Endocrine, cardiac and neuropsychological aspects of adult congenital adrenal hyperplasia

OBJECTIVE

To investigate the metabolic, cardiovascular, and neuropsychological phenotype, quality of life (QoL), and hormonal regulation in individuals with congenital adrenal hyperplasia (CAH), a group of autosomal recessive disorders characterized by impaired synthesis of cortisol in the adrenal cortex and, if untreated compensatory hyperandrogenism. CAH is associated with an increased cardiovascular and metabolic morbidity, possibly due to overtreatment with glucocorticoids, leading to weight gain, insulin resistance, and metabolic syndrome.

DESIGN, PARTICIPANTS, MEASUREMENTS

Thirty-seven individuals with CAH and 33 age- and sex-matched controls were evaluated at a single centre at Aarhus University Hospital with echocardiography, electrocardiogram, 24-h blood pressure, biochemistry, anthropometrics, and autism spectrum, anxiety, depression, personality, cognitive failures, and QoL were assessed using questionnaires.

RESULTS

CAH individuals had lower height than controls (170.5 vs. 182.9 cm in males and 160.2 vs. 170.1 cm in females, p < 0.01). Compared with female controls, females with CAH had higher haemoglobin (8.8 vs. 8.2 mmol/L, p = 0.003) and BMI (29.7 vs. 25.5 kg/m2, p = 0.006), reduced insulin sensitivity (HOMA-IR): 2.7 vs. 1.9, p = 0.018), prolonged E-wave deceleration time (193 vs. 174 cm, p = 0.015), and E/é ratios (5.4 vs. 4.5, p = 0.017), and lower self-reported QoL. Males with CAH had more cognitive complaints (p = 0.034) and higher autistic scores (19.9 vs. 14.9; p = 0.068) compared with male controls. More individuals with CAH than controls reported writing problems.

CONCLUSION

A sex-specific comorbidity profile is evident in CAH, with females presenting with decreased metabolic and overall self-reported health, whereas males with CAH presented with increased cognitive complaints and autistic traits.

Intersession reliability of lower limb muscle strength assessments in adults with obesity eligible for bariatric surgery

BACKGROUND

The aim of this study was to examine the test-retest reliability in lower limb muscle strength and rate of torque development (RTD) using isokinetic dynamometry in adults with obesity, with a body mass index (BMI) ≥ 35 kg/m2 .

METHOD

Thirty-two adults with a BMI of 43.8 ± 6.6 kg/m2 eligible for bariatric surgery were enroled in the study. Isokinetic and isometric knee extensor (KE) and flexor (KF) strength were assessed in an isokinetic dynamometer (Biodex 4) during three test sessions separated by 3-7 days.

RESULTS

There were no statistical differences in peak KE and KF torque for any test modalities between sessions. Intraclass correlation (ICC) was 0.91-0.94 between sessions 1 and 2 and 0.94-0.97 between sessions 2 and 3. Standard error of measurement (SEM%) and coefficient of variation (CV) ranged across test sessions from 4.3% to 7.3%. KE RTD showed high test-retest reliability following familiarization, with ICC, CV and SEM% values ranging from 0.84 to 0.90, 13.3%-20.3% and 14.6%-24.9%, respectively.

CONCLUSION

Maximal lower limb muscle strength measured by isokinetic dynamometry showed excellent test-retest reliability manifested by small measurement errors and low CV. Reliability was slightly improved by including a familiarization session. KE RTD but not KF RTD demonstrated high test-retest reliability following familiarization. The present data indicate that isokinetic dynamometry can be used to detect even small changes in lower limb muscle strength in adults with obesity.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Evaluation of Genetic or Cellular Impairments in Type I IFN Immunity in a Cohort of Young Adults with Critical COVID-19

Several genetic and immunological risk factors for severe COVID-19 have been identified, with monogenic conditions relating to 13 genes of type I interferon (IFN) immunity proposed to explain 4.8% of critical cases. However, previous cohorts have been clinically heterogeneous and were not subjected to thorough genetic and immunological analyses. We therefore aimed to systematically investigate the prevalence of rare genetic variants causing inborn errors of immunity (IEI) and functionally interrogate the type I IFN pathway in young adults that suffered from critical COVID-19 yet lacked comorbidities. We selected and clinically characterized a cohort of 38 previously healthy individuals under 50 years of age who were treated in intensive care units due to critical COVID-19. Blood samples were collected after convalescence. Two patients had IFN-α autoantibodies. Genome sequencing revealed very rare variants in the type I IFN pathway in 31.6% of the patients, which was similar to controls. Analyses of cryopreserved leukocytes did not indicate any defect in plasmacytoid dendritic cell sensing of TLR7 and TLR9 agonists in patients carrying variants in these pathways. However, lymphocyte STAT phosphorylation and protein upregulation upon IFN-α stimulation revealed three possible cases of impaired type I IFN signaling in carriers of rare variants. Together, our results suggest a strategy of functional screening followed by genome analyses and biochemical validation to uncover undiagnosed causes of critical COVID-19.

Trabecular bone deterioration in a postmenopausal female suffering multiple spontaneous vertebral fractures due to a delayed denosumab injection - A post-treatment re-initiation bone biopsy-based case study

Background

Denosumab, is a potent anti-resorptive that, increases bone mineral density, and reduces fracture risk in osteoporotic patients. However, several case studies have reported multiple vertebral fractures in patients discontinuing denosumab.

Case presentation

This case report describes a 64-year-old female with postmenopausal osteoporosis treated with denosumab, who had her 11th injection delayed by 4 months. The patient suffered eight spontaneous vertebral fractures. After consent, an iliac crest bone biopsy was obtained following re-initiation of the denosumab treatment and analyzed by micro-computed tomography and histomorphometry.

Results

micro-computed tomography analysis revealed a low trabecular bone volume of 10 %, a low trabecular thickness of 97 μm, a low trabecular spacing of 546 μm, a high trabecular number of 1.8/mm, and a high structure model index of 2.2, suggesting trabecular thinning and loss of trabecular plates. Histomorphometric trabecular bone analysis revealed an eroded perimeter per bone perimeter of 33 % and an osteoid perimeter per bone perimeter of 62 %. Importantly, 88 % of the osteoid perimeter was immediately above an eroded-scalloped cement line with no sign of mineralization, and often with no clear bone-forming osteoblasts on the surface. Moreover, only 5 % of the bone perimeter was mineralizing, reflecting that only 8 % of the osteoid perimeter underwent mineralization, resulting in a mineralization lag time of 545 days. Taken together, this indicates limited bone formation and delayed mineralization.

Conclusion

We present a case report of multiple vertebral fractures after denosumab discontinuation with histomorphometric evidence that denosumab discontinuation leads to extensive trabecular bone resorption followed by a limited bone formation and delayed mineralization if the denosumab treatment is reinitiated. This highlights the importance of developing optimal discontinuation strategies for patients that are to discontinue treatment.

Abdominal ultrasound in head and neck squamous cell carcinoma staging: yes or no?

PURPOSE

Abdominal ultrasound is a diagnostic staging procedure for distant metastases in head and neck squamous cell carcinoma (HNSCC). However, currently performed abdominal staging procedures do not follow consistent standards. Therefore, this retrospective study on 498 patients aimed at investigating on abdominal ultrasound as a staging procedure in HNSCC.

