIONS BETWEEN 2015 AND 2018

Introduction

The Hip fracture Multidisciplinary metabolic bone Team (MDT) was developed in June 2016 as a collaboration between Orthogeriatricians and the Metabolic Bone Team. The objective was to improve the quality of bone protection treatment decisions. This audit aimed to assess the impact of the new MDT by reviewing treatment decisions prior to and post its introduction. Data collection and.

Methodology

Case notes were reviewed for admissions from September to October 2015 and from September to November 2018. For both time periods the inpatient list, discharge summary and blood tests were reviewed in order to collect data regarding demographics, type of surgery, co-morbidities, calcium and vitamin D levels, bone protection prior to admission and bone protection decisions at discharge.

Results

In 2015, 83% of patients were admitted with no form of bone protection. Around 6% of patients were admitted on a bisphosphonate and 36% were discharged on a bisphosphonate. Less than 2% of people received denosumab prior to their admission, with this number rising to 9.4% at discharge. In 2018, 77% of patients were admitted on no form of bone protection. 5.4% were admitted on a bisphosphonate rising to 16% on discharge. No patients were admitted on denosumab, but 27% were discharged having received it in hospital, or with a plan to receive it from their GP.

Conclusions

There was a fall in bisphosphonate use and a significant increase in the frequency of denosumab prescription after the introduction of the Bone MDT. This MDT facilitated better decision-making through access to the further specialist skills from the endocrinologist and specialist nurses. Individual case discussion enhanced the delivery of personalised medicine.

Automated anti-Mullerian hormone measurement: data review to provide insights and interpretation

RESULTS

AMH results were pooled and a table with 2.5 and 97.5 percentiles for each age group constructed. Based on Youden index, the optimal cut off for low responders (0-3 eggs), was 5.5 pmol/l (87% sensitivity, 55% specificity) and for high responders (>15 eggs) 15.6 pmol/l (78% sensitivity, 57% specificity). AMH correlated with number of eggs collected (r = 0.48) and clinical pregnancies (r = 0.14), (p < .0001).

CONCLUSIONS

The table of AMH levels measured using the Access 2 fully automated immunoassay system according to age may be used as a reference and cutoff levels for high and poor responders are clearly defined to help tailor controlled ovarian stimulation, maximizing efficiency and ensuring patient safety. The use of a random access automated immunoassay system means that blood sampled on arrival can produce an AMH result in 40 mins by the time the subject enters the doctor's clinic together with other relevant endocrine markers.

341 Acute effects of seltorexant, a selective orexin-2 antagonist (JNJ- 42847922), on driving after bedtime administration

Introduction

Seltorexant (JNJ-42847922), a potent and selective antagonist of the human orexin-2 receptor, is being developed for the treatment of major depressive disorder. Seltorexant also has sleep-promoting properties. Investigating the effects of sleep-promoting medications on driving is important because some of these agents (e.g. GABAA receptor agonists) may be associated with increased risk of motor vehicle accidents. We evaluated the effect of seltorexant on driving after forced awakening at night, using a validated driving simulator.

Methods

This double-blind, placebo and active-controlled, randomized, 3-way cross-over study was conducted in 18 male and 18 female healthy subjects. All subjects received seltorexant 40 mg, zolpidem 10 mg, or placebo 15 minutes before bedtime. Eighteen subjects were awakened at 2- and 6-hours post-dose, and the other 18 at 4- and 8-hours post-dose. At those timepoints, pharmacokinetics, objective (standard deviation of the lateral position [SDLP]) and subjective effects (using Perceived Driving Quality and Effort Scales) on driving ability, postural stability and subjective sleepiness were assessed.

Results

For seltorexant, the SDLP difference from placebo (95% confidence interval) at 2-, 4-, 6- and 8-hours post-dose was 3.9 cm (1.26, 6.60), 0.9 cm (-1.08, 2.92), 1.1 cm (-0.42, 2.63), and 0.6 cm (-2.75, 1.55), respectively vs. 9.6 cm (6.97, 12.38), 6.6 cm (3.53, 9.60), 4.7 cm (1.46, 7.85), and 1.3cm (-1.16, 3.80), respectively for zolpidem. The difference from placebo was significant at 2-hours after taking seltorexant, while the difference from placebo was significant at 2, 4 and 6-hours after zolpidem. Subjective driving quality was decreased for both drugs at all time points and driving effort was increased up to 4-hours post-dose for both medications. Subjective sleepiness showed a significant increase compared to placebo 2- and 4-hours after administration of either drug. Postural stability was decreased up to 2-hours after administration of seltorexant, and up to 4-hours after administration of zolpidem.

Conclusion

Compared to zolpidem, objective effects on driving performance were more transient after seltorexant administration and largely normalized by 4–6 hours post-dose.

Support (if any)

This work was sponsored by Janssen R&D.

MED27 Variants Cause Developmental Delay, Dystonia, and Cerebellar Hypoplasia

The Mediator multiprotein complex functions as a regulator of RNA polymerase II-catalyzed gene transcription. In this study, exome sequencing detected biallelic putative disease-causing variants in MED27, encoding Mediator complex subunit 27, in 16 patients from 11 families with a novel neurodevelopmental syndrome. Patient phenotypes are highly homogeneous, including global developmental delay, intellectual disability, axial hypotonia with distal spasticity, dystonic movements, and cerebellar hypoplasia. Seizures and cataracts were noted in severely affected individuals. Identification of multiple patients with biallelic MED27 variants supports the critical role of MED27 in normal human neural development, particularly for the cerebellum. ANN NEUROL 2021;89:828-833.

Early recurrence after pulmonary vein isolation is associated with inferior long-term outcomes: Insights from a retrospective cohort study

AIMS

The aim of this retrospective cohort study was to assess the influence of early recurrence (ER) after pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) on long-term outcomes and to identify clinical variables associated with ER.

METHODS

We retrospectively collected clinical and procedural data from 1285 patients with paroxysmal AF who underwent PVI from 2011 to 2016. Kaplan-Meier, receiver operating characteristic (ROC) curve, logistic and Cox regression analyses were performed to analyze the influence of ER on long-term outcomes.

RESULTS

ER was observed in 13% of patients. Kaplan-Meier analyses showed significantly different outcomes in 1285 patients with and without ER (49% vs 74%, log rank P < .01) and in 286 patients in the subgroup that underwent reablation (44% vs 79%, log rank P < .01). The hazard ratio (HR) of ER was 1.7 within 48 hours (5% of patients), 2.7 within 1 month (5%), 3.0 within 2 months (2%), and 6.4 within 3 months (1%) for late recurrence (LR), P < .01. ROC analysis (area under the curve [AUC] = 0.79) resulted in 70.3% sensitivity and 74.2% specificity for a 14-day blanking period, and 53.1% sensitivity and 85.5% specificity for a 30-day blanking period. Female patients (odds ratio [OR] 1.69, P < .01) and those with diabetes (OR 1.95, P = .01) were at higher risk for ER.

CONCLUSIONS

ER is observed in a substantial number of patients with paroxysmal AF after PVI and has a continuous direct effect on LR according to the timing of ER. Randomized trials are required to assess the safety and effects of reablations in a shortened blanking period on long-term outcomes.

CBETA: First Multipass Superconducting Linear Accelerator with Energy Recovery

Energy recovery has been achieved in a multipass linear accelerator, demonstrating a technology for more compact particle accelerators operating at higher currents and reduced energy consumption. Energy delivered to the beam during the first four passes through the accelerating structure was recovered during four subsequent decelerating passes. High-energy efficiency was achieved by the use of superconducting accelerating cavities and permanent magnets. The fixed-field alternating-gradient optical system used for the return loop successfully transported electron bunches of 42, 78, 114, and 150 MeV in a common vacuum chamber. This new kind of accelerator, an eight-pass energy recovery linac, has the potential to accelerate much higher current than existing linear accelerators while maintaining small beam dimensions and consuming much less energy per electron.

The stroke navigator: meaningful use of the electronic health record to efficiently report inpatient stroke care quality

To facilitate high-quality inpatient care for stroke patients, we built a system within our electronic health record (EHR) to identify stroke patients while they are in the hospital; capture necessary data in the EHR to minimize the burden of manual abstraction for stroke performance measures, decreasing daily time requirement from 2 hours to 15 minutes; generate reports using an automated process; and electronically transmit data to third parties. Provider champions and support from the EHR development team ensured that we balanced the needs of the hospital with those of frontline providers. This work summarizes the development and implementation of our stroke quality system.

306. CD8+ T-Cell Responses to Chronic Hepatitis C in Pregnancy

Background

Chronic hepatitis C virus (HCV) infection is marked by stable, high -level viremia and a failed T-cell response. HCV-specific CD4+ helper T cells are rare, and CD8+ cytotoxic T cells are functionally exhausted or ineffective due to viral escape mutations. Postpartum, a subset of infected women experience a substantial drop in viremia. Preliminary data indicate that this unusual viral decline may be linked to a resurgence of HCV-specific CD4+ T cells producing Th1 cytokines. How improved CD4+ helper T-cell function might affect viral replication in this scenario is not established. Here we tested the hypothesis that improved CD4+ T cell help mediates control of chronic HCV replication through enhanced CD8+ T-cell function.