MATERIALS AND METHODS

A retrospective analysis of 498 head and neck cancer patients treated in our Department of Head and Neck Surgery between 2008 and 2015 was performed. Disease-related data were collected over a mean follow-up time of 30.3 months, and results of abdominal ultrasound were analyzed.

RESULTS

426 patients received abdominal ultrasound as a staging procedure. 7% (29) were suspicious for metastases. In 19 cases (66%), the detected abnormalities were masses of the liver. In four patients, abdominal metastases were confirmed at the time of initial diagnosis. 16 patients developed abdominal metastases in the course of the disease (on average 623 days after initial diagnosis). 19 out of 20 patients with abdominal metastases had an N2/N3 cervical lymph node status. In this study, the negative predictive value of abdominal ultrasound for HNSCC staging was 99.03%, while the positive predictive value yielded 5.88% (N2/N3-patients).

CONCLUSION

Only in patients with locally advanced lymph-node-status (N2/N3), abdominal ultrasound can be useful as a staging investigation to exclude abdominal metastasis in HNSCC patients. For N0/N1 patients, abdominal ultrasound might be dispensed. Of note, in case of a positive result, further diagnostic procedures are mandatory.

Reducing urinary catheter use in geriatric patients - results of a single-center champion-led intervention

BACKGROUND

Indwelling urinary tract catheters (UTC) are a well-known risk factor for urinary tract infections (UTI). Because geriatric patients are at high risk of infection, an intervention with a focus on appropriate and minimal UTC use was introduced in 4 acute care geriatric wards.

METHODS

Between 11/2018 and 1/2020, unit-based data on UTC use and nosocomial UTI was collected in accordance with the methods of the German national surveillance system KISS. From 6/2019 to 1/2020, a champion-led intervention was implemented which focused on: (i) feedback of surveillance data, (ii) education and training in aseptic UTC insertion and maintenance, (iii) HCW's daily assessment of UTC necessity based on a checklist and (iv) timely removal of unnecessary UTCs. UTC use, incidence, and incidence densities for catheter-associated UTI (CAUTI) were calculated before and during the intervention. In addition, we analyzed adherence to a scheduled daily assessment of UTC necessity. Rate ratios (RR) with 95% confidence intervals (95%CI) were calculated. Differences based on the quality of checklist completion were evaluated using the Kruskal Wallis test.

RESULTS

We analyzed the data of 3,564 patients with a total 53,954 patient days, 9,208 UTC days, and 61 CAUTI. Surveillance data showed a significant decrease in the pooled UTC utilization rate from 19.1/100 patient days to 15.2/100 patient days (RR = 0.80, 95%CI 0.77-0.83, p < 0.001). CAUTI per 100 patients dropped from 2.07 to 1.40 (RR = 0.68, 95%CI 0.41-1.12, p = 0.1279). Overall, 373 patients received a UTC during the intervention. Of those patients 351 patients had an UTC ≥ 2 days. The analysis of these patients showed that 186 patients (53%) received a checklist as part of their chart for daily evaluation of UTC necessity. 43 (23.1%) of the completed checklists were of good quality; 143 (76.9%) were of poor quality. Patients in the group whose checklists were of good quality had fewer UTC days (median 7 UTC days IQR (3-11)) than patients whose checklists were of poor quality (11 UTC days IQR (6-16), p = 0.001).

CONCLUSION

We conclude that a champion-led, surveillance-based intervention reduces the use of UTC among geriatric patients. Further research is needed to determine to what extent the use of checklists in daily medical UTC assessment affects the prevention of CAUTI. The fact that patients whose checklists were completed well had fewer UTC days should encourage a conscientious and thorough daily review of the need for UTC.

Do bone turnover markers reflect changes in bone microarchitecture during treatment of patients with thyroid dysfunction?

PURPOSE

This study aimed to compare changes in the bone turnover markers (BTMs)-C-terminal telopeptide of type I collagen (CTX-I) and procollagen I N-terminal peptide (PINP)-with changes in the bone microarchitecture, assessed by high-resolution peripheral quantitative computed tomography (HR-pQCT), during treatment of patients with thyroid dysfunction.

METHODS

In women with newly diagnosed hypo- or hyperthyroidism, HR-pQCT variables, obtained from the tibia and the radius, were compared with BTMs. Data were collected at diagnosis and after at least 12 months of euthyroidism.

RESULTS

73 women completed the study (hypothyroidism, n = 27; hyperthyroidism, n = 46). Among hyperthyroid patients, correlations were found between changes in BTMs and HR-pQCT variables, primarily for cortical variables in the tibia, i.e. cortical thickness (CTX-I, p < 0.001; PINP, p < 0.001), and volumetric bone mass density (vBMD) (CTX-I, p < 0.001; PINP, p < 0.001). Moreover, correlations between BTMs and estimated bone strength were found. In the hypothyroid subgroup, no significant findings existed after adjustment. Following treatment, less decrease in tibial vBMD was seen among patients with increasing CTX-I compared to those with a decreasing CTX-I level (p = 0.009). Opposite findings applied to PINP, as patients with decreasing PINP showed an increase in tibial vBMD, in contrast to a decline in this parameter among patients with increasing PINP (p < 0.001).

CONCLUSION

Changes in CTX-I and PINP correlated with HR-pQCT variables during the treatment of women with thyroid dysfunction. To some extent, these BTMs reflected the restoration of bone microarchitecture. CTX-I seems to be the most sensitive BTM in treatment-naïve thyroid diseases, while PINP is more useful for monitoring during treatment.

TRIAL REGISTRATION NUMBER

NCT02005250. Date: December 9, 2013.

How, where and when to screen for porcine cytomegalovirus (PCMV) in donor pigs for xenotransplantation

Porcine cytomegalovirus (PCMV), that is actually a porcine roseolovirus (PRV), is a common herpesvirus in domestic pigs and wild boars. In xenotransplantation, PCMV/PRV has been shown to significantly reduce the survival time of pig kidneys and hearts in preclinical trials with different non-human primates. Furthermore, PCMV/PRV has been transmitted in the first pig to human heart xenotransplantation and contributed to the death of the patient. Although transmitted to the recipient, there is no evidence that PCMV/PRV can infect primate cells including human cells. PCMV/PRV is closely related to the human herpesviruses 6 and 7, and only distantly related to the human CMV (HCMV). Antiviral drugs used for the treatment of HCMV are less effective against PCMV/PRV. However, there are well described strategies to eliminate the virus from pig facilities. In order to detect the virus and to eliminate it, highly sensitive detection methods and the knowledge of how, where and when to screen the donor pigs is required. Here, a comparative testing of organs from pigs of different ages using polymerase chain reaction (PCR)-based and immunological methods was performed. Testing young piglets, PCMV/PRV was detected effectively by PCR in blood, bronchoalveolar lavage fluid, tonsils and heart. In adult animals, detection by PCR was not successful in most cases, because the virus load was below the detection limit or the virus was in its latent stage. Therefore, detection of antibodies against selected recombinant proteins corresponding to epitopes detected by nearly all infected animals in a Western blot assay is advantageous. By contrast, immunological testing is not beneficial in young animals as piglets might have PCMV/PRV-specific antibodies obtained from their infected mother via the colostrum. Using a thoughtful combination of PCR-based and immunological methods, detection of PCMV/PRV in donor pigs for xenotransplantation is feasible and a controlled elimination of the virus by early weaning or other methods is possible.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

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.

Global airways – a novel Standard Tests for Asthma, allergic Rhinitis, and chronic Rhinosinusitis (STARR-15)

Background: Global airway disease, with symptoms from both upper and lower airways, is a challenging problem for clinicians. Our goal is to design one single standard test for the awareness of global airway diseases to be used in clinical setting. Material and Methods: During 2019, rhinologists and pulmonologists generated a pool of items based on literature, patient-reported outcome measures and clinical experience. The items were administered to 206 patients with known asthma, CRS, allergic rhinitis, or a combination thereof. The patients also completed the Asthma Control Questionnaire (ACQ-5) and the Sino-Nasal Outcome Test (SNOT-22). Using a mix of clinical knowledge and data-driven methods a global airways questionnaire was developed. Results: Mean ACQ score was highest in patients with all three, whereas the highest SNOT-22 score was observed in patients with CRS and asthma. After the development process, analysis of responses from 206 patients to 44 items on a new global airway’s questionnaire led to identification of 15 items that form the STARR-15 questionnaire with three underlying domains (an allergic rhinitis sub-factor, a CRS sub-factor and an asthma sub-factor). Conclusion: STARR-15 represents the first global airways questionnaire, to be used when examining patients with upper and lower airways symptoms. Future analyses are warranted to evaluate the clinical and psychometric properties of STARR-15.

Is There an Association Between Bone Microarchitecture and Fracture in Patients who were Treated for High-grade Osteosarcoma? A Controlled Study at Long-term Follow-up Using High-resolution Peripheral Quantitative CT

BACKGROUND

Neoadjuvant chemotherapy in patients with primary osteosarcoma improves survival rates, but it also causes side effects in various organs including bone. Low bone mineral density (BMD) can occur owing partly to chemotherapy or limited mobility. This can cause a higher risk of fractures compared with those who do not receive such treatment. Changes in BMD alone cannot explain the propensity of fractures. Studying microarchitectural changes of bone might help to understand the effect.

QUESTIONS/PURPOSES

(1) Do patients who were treated for osteosarcoma (more than 20 years previously) have low BMD? (2) Do these patients experience more fractures than controls who do not have osteosarcoma? (3) What differences in bone microarchitecture are present between patients treated for high-grade osteosarcoma and individuals who have never had osteosarcoma?

METHODS

We contacted 48 patients who were treated for osteosarcoma and who participated in an earlier study. These patients underwent multimodal treatment including chemotherapy more than 20 years ago. Of the original patient group, 60% (29 of 48) were missing, leaving 40% (19 of 48) available for inclusion in this study; all 19 agreed to participate. There were nine men and 10 women with a mean age of 46 ± 4 years and a mean time from surgery to examination of 28 ± 3 years. BMD was measured by dual-energy x-ray absorptiometry, and any fracture history was assessed using a questionnaire. Additionally, high-resolution peripheral quantitative CT was performed to compare the groups in terms of microarchitectural changes, such as cortical and trabecular area, cortical and trabecular thickness, cortical porosity, and endocortical perimeter. Participants in the control group were selected from a cohort consisting of a population-based random sample of 499 healthy adult women and men. Osteoporosis or low BMD was not an exclusion criterion for entering this study; however, the patients in the control group were selected based on a normal BMD (that is, T score > -1.0 at both the spine and hip). Also, the participants were matched based on age and sex. Differences between patients and controls were assessed using the Wilcoxon rank sum test for continuous variables and a chi-square test for categorical variables. A multiple regression analysis was performed. Model assumptions were checked using histograms and quantile-quantile plots of residuals.

RESULTS

Twelve of 19 patients who were treated for osteosarcoma had either osteopenia (eight patients) or osteoporosis (four patients). More patients with osteosarcoma reported sustaining fractures (11 of 19 patients) than did control patients (2 of 19 controls; p < 0.001). Among all microarchitectural parameters, only the endocortical perimeter was increased in patients compared with the control group (75 ± 15 mm versus 62 ± 18 mm; p = 0.04); we found no differences between the groups in terms of cortical and trabecular area, cortical and trabecular thickness, or cortical porosity.

CONCLUSION

Although patients who were treated for osteosarcoma had osteopenic or osteoporotic BMD and a higher proportion of patients experienced fractures than did patients in the control group, we could not confirm differences in microarchitectural parameters using high-resolution peripheral quantitative CT. Therefore, it seems that bone geometry and microstructural parameters are not likely the cause of the increased proportion of fractures observed in our patients who were treated for osteosarcoma. Until we learn more about the bone changes associated with chemotherapy in patients with osteosarcoma, we recommend that patients undergo regular BMD testing, and we recommend that physicians consider osteoporosis treatment in patients with low BMD. These data might provide the impetus for future multicenter prospective studies examining the association between chemotherapy and bone microarchitecture.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Integrative single cell RNA-sequencing descrambles a substantial divergence of adaptive immune cell identities and transcriptional programs in mouse and human atherosclerosis

Aims

The distinct function of immune cells in human atherosclerosis has been mostly defined by preclinical mouse studies. Contrastingly, the immune cell composition of human atherosclerotic plaques and their contribution to disease progression is only poorly understood. It remains uncertain whether genetic animal models allow for valuable translational approaches.

Methods and results

We performed single cell RNA-sequencing (scRNAseq) to define the immune cell landscape in human carotid atherosclerotic plaques. The human immune cell repertoire was dominated by T cells with a considerable inter-patient variability and an unexpected heterogeneity. We performed bioinformatical integration with 7 mouse data sets and discovered a total of 38 cellular identities, of which some were not conserved between species and exclusively found in mice or humans. Locations, frequencies, and transcriptional programs of immune cells in preclinical mouse models did not resemble the immune cell landscape in human atherosclerosis. In contrast to mice, human plaques were not myeloid- and B cell-dominated and instead contained several T cell phenotypes with hallmarks of T cell memory, dysregulation, exhaustion, and activation. Human immune cells were predominantly enriched for transcriptional programs of hypoxia, glucose, and autoimmunity. In a validation cohort of 43 patients activated immune cell subsets defined by multi-colour flow cytometry associated with cerebral ischemia and coronary artery disease.

Conclusion

Here, we uncover yet undefined immune cell types associating with clinical disease. This leukocyte atlas of human atherosclerosis builds the conceptual basis for subsequent identification of cellular targets for clinical immunomodulatory therapies and risk prediction.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ERC Starting Grant

Progressive valvular calcifications with critical aortic stenosis in a 25-year-old woman with end-stage renal disease on haemodialysis: a case report

Background 

The increased risk of cardiovascular morbidity and mortality in chronic kidney disease (CKD) and end-stage renal disease (ESRD) seems particularly pronounced in patients with concomitant aortic and mitral valvular calcifications. Valvular calcification (VC) is accelerated in patients with CKD and even more so with ESRD and haemodialysis (HD) due to premature endothelial cell dysfunction. Mineral and bone disorder (CKD-MBD) is a common complication of CKD/ESRD and may play a pivotal role in VC.