Methods

We examined plasma HCV RNA viral load (VL) and HCV-specific T-cell responses in 33 women with chronic HCV during the third trimester (T3) and at 3 months postpartum (3P). HCV-specific CD4+ and CD8+ T-cell IL2 and IFNγ responses were measured by intracellular cytokine staining following stimulation of peripheral blood mononuclear cells with peptide pools corresponding to the HCV proteins NS3, NS4a, and NS4B.

Results

Median VL dropped from 5.87 log₁₀ at T3 to 5.25 log₁₀ at 3P (P < 0.0001, Wilcoxson signed rank), with a wide range from +0.4 log₁₀ to -4.2 log₁₀. The degree of decline correlated significantly with improved frequencies of HCV-specific CD4+ T cells producing IFNγ (P = 0.015 Spearman) but did not correlate with CD8+ T-cell changes. Nevertheless, improved T helper function correlated with increased HCV-specific CD8+ T-cell function (ΔCD4+IL2+ vs. ΔCD8+IFNγ+, P = 0.015 Spearman, graph 1; ΔCD4+IFNγ+ vs. CD8+IFNγ+ at 3P, P = 0.004 Spearman, graph 2).

Conclusion

Despite no significant association between virus-specific CD8+ T-cell Tc1 cytokine production and postpartum viral control, our data suggest that recovery of CD4+ T-cell help may augment CD8+ T-cell function. Further study incorporating viral genomic sequences to focus on intact class I epitopes is needed to clarify the relationship of improved CD8+ function and viral control in this unique model of immune restoration.

Disclosures

All authors: No reported disclosures.

A non-synonymous SNP in exon 3 of the KIT gene is responsible for the classic grey phenotype in alpacas (Vicugna pacos)

The alpaca classic grey phenotype is of particular interest to the industry. Until now, there were only indirect data suggesting that the KIT gene was involved in the classic grey phenotype. All exons of KIT in three black and three classic silvergrey alpacas were sequenced. Five non-synonymous SNPs were observed. There was only one SNP found that was present only in the silvergrey alpacas, and this was also the only SNP predicted to be damaging. This variant results in a change of a glycine (Gly) to an arginine (Arg) at amino acid position 126 (c.376G>A), occurring in the second Ig-like domain of the extracellular domain of KIT. Basic protein modelling predicted that this variant is likely destabilising. Therefore, an additional 488 alpacas were genotyped for this SNP using the tetra-primer amplification refractory mutation system PCR (Tetra-primer ARMS-PCR). All classic grey alpacas were observed to be heterozygous, and 99.3% of non-grey dark base colour alpacas were found to be homozygous for the wildtype allele in this position. These results confirm that the classic grey phenotype in alpacas is the result of a c.376G>A (p.Gly126Arg) SNP in exon 3 of KIT. These data also support the hypothesis that the grey phenotype is autosomal dominant and that the mutation is most likely homozygous lethal.

Programme theory development and formative evaluation of a provincial knowledge translation unit

Background

Research shows a significant gap between healthcare research and evidence-based healthcare policy and practice. Knowledge translation (KT) has an important role in addressing this gap by bolstering evidence-informed healthcare. Canada’s Strategy for Patient-Oriented Research (SPOR) is a nationally mandated and supported initiative developed to respond to the gap between research and practice. One aspect of SPOR is the provincial/territorial SUpport for People and Patient-Oriented Research and Trials (SUPPORT) Units, intended to assist local health researchers and systems to reach the goal of improving the quality and quantity of patient-oriented research in Canada. This article presents the programme theory development and a formative evaluation of the KT Platform in Alberta’s SPOR SUPPORT Unit.

Methods

We used a mixed-methods approach to develop the KT Platform’s programme theory and subsequently conducted the formative evaluation. An extensive needs assessment, comprised of 59 qualitative interviews with researchers and health systems employees in Canada with an interest in KT, served as the basis for our programme theory design. Three years after launching the KT Platform, we hired an evaluation consultant to conduct a formative evaluation of the Platform’s programme theory and operations. The evaluation was performed by conducting nine interviews with KT Platform service users (n = 6) and KT experts acting in advisory capacities to the KT Platform (n = 3).

Results

The KT Platform developed a ‘4C Model’ as a summary of the Platform’s programme theory. This model is designed to meet local needs for capacity-building, a community of practice, consultation services, and contributions to KT science. This suite of services was found to help the local health system implement health evidence with measurable positive health outcomes. However, the community remains hesitant about their capacity as individuals to design and perform important KT activities independently.