Case summary 

A 25-year-old woman with congenital hypoplastic kidneys and ESRD on HD from the age of 19 was admitted to the emergency department suffering from chest pain and dyspnoea. Transthoracic echocardiogram (TTE) revealed critical aortic stenosis (AS) with indexed aortic valve area 0.4 cm²/m², a mean gradient 58 mmHg and a moderate mitral stenosis with a mean gradient 6–8 mmHg developed over the course of 2 years, as a normal TTE was performed at that time. During HD, the patient had longstanding alterations in calcium and phosphate metabolism including secondary hyperparathyroidism that eventually progressed into tertiary hyperparathyroidism. Efforts were made to treat CKD-MBD but patient compliance was low. Subtotal parathyroidectomy was performed 6 months prior to admission. The patient had dual mechanical valve replacement.

Discussion 

Valvular calcification is common in patients with CKD/ESRD and in particular in patients on HD. Rapid progression of valve disease in this case may be related to the combination of low patient adherence and sustained disturbed calcium and phosphate metabolism with tertiary hyperparathyroidism. Transthoracic echocardiogram should be performed in patients on HD even with minor suspicion of VC and in patients with low adherence and disturbance of calcium and phosphate metabolism.

A22 PREVALENCE OF IRON DEFICIENCY AND SUPPLEMENTATION PRACTICES FOR PATIENTS ON HOME PARENTERAL NUTRITION

Background

Iron deficiency (ID) is common in patients receiving parenteral nutrition (PN), likely due to a lack of iron in the PN formula. There is no clear consensus on how often serum iron should be tested or iron supplementation should be given, at which dose or route, in patients on long-term PN. Within the Hamilton Health Sciences (HHS) home PN (HPN) program, the prevalence of ID or iron deficiency anemia (IDA) is unknown. This knowledge will contribute to better iron prescribing practices with ultimate benefit on patient’s health.

Aims

To assess the prevalence of ID and IDA in patients enrolled in the HHS HPN Program. The secondary aim was to assess supplementation practices for patients enrolled in the HPN program according to gastrointestinal(GI) diagnosis and duration on PN.

Methods

We conducted a retrospective study including consecutive adult patients enrolled in the HHS-HPN program from January 2015 to November 2020. We collected data on demographics (age, sex, and GI diagnosis), iron supplementation (dose, duration, and route), and information related to iron-deficiency (hemoglobin, serum iron, ferritin, TIBC, and folate) at pre-set intervals (enrollment, 3, 6, 12, 18, 24, 30, 36, 48, 60 months) and last measured. ID was defined as ferritin ≤45μg/L or serum iron ≤9μmol/L. IDA was defined as hemoglobin &lt;130g/L in men or &lt;120g/L in women in the context of ID. Data were expressed as median (IQR) for continuous variables and n/N(%) for categorical variables. Chi2 was performed to assess differences between groups and logistic regression to assess predictors of ID and IDA. The analysis was conducted using SPSS software(v26).

Results

The analysis included 125 HPN patients (50 males, median age of 55 (40–65) years). Patients received PN for a median of 195 (83–521) days. The most common diagnoses were malignancy (36.8%) and inflammatory bowel disease (23.2%); the most common indications for HPN was short bowel (29.6%) and bowel obstruction (27.2%). Iron profiles were measured in 77% of patients. At enrollment, 42.2% of patients had ID and 38.9% had IDA. Only 13% of patients with ID and 22.8% with IDA had iron supplementation (Figure 1). A total of 38 patients received iron either oral or IV (oral=44.7% vs IV=55.3%; p=0.66). There was no correlation between low levels of serum iron or ferritin with iron supplementation (p=0.23, 0.45 respectively). Age, sex, diagnosis, or reason for PN did not correlate with ID or IDA at any time point.

Conclusions

Iron-deficiency and IDA are common in patients enrolled in the HHS HPN program independently of age, sex, diagnosis and reason for PN. Prospective studies are needed to implement the most effective way to ensure proper monitoring and treatment of iron deficiency in this population.

Funding Agencies

None

The transCampus Metabolic Training Programme Explores the Link of SARS-CoV-2 Virus to Metabolic Disease

Currently, we are experiencing a true pandemic of a communicable disease by the virus SARS-CoV-2 holding the whole world firmly in its grasp. Amazingly and unfortunately, this virus uses a metabolic and endocrine pathway via ACE2 to enter our cells causing damage and disease. Our international research training programme funded by the German Research Foundation has a clear mission to train the best students wherever they may come from to learn to tackle the enormous challenges of diabetes and its complications for our society. A modern training programme in diabetes and metabolism does not only involve a thorough understanding of classical physiology, biology and clinical diabetology but has to bring together an interdisciplinary team. With the arrival of the coronavirus pandemic, this prestigious and unique metabolic training programme is facing new challenges but also new opportunities. The consortium of the training programme has recognized early on the need for a guidance and for practical recommendations to cope with the COVID-19 pandemic for the community of patients with metabolic disease, obesity and diabetes. This involves the optimal management from surgical obesity programmes to medications and insulin replacement. We also established a global registry analyzing the dimension and role of metabolic disease including new onset diabetes potentially triggered by the virus. We have involved experts of infectious disease and virology to our faculty with this metabolic training programme to offer the full breadth and scope of expertise needed to meet these scientific challenges. We have all learned that this pandemic does not respect or heed any national borders and that we have to work together as a global community. We believe that this transCampus metabolic training programme provides a prime example how an international team of established experts in the field of metabolism can work together with students from all over the world to address a new pandemic.

[Perioperative medical prophylaxis of venous thromboembolic events in head and neck surgery : A retrospective study and recommendations]

BACKGROUND

In the authors' department, a newly implemented clinical algorithm for application of perioperative thrombosis prophylaxis in head and neck surgery recommends restrictive handling of anticoagulants. This retrospective study aims to evaluate the algorithm by comparing incidences of venous thromboembolic events (VTE) and surgical revisions due to postoperative hemorrhage.

MATERIALS AND METHODS

Perioperative incidences of deep vein thrombosis and pulmonary embolism as well as surgical revisions due to postoperative hemorrhage after head and neck surgery were determined based on all patients operated in the department over a period of 36 months. The incidences before (group I) and after (group II) implementation of the restrictive algorithm were compared.

RESULTS

A total of 9276 patients were included. The incidences of VTE (0.12%) and surgical revisions due to postoperative hemorrhage (1.4%) were low. Incidences of VTE were non-significantly higher in group II (0.16%) than in group I (0.08%; p > 0.45, chi-square-test). Case analysis revealed that this difference was not due to implementation of the restrictive algorithm. The incidence of surgical revision due to postoperative hemorrhage was identical in the two groups (1.4%).

CONCLUSION

After restricting the indication for thrombosis prophylaxis, the incidence of VTE or surgical revision due to postoperative hemorrhage did not change significantly. The provided clinical algorithm represents a low-risk and low-cost strategy of perioperative risk stratification.

Using behavioural skills training via telehealth to increase teachers use of communication interventions and increase student use of speech-generating devices in a high school functional skills classroom

BACKGROUND

Behavioural skills training (BST) has demonstrated effectiveness in training teachers in evidence-based interventions to increase communication for children with limited repertoires. However, research has yet to extend to youth with developmental disabilities who are learning to communicate using speech-generating devices. The emergent use of telehealth technology in applied behaviour analysis has been associated with greater access to therapeutic services. Although the use of telehealth has been extended as an avenue for parents to access behavioural intervention services for their child, fewer studies have evaluated the use of telehealth for teacher behavioural consultation or with adolescents and young adults with complex communication needs.