Conclusions

With the mandate and support provided by SPOR, the KT Platform was able to design a strong programme theory based on evidence from an extensive needs assessment of the local community. The resulting 4C Model has provided a framework for KT work to assist in improving local health outcomes and can be considered by others designing KT programmes as a useful model to follow. Ongoing monitoring and assessment are required to continue to identify and respond to local needs.

Health Misinformation and the Power of Narrative Messaging in the Public Sphere

Numerous social, economic and academic pressures can have a negative impact on representations of biomedical research. We review several of the forces playing an increasingly pernicious role in how health and science information is interpreted, shared and used, drawing discussions towards the role of narrative. In turn, we explore how aspects of narrative are used in different social contexts and communication environments, and present creative responses that may help counter the negative trends. As traditional methods of communication have in many ways failed the public, changes in approach are required, including the creative use of narratives.

Repeat ablation for paroxysmal atrial fibrillation - Does adenosine play a role in predicting pulmonary vein reconnection patterns?

BACKGROUND

Pulmonary vein (PV) reconduction after PV isolation (PVI) unmasked by adenosine is associated with a higher risk for paroxysmal atrial fibrillation (PAF) recurrence. It is unknown if the reconnected PVs after adenosine testing and immediate re-ablation can predict reconnection and reconnection patterns of PVs at repeat procedures. We assessed reconnection of PVs with and without dormant-conduction (DC) during the first and the repeat procedure.

METHODS

We included 67 patients undergoing PVI for PAF and a second procedure for PAF recurrence. DC during adenosine administration at first procedure was seen in 31 patients (46%). 264 PVs were tested with adenosine; DC was found in 48 PVs (18%) and re-ablated during first procedure. During the second procedure, all PVs where checked for reconnection.

RESULTS

Fifty-eight patients (87%) showed PV reconnection during the second procedure. Reconnection was found in 152/264 PVs (58%). Of 216 PVs without reconnection during adenosine testing at the first ablation, 116 PVs (53.7%) showed reconnection at the repeat procedure. Overall, 14.9% of patients showed the same PV reconnection pattern in the first and second procedure, expected statistical probability of encountering the same reconnection pattern was only 6.6%(p = 0.012).

CONCLUSIONS

In repeat procedures PVs showed significantly more often the same reconnection pattern as during first procedure than statistically expected. More than 50% of initial isolated PVs without reconnection during adenosine testing showed a reconnection during repeat ablation. Techniques to detect susceptibility for PV re-connection like prolonged waiting-period should be applied. Elimination of DC should be expanded from segmental to circumferential re-isolation or vaster RF application.

Exclusion of left atrial thrombus by dual-source cardiac computed tomography prior to catheter ablation for atrial fibrillation

OBJECTIVES

Thromboembolic complications during atrial fibrillation (AF) ablation due to mobilisation of a pre-existing thrombus formation (TF) in the left atrium (LA) are devastating. The gold standard to exclude LA TF is transesophageal echocardiography (TEE). The present study compares sensitivity and specificity of a dual-source cardiac-computed tomography (DS-CT) with TEE for TF exclusion prior to AF ablation. In addition, CT protocols with and without ECG synchronized were evaluated.

METHODS

In 622 patients, DS-CT as well as TEE to exclude TF was performed less than 48 h prior to AF ablation. Mean age of patients was 60 ± 10 years (69% males, 61% paroxysmal AF). During DS-CT, 280 patients (45%) were in AF. An ECG-synchronized DS-CT was performed in 332 patients, whereas 290 patients underwent DS-CT without ECG synchronization.

RESULTS

In all patients without suspected TF on DS-CT (n = 552; 88.7%), no thrombus was found on TEE. A TF was suspected on DS-CT in 70 patients, of whom only three patients showed TF on TEE. No TF was detected in the other 67 patients (Fig. 1). Overall, sensitivity for TF detection in DS-CT was 100% and specificity was 89.2% (positive predictive value 4.3%, negative predictive value 100%). The CT protocol (ECG-synchronized versus non-ECG-synchronized) had no significant influence on diagnostic accuracy. Mean dose length product during DS CT was 282 ± 287 mGy cm (synchronized) versus 136 ± 55 mGy cm (non-synchronized) with p < 0.0001.

CONCLUSIONS

DS-CT is a highly sensitive method for LA thrombus detection in patients undergoing AF ablation. It delivers additional anatomic details of pulmonary veins and LA anatomy with an acceptable radiation exposure. Non-ECG-synchronized DS-CT showed a significantly lower radiation exposure, whereas diagnostic accuracy was comparable. Therefore, DS-CT might serve as primary method to exclude LA TF in patients undergoing AF ablation.

Safety of Uninterrupted Periprocedural Edoxaban Versus Phenprocoumon for Patients Who Underwent Left Atrial Catheter Ablation Procedures

Data about the safety of edoxaban in patients who underwent left atrial (LA) radiofrequency (RF) ablation procedures are lacking. This study sought to compare the safety of uninterrupted edoxaban with uninterrupted phenprocoumon administration during LA RF ablation for atrial fibrillation and atrial tachycardia. In total, 231 patients (mean age 64 ± 11years, male 71%) who underwent LA RF ablation under continuous oral anticoagulation (OAC) with edoxaban or phenprocoumon were included in the study. Patients on uninterrupted edoxaban (60 mg or 30 mg/day for at least 4 weeks) were matched for gender, age and type of arrhythmia with 2 patients on uninterrupted phenprocoumon (international normalized ratio 2 to 3). We identified 77 consecutive patients on edoxaban and n = 154 patients on phenprocoumon. Heparin was administered periprocedurally to achieve an activated clotting time of 280 to 300 seconds. No protamine was administered periprocedurally. The primary end point was a composite of bleeding, thromboembolic events, and death. The primary end point was met in 9 patients in the edoxaban group and in 22 patients in the phenprocoumon group (p = 0.69). No patient in either group died or had a thromboembolic complication. No major bleeding complication was observed in the edoxaban group, whereas one was found in 1 patient in the phenprocoumon group (p ≥0.99). Minor bleeding complications occurred in 9 patients (12%) in the edoxaban group and in 21 patients (14%) in the phenprocoumon group (p = 0.84). Uninterrupted OAC with edoxaban appeared to be as safe as uninterrupted OAC with phenprocoumon in patients who underwent LA RF ablation procedures.

First detection of Edwardsiella ictaluri (Proteobacteria: Enterobacteriaceae) in wild Australian catfish

The bacterium Edwardsiella ictaluri is considered to be one of the most significant pathogens of farmed catfish in the United States of America and has also caused mortalities in farmed and wild fishes in many other parts of the world. E. ictaluri is not believed to be present in wild fish populations in Australia, although it has previously been detected in imported ornamental fishes held in quarantine facilities. In an attempt to confirm freedom from the bacterium in Australian native fishes, we undertook a risk-based survey of wild catfishes from 15 sites across northern Australia. E. ictaluri was detected by selective culturing, followed by DNA testing, in Wet Tropics tandan (Tandanus tropicanus) from the Tully River, at a prevalence of 0.40 (95% CI 0.21-0.61). The bacterium was not found in fishes sampled from any of the other 14 sites. This is the first report of E. ictaluri in wild fishes in Australia.

Insights into ablation of persistent atrial fibrillation: Lessons from 6-year clinical outcomes

INTRODUCTION

Ablation of persistent atrial fibrillation (AF) is a potential treatment option for symptomatic patients. We sought to evaluate the critical role of circumferential pulmonary vein isolation (CPVI) in the ablation of persistent AF.

METHODS AND RESULTS

A total of 341 ablation procedures were performed in 174 consecutive patients with persistent AF. CPVI was performed in all patients, additional ablation was only performed if electrical cardioversion failed after CPVI. During a median follow-up (FU) of 89 (63; 89) months, stable sinus rhythm was documented in 42/170 (25%) patients after a single procedure and in 111/164 (68%) patients after 1.9 ± 1.1 procedures. Stable SR was achieved in 40/75 (53%) patients in whom only CPVI was performed during the index and repeat procedures and in 71/89 (79%) patients with CPVI plus additional ablation. The main predictor for ablation success was duration of persistent AF before the index procedure (P < 0.001, HR ± CI: 1.608 [1.034, 1.103]). Responders to CPVI during the initial procedure had a significantly better multiple-procedure outcome after 42 months of FU compared to CPVI nonresponders (P  =  0.0365). Conversion during the index procedure had no impact on clinical outcomes (P  =  0.0903). Persistent AF regressed to paroxysmal AF in 16% of patients.

CONCLUSIONS

We demonstrate a 25% single- and 68% multiple-procedure success in patients with persistent AF, while stable SR was achieved in 53% of patients with pure CPVI during all procedures and in 79% of patients with CPVI plus additional ablation. Only duration of persistent AF before ablation had a statistically significant impact on ablation outcome.