METHOD

In the present study, four teaching staff were trained via telehealth to implement communication facilitation strategies with augmentative and alterative communication users in a high school functional skills classroom. During the coaching sessions, the staff were provided BST on the basic behaviour analytic teaching strategies (e.g. assessing preference, environmental arrangement, and reinforcement strategies). Independent adapted ABAB designs were used to evaluate the effectiveness of modified BST delivered via telehealth on increased teaching staff-implemented communication opportunities within the functional skills classroom and the effectiveness of staff-implemented communication intervention on increased speech-generating device mands for four adolescents/young adults with developmental disabilities.

RESULTS

The results indicated that the improved staff fidelity of the communication interventions was associated with the increased level of independent student mands for each dyad. Lastly, social validity data suggest that the procedures were acceptable and feasible. These data indicate that the use of telehealth may be a viable model for specialised classroom consultation.

CONCLUSION

The use of a telehealth delivery model to train classroom staff may be a viable option when specialised support is necessary, but access is limited.

Consequences of Hyperthyroidism and Its Treatment for Bone Microarchitecture Assessed by High-Resolution Peripheral Quantitative Computed Tomography

Background: Hyperthyroidism is associated with bone mass reduction and increased fracture risk, but the effects on other important bone parameters have been sparsely examined. Therefore, we investigated bone microarchitecture and estimated bone strength by high-resolution peripheral quantitative computed tomography (HR-pQCT) in hyperthyroid patients at diagnosis and after being euthyroid for at least one year. Methods: Two approaches were used: (A) a case-control study comparing 61 hyperthyroid women with 61 euthyroid women matched for age and menopause status; (B) a follow-up study, in which 46 of the 61 women were re-examined after having been euthyroid for one year. HR-pQCT of the distal radius and tibia, and dual-energy X-ray absorptiometry (DXA) of the lumbar spine and the hip were performed. Results: In analysis A: In the radius, compared with the healthy controls, hyperthyroid patients had higher total area (16.9% ± 29.5%; p < 0.001), trabecular area (28.6% ± 45.7%; p < 0.001), and lower cortical area (-11.7% ± 23.2%; p < 0.001). Total volumetric bone mineral density (vBMD) (-13.9% ± 26.5%; p < 0.001), cortical vBMD (-5.8% ± 7.9%; p < 0.001), cortical thickness (-16.7% ± 26.0%; p < 0.001), and estimated bone strength (-6.6% ± 19.5%; p < 0.01) were lower. No significant differences were found in the tibia or in the DXA parameters. In analysis B: In the radius, significant improvements were observed in the cortical area (2.1% ± 4.6%; p < 0.01), cortical thickness (2.5% ± 5.1%; p < 0.001), and total vBMD (0.8% ± 3.0%; p < 0.05). Trabecular area decreased (-0.5% ± 1.0%; p < 0.01) and trabecular separation increased (2.0% ± 8.3%; p < 0.05). In the tibia, cortical area (3.6% ± 7.3%; p < 0.01) and cortical thickness (3.8% ± 7.6%; p < 0.01) increased, and trabecular area decreased (-0.5% ± 1.1%; p < 0.01). Areal BMD, measured by DXA, increased in the spine (1.1% ± 3.4%; p < 0.05) and in the hip (2.0% ± 3.8%; p < 0.01). Conclusions: Compared with the healthy control group, hyperthyroid women had lower vBMD, lower estimated bone strength, and compromised cortical microarchitecture in the radius. After restoration of euthyroidism, significant improvements in vBMD and cortical microarchitecture were observed, highlighting the importance of achieving and maintaining euthyroidism.

Restoration of euthyroidism in women with Hashimoto's thyroiditis changes bone microarchitecture but not estimated bone strength

PURPOSE

Fracture risk in hypothyroid patients is debated, and since the effects of hypothyroidism on bone microarchitecture and strength are unclarified, we investigated these characteristics by high-resolution peripheral quantitative computed tomography (HR-pQCT).

METHODS

Two approaches were used: a cross-sectional control study, comparing 32 hypothyroid women (mean age; 47 ± 12 years) suffering from Hashimoto's thyroiditis with 32 sex-, age-, and menopause-matched healthy controls; a prospective study, where 27 of the women were reexamined 1 year after restoration of euthyroidism. HR-pQCT of the distal radius and tibia, and dual-energy X-ray absorptiometry (DXA) of the spine and hip were performed. Bone strength was estimated using a finite element analysis (FEA).

RESULTS

Cross-sectional control study: in the radius, total (mean 14.6 ± 29.3% (SD); p = 0.04) and trabecular bone areas (19.8 ± 37.1%, p = 0.04) were higher, and cortical volumetric bone mineral density (vBMD) lower (-2.2 ± 6.5%, p = 0.032) in hypothyroid patients than in controls. All indices of tibia cortical and trabecular vBMD, microarchitecture, and estimated bone strength were similar between groups, as was hip and spine areal BMD (aBMD). Prospective study: in the radius, mean cortical (-0.9 ± 1.8%, p = 0.02) and trabecular (-1.5 ± 4.6%, p = 0.02) vBMD decreased, and cortical porosity increased (18.9 ± 32.7%, p = 0.02). In the tibia, mean total vBMD (-1.1 ± 1.9%, p = 0.01) and cortical vBMD (-0.8 ± 1.4%, p = 0.01) decreased, while cortical porosity (8.2 ± 11.5%, p = 0.002) and trabecular area (0.2 ± 0.6%, p = 0.047) increased. No changes in FEA were detected. Lumbar spine aBMD decreased (-1.3 ± 3.0%, p = 0.04).

CONCLUSIONS

Hypothyroidism was associated with an increased trabecular bone area and a lower mineral density of cortical bone in the radius, as assessed by HR-pQCT. Restoration of euthyroidism mainly increased cortical porosity, while estimated bone strength was unaffected.

Fast electron transport dynamics and energy deposition in magnetized, imploded cylindrical plasma

Inertial confinement fusion approaches involve the creation of high-energy-density states through compression. High gain scenarios may be enabled by the beneficial heating from fast electrons produced with an intense laser and by energy containment with a high-strength magnetic field. Here, we report experimental measurements from a configuration integrating a magnetized, imploded cylindrical plasma and intense laser-driven electrons as well as multi-stage simulations that show fast electrons transport pathways at different times during the implosion and quantify their energy deposition contribution. The experiment consisted of a CH foam cylinder, inside an external coaxial magnetic field of 5 T, that was imploded using 36 OMEGA laser beams. Two-dimensional (2D) hydrodynamic modelling predicts the CH density reaches [Formula: see text], the temperature reaches 920 eV and the external B-field is amplified at maximum compression to 580 T. At pre-determined times during the compression, the intense OMEGA EP laser irradiated one end of the cylinder to accelerate relativistic electrons into the dense imploded plasma providing additional heating. The relativistic electron beam generation was simulated using a 2D particle-in-cell (PIC) code. Finally, three-dimensional hybrid-PIC simulations calculated the electron propagation and energy deposition inside the target and revealed the roles the compressed and self-generated B-fields play in transport. During a time window before the maximum compression time, the self-generated B-field on the compression front confines the injected electrons inside the target, increasing the temperature through Joule heating. For a stronger B-field seed of 20 T, the electrons are predicted to be guided into the compressed target and provide additional collisional heating. This article is part of a discussion meeting issue 'Prospects for high gain inertial fusion energy (part 2)'.

Thermographic visualization of facial vasoconstriction is associated with 30-day all-cause mortality in medical patients; prospective observational two-site cohort study

INTRODUCTION

Quick and reliable assessment of acute patients is required for accurate triage. The temperature gradient between core and peripheral temperature could possibly instantly provide information on circulatory status.

METHODS

Adult medical patients, who did not receive supplementary oxygen, attending two emergency departments, had a thermographic image taken on arrival. The association between 30-day mortality and gradients was tested using logistic regression.

RESULTS

726 patients were studied, median age was 64 years and 14 (1.9%) died within 30 days. There was a significant association between mortality and temperature gradient, comparable to vital signs, age, and clinical intuition.

CONCLUSION

Temperature gradient between nose and eye had an acceptable discriminatory power for 30-day all-cause mortality.

Atlas of the immune cell repertoire in human atherosclerotic plaques characterized by single cell RNA-sequencing and multi-color flow cytometry

Rationale

Atherosclerosis is a chronic inflammatory disease that is driven by the accumulation of pro- and anti-inflammatory leukocytes in the intima of affected arteries. Yet, the cellular composition of human atherosclerotic plaques is only poorly understood. Here, we characterized immune cells to human carotid atherosclerotic plaques by multi-color flow cytometry and scRNAseq.

Methods and results

First, we compared a set of previously reported digestion protocols to liberate leukocytes from human carotid plaques after surgical thrombendarteriectomy. One digestion cocktail, containing Collagenase IV and DNase I, was superior regarding cell survival and cell surface marker preservation. Second, leukocytes from 56 surgical specimen were characterized by flow cytometry with a set of 16 parameters and cell surface markers capable of identifying principal hematopoietic leukocyte lineages. This protocol allowed to extract and analyze on average 4x103 viable CD45+ leukocytes from a mean of 988 mg plaque tissue. Surprisingly, we found that atherosclerotic plaques were dominated by T cells with 33.7±2.2% CD4+ T-helper cells and 25.6±2.5% CD8+ cytotoxic T cells. CD11b+ myeloid cells, including monocytes and macrophages, represented only 20.2±4.0% of all CD45+ leukocytes. CD19+B cells and CD56+ NK-cells accounted for 3.9±1.2 and 3.3±0.5%, respectively. TCR-g/d+ T cells and neutrophils were undetectable in atherosclerotic plaques. This cellular composition differed significantly from peripheral blood, but was not relevantly changed between different plaque locations, indicating that macrophage-rich necrotic cores mostly contain dead cells. We confirmed the principal composition of human plaques by single-cell RNA-sequencing from six patients. To allow an estimation of cellular heterogeneity independent of classical cell surface marker assignment, we performed an unsupervised cluster detection algorithm by t-distributed stochastic neighbor embedding (tSNE) and found more than 16 leukocyte clusters with unique cell surface marker expression, suggesting an unexpected high diversity of plaque leukocytes.

Conclusion

We developed an immune cell phenotyping protocol optimized for human carotid plaques. The definition of phenotypes and frequencies in atherosclerotic plaques will allow to build clinical associations between the immune cell composition and clinical outcomes in future.

Funding Acknowledgement

Type of funding source: None

[Elective tracheostomy in COVID-19 patients: experience with a standardized interdisciplinary approach]

Berichtet wird über die Erfahrungen mit einer interdisziplinären klinikinternen SOP (Standard Operation Procedure) zur Tracheostomie (TS) bei „Coronavirus-Disease“(COVID-19)-Patienten, unter Berücksichtigung der allgemeinen nationalen und internationalen Empfehlungen. Der interdisziplinär festgelegte operative Zeitpunkt der TS aufgrund einer prolongierten invasiven Beatmung und frustranen Weaning-Versuchen betraf Phasen sowohl hoher als auch niedriger Erkrankungsaktivität. Es wurden 5 TS bei Patienten mit einem Durchschnittsalter von 70,6 Jahren durchgeführt. Neben den Standard-COVID-19-Schutzmaßnahmen für das medizinische Personal zur Vermeidung einer nosokomialen COVID-19-Infektion führt die SOP-unterstützte Kommunikation während der TS zu einer periprozeduralen Sicherheit aller Beteiligten. COVID-19-Erkrankungen des medizinischen Personals der beteiligten Abteilungen sind bisher nicht bekannt.

The combined effect of parathyroid hormone (1-34) and whole-body vibration exercise on physical performance in OSteoporotic women (PaVOS study): a secondary analysis from a randomised controlled trial

Background

The aim of this study was to investigate the effect on physical performance of combining whole-body vibration exercise (WBV) with parathyroid hormone 1-34 (teriparatide) compared to teriparatide alone.

Methods

A secondary analysis from a RCT where postmenopausal women with severe osteoporosis were randomised to WBV plus teriparatide (intervention) or teriparatide alone (control). WBV was applied three times/week (6x1min WBV:1 min rest, (peak acceleration 3.6 g)) for twelve months. Both groups received teriparatide 20 μg s.c./day. The primary endpoint (bone mineral density) is reported elsewhere. Physical performance measures (Short Physical Performance Battery (SPPB), Timed-Up-and-Go (TUG), leg extension power, and grip strength) were obtained at baseline, three-, six-, and twelve months, lean mass at baseline and twelve months. Data were analysed with mixed linear regression model or robust cluster regression in an intention to treat analysis.

Results

Thirty-five women aged (mean ± SD) 69 ± 7) years were recruited of which thirty-two (91%) completed the twelve months follow-up (WBV + teriparatide = 15, teriparatide = 17). SPPB score (mean ± SD) improved significantly at three months in the WBV + teriparatide group from 9.13 ± 2.03 to 10.35 ± 1.69 (p = 0.014) with a statistical trend towards a between-group change in favor of the WBV + teriparatide group (0.86 [95%CI(- 0.05,1.77), p = 0.065]). Both groups improved in leg extension power during the study period whereas no changes were seen in TUG, grip strength, or lean mass in either group. No statistical significant between-group differences were observed.

Conclusion

WBV may improve some short-term aspects of physical performance in severely osteoporotic postmenopausal women who are receiving teriparatide treatment.

Trial Registration

ClinicalTrials.gov, ID:NCT02563353.

Targeted next-generation sequencing of adult gliomas for retrospective prognostic evaluation and up-front diagnostics

AIMS

We aimed to reclassify a population-based cohort of 529 adult glioma patients to evaluate the prognostic impact of the 2016 World Health Organization (WHO) central nervous system tumour classification. Moreover, we evaluated the feasibility of gene panel next-generation sequencing (NGS) in daily diagnostics of 225 prospective glioma patients.

METHODS

The retrospective cohort was reclassified according to WHO 2016 criteria by immunohistochemistry for IDH-R132H, fluorescence in situ hybridization for 1p/19q-codeletion and gene panel NGS. All tumours of the prospective cohort were subjected to NGS analysis up-front.

RESULTS

The entire population-based cohort was successfully reclassified according to WHO 2016 criteria. NGS results were obtained for 98% of the prospective patients. Survival analyses in the population-based cohort confirmed three major prognostic subgroups, that is, isocitrate dehydrogenase (IDH)-mutant and 1p/19q-codeleted oligodendrogliomas, IDH-mutant astrocytomas and IDH-wildtype glioblastomas. The distinction between WHO grade II and III was prognostic in patients with IDH-mutant astrocytoma. The survival of patients with IDH-wildtype diffuse astrocytomas carrying TERT promoter mutation and/or EGFR amplification overlapped with the poor survival of IDH-wildtype glioblastoma patients.

CONCLUSIONS

Gene panel NGS proved feasible in daily diagnostics. In addition, our study confirms the prognostic role of glioma classification according to WHO 2016 in a large population-based cohort. Molecular features of glioblastoma in IDH-wildtype diffuse glioma were linked to poor survival corresponding to IDH-wildtype glioblastoma patients. The distinction between WHO grade II and III retained prognostic significance in patients with IDH-mutant diffuse astrocytic gliomas.

0399 The MSSA: A Novel Instrument to Assess Sleep and Sleep Disturbances in Military Men and Women

Introduction

Military personnel experience unique stressors (e.g., deployments, shift work, family separation) which can cause sleep disturbances. However, little is known regarding the general sleep quality of military personnel and how it changes throughout their service, what types of stressors precipitate sleep disturbances, and how this differs among military men and women. We present findings from a new self-report measure, the Military Service Sleep Assessment (MSSA), which was designed to assess (1) current primary problems with sleep, (2) sleep quality throughout military service (3) life events that may have impacted their sleep and (4) the specific events which most effected sleep.

Methods

A total of 69 military personnel (22 women and 47 men) completed the MSSA and 49 also completed a diagnostic polysomnogram (PSG). Chi-square tests were run to differences in responses between men and women.

Results

No significant differences were found between men and women. In general, sleep quality progressively decreased over a participant’s military career from 3 to 2 on a 5-point Likert scale (1=low, 5=high). For those with at least one deployment (n=52), 73% reported that deployment and 54% reported that a redeployment (return from deployment) negatively impacted sleep quality for 3 months. Women reported that permanent change of station (PCS) negatively impacted their sleep more frequently than men (36% vs. 28%). The reported events that most significantly impacted sleep quality were deployment, military service other than deployment and trauma.

Conclusion

The MSSA is a novel instrument that can be used to increase understanding of sleep disturbances in military men and women which can inform prevention and treatment strategies. This measure is being used to systematically evaluate the factors which may precipitate or perpetuate sleep disturbances in military men and women such as military service-associated factors, training, deployment history, changing stations, and exposure to trauma or other stressful life events.

Support

This study is supported by the Defense Health Agency, Defense Medical Research and Development Program, Clinical Research Intramural Initiative for Military Women’s Health.

0860 Sleep Disorders In Female Military Personnel

Introduction

Sleep is an essential biological function and the disruption of sleep has deleterious consequences. Military personnel experience unique stressors related to their service, elevating the risk of developing sleep disorders. The etiologies and impact of sleep disorders on military women’s health is poorly understood. This study is the first to prospectively assess whether military women with insomnia, obstructive sleep apnea (OSA), or comorbid insomnia and OSA (COMISA) have different gender roles, military service-associated factors, and biological characteristics than military men with the same disorders.

Methods

This is a prospective observational study of military personnel with sleep disturbances. The study will evaluate women and men matched for sleep disorder. Participants will complete an evaluation to include polysomnography (PSG), sleep questionnaires and validated clinical assessments of associated disorders of interest. The baseline demographics, questionnaire, and PSG results will be analyzed to assess for commonalities or differences between genders.

Results

We have enrolled 45 patients (24% female). Males had a higher BMI (29.1) than females (26). Males were also older (38) than females (35). The leading diagnosis in males was OSA (44%) and insomnia in females (64%). In males, the apnea-hypopnea index (AHI) was 11.3/hr, arousal index (ARI) was 20/hr, and sleep efficiency (SE) was 86.5%. Total sleep time (TST), wake after sleep onset (WASO), and sleep onset latency (SOL) were 364.6, 40.9, and 12.6 minutes, respectively. In females, the average AHI was 6.6/hr, ARI was 15/hr, and SE was 87.2%. Their TST, WASO, and SOL were 359, 44, and 12.6 minutes, respectively.

Conclusion

Military personnel are at increased risk of sleep disorders. Literature comparing male and female characteristics and sleep disorders is scarce. In this study, baseline demographics were similar in both groups but insomnia was the leading diagnosis for women. This emphasizes the importance of adequate recognition and treatment of insomnia in this group.

Support

This study is supported by the Defense Health Agency, Defense Medical Research and Development Program, Clinical Research Intramural Initiative for Military Women’s Health.

Exploring the link between character, personality disorder, and neuropsychological function

Personality deviations and deficits in cognitive executive function are common among forensic populations. The present study on incarcerated offenders explored whether there are links between the two domains. Personality was assessed using the Temperament and Character Inventory (TCI). Neuropsychological performance, including visual working memory, attentional set-shifting and planning, were tested with the Cambridge Neuropsychological Test Automated Battery (CANTAB). Subjects with personality disorders scored high on harm avoidance, and low on self-directedness and cooperativeness. Personality disordered offenders did not differ from the comparison groups (offenders without personality disorder, and non-criminal controls) with regard to CANTAB measures of visual working memory (delayed matching to sample, spatial working memory) and planning (Stockings of Cambridge), but they made a larger number of errors on the attentional set-shifting task. Dimensional analysis of the personality and neuropsychological variables revealed significant associations between self-directedness and cooperativeness on the one hand, and attentional set-shifting on the other. Intellectually disabled, non-criminal individuals (marginal mental retardation) who performed poorly on attentional set-shifting also scored low on self-directedness and cooperativeness. The results indicate that poor development of certain personality traits may be associated with deficits in neuropsychological functioning.

Continuous decline in bone mineral density and deterioration of bone microarchitecture 7 years after Roux-en-Y gastric bypass surgery

OBJECTIVE

Roux-en-Y-gastric bypass (RYGB) surgery is an effective treatment for morbid obesity. A possible overlooked side effect is negative bone metabolic consequences.

DESIGN

A seven-year prospective study following ten women and seven men after RYGB (baseline mean age 43 ± 8 years, BMI 42 ± 6 kg/m2).

METHODS

Lumbar spine and total hip bone mineral density (BMD) using dual energy x-ray absorptiometry, distal radius and tibia bone geometry, volumetric BMD, microarchitecture and finite element estimated bone strength using high-resolution peripheral quantitative CT and biochemical markers of bone remodelling were assessed at baseline, 2 and 7 years.

RESULTS

Compared to baseline, body weight was 24 ± 10% lower after 2 years and 21 ± 11% after 7 years. During the 7 years of follow-up, radius and tibia vBMD had declined 13 ± 8% and 8 ± 7% from baseline to 2 years and further 10 ± 7% and 7 ± 8% from 2 to 7 years (all P < 0.001). At both radius and tibia, cortical thickness declined and cortical porosity increased. From baseline to 7 years, there were clear indications of deteriorations of the trabecular network with fewer, more widely spaced and more in-homogeneously distributed trabeculae in both radius and tibia. Overall, declines in estimated bone strength of 16 ± 9% in radius and 16 ± 7% in tibia were observed (both P < 0.001).

CONCLUSION

Seven years after RYGB, evidence of continuous declines in BMD and ongoing deterioration of bone microarchitecture and reduced estimated bone strength compared to baseline and 2 years post-surgery results were found. These findings emphasize the need for regular assessment of bone health in patients with prior RYGB.

Testing of the WHO Infection Prevention and Control Assessment Framework at acute healthcare facility level

BACKGROUND

Monitoring and evaluation are an essential part of infection prevention and control (IPC) implementation. The authors developed an IPC assessment framework (IPCAF) to support implementation of the World Health Organization (WHO) guidelines on core components of IPC programmes in acute healthcare facilities.

AIM

To evaluate the usability and reliability of the IPCAF tool for global use.

METHODS

The IPCAF is a questionnaire with a scoring system to measure the level of IPC implementation according to the eight WHO core components. The tool was pre-tested qualitatively, revised and translated selectively. A convenience sample of hospitals was invited to participate in the final testing. At least two IPC professionals from each hospital independently completed the IPCAF and a usability questionnaire online. The tool's internal consistency and interobserver reliability or intraclass correlation coefficient (ICC) were assessed, and usability questions were summarized descriptively.

FINDINGS

In total, 46 countries, 181 hospitals and 324 individuals participated; 52 (16%) and 55 (17%) individual respondents came from low- and lower-middle income countries, respectively. Fifty-two percent of respondents took less than 1 h to complete the IPCAF. Overall, there was adequate internal consistency and a high ICC (0.92, 95% confidence interval 0.89-0.94). Ten individual questions had poor reliability (ICC <0.4); these were considered for revision according to usability feedback and expert opinion.

CONCLUSIONS

The WHO IPCAF was tested using a robust global study and revised as necessary. It is now an effective tool for IPC improvement in healthcare facilities.

Rapid Determination of Total trans Fat Content—An Attenuated Total Reflection Infrared Spectroscopy International Collaborative Study

Interest in trans fat labeling has prompted efforts to develop new, more efficient methods for rapidly and accurately determining trans fat content of foods. A novel and rapid (5 min) attenuated total reflection–Fourier transform infrared (ATR–FTIR) spectroscopic procedure was recently developed and applied to food products. This procedure was voted official method AOCS Cd 14d-99 by the American Oil Chemists' Society in 1999 after testing in a 12 laboratory international collaborative study. The results of the study are described in this paper. Analytical ATR–FTIR results exhibited high accuracy in the range 5–40% trans; results tended to have &lt;2% high bias relative to the gravimetrically determined values. The precision of this internal reflection method was found to be superior to the precision of transmission infrared official methods. It is recommended that the applicability of the ATR–FTIR method be limited to trans levels of &gt;5% (as percent of total fat).

The combined effect of Parathyroid hormone (1-34) and whole-body Vibration exercise in the treatment of postmenopausal OSteoporosis (PaVOS study): a randomized controlled trial

Treatment effects of combining teriparatide and whole-body vibration exercise (WBV) vs teriparatide alone in twelve months were compared using bone mineral density (BMD), bone microarchitecture, and bone turnover markers. We found an increased effect in lumbar spine BMD by adding WBV to teriparatide in postmenopausal osteoporotic women.

INTRODUCTION

The parathyroid hormone (PTH) analogue teriparatide is an effective but expensive anabolic treatment for osteoporosis. Whole-body vibration exercise (WBV) has been found to stimulate muscle and bone strength in some studies. Animal data demonstrate a beneficial effect on bone when combining PTH with mechanical loading. The aim of this study was to investigate if combining WBV exercise and teriparatide treatment gives additional beneficial effects on bone compared to teriparatide alone in postmenopausal women with osteoporosis.

METHODS

The PaVOS study is a randomized controlled trial where postmenopausal osteoporotic women starting teriparatide 20 μg/day were randomized to WBV + teriparatide or teriparatide alone. WBV consisted of three sessions a week (12 min, including 1:1 ratio of exercise:rest). Bone mineral density (BMD) and bone microarchitecture, bone turnover markers, and sclerostin measurements were obtained. Data were analyzed using a linear mixed regression model with adjustment for baseline values or robust cluster regression in an intention-to-treat (ITT) analysis.

RESULTS

Thirty-five women were randomized (17 in teriparatide + WBV group and 18 in teriparatide group). At 12 months, both groups increased significantly in BMD at the lumbar spine. The teriparatide + WBV group increased by (mean ± SD) 8.90% ± 5.47 and the teriparatide group by 6.65% ± 5.51. The adjusted treatment effect of adding WBV to teriparatide was statistically significant at 2.95% [95% CI = 0.14-5.77; P = 0.040]. Markers of bone turnover increased significantly in both groups at three and six months with no significant difference between groups. No other treatment effects were observed in hip BMD, bone microarchitecture parameters, or sclerostin levels in either group.

CONCLUSION

Twelve months of WBV and teriparatide had a significant clinically relevant treatment effect in lumbar spine BMD compared to teriparatide alone in postmenopausal osteoporotic women. ClinicalTrials.gov :(NCT02563353).

Prevalence and incidence of surgical site infections in the European Union/European Economic Area: how do these measures relate?

BACKGROUND

In 2011-2012, the European Centre for Disease Prevention and Control (ECDC) initiated the first European point prevalence survey (PPS) of healthcare-associated infections (HCAIs) in addition to targeted surveillance of the incidence of specific types of HCAI such as surgical site infections (SSIs).

AIM

To investigate whether national and multi-country SSI incidence can be estimated from ECDC PPS data.

METHODS

In all, 159 hospitals were included from 15 countries that participated in both ECDC surveillance modules, aligning surgical procedures in the incidence surveillance to corresponding specialties from the PPS. National daily prevalence of SSIs was simulated from the incidence surveillance data, the Rhame and Sudderth (R&S) formula was used to estimate national and multi-country SSI incidence from the PPS data, and national incidence per specialty was predicted using a linear model including data from the PPS.

FINDINGS

The simulation of daily SSI prevalence from incidence surveillance of SSIs showed that prevalence fluctuated randomly depending on the day of measurement. The correlation between the national aggregated incidence estimated with R&S formula and observed SSI incidence was low (correlation coefficient = 0.24), but specialty-specific incidence results were more reliable, especially when the number of included patients was large (correlation coefficients ranging from 0.40 to 1.00). The linear prediction model including PPS data had low proportion of explained variance (0.40).

CONCLUSION

Due to a lack of accuracy, use of PPS data to estimate SSI incidence is recommended only in situations where incidence surveillance of SSIs is not performed, and where sufficiently large samples of PPS data are available.

Elevated Bone Remodeling Markers of CTX and P1NP in Addition to Sclerostin in Patients with X-linked Hypophosphatemia: A Cross-Sectional Controlled Study

Aspects of bone remodeling have only been scarcely studied in X-linked hypophosphatemia (XLH). In this cross-sectional controlled study, we assessed biochemical indices of bone remodeling and sclerostin in 27 adult patients (median age 47 [range 24-79] years, 19 women, 8 men) with XLH matched with 81 healthy control subjects (1:3) with respect to age-, sex-, and menopausal status. Markers of bone resorption (carboxyterminal cross-linked telopeptide of type 1 collagen, CTX) and formation (N-terminal propeptide of type 1 procollagen, P1NP) were higher in XLH patients compared to controls (median [IQR] 810 [500-1340] vs 485 [265-715] ng/l and 90 [57-136] vs 49 [39-65] ug/l, respectively, both p < 0.001) as well as sclerostin (0.81 [0.60-1.18] vs 0.54 [0.45-0.69] ng/ml, p < 0.001). Similar differences were found when comparing currently treated (with phosphate and alfacalcidol) (n = 11) and untreated (n = 16) XLH patients with their respective controls. We found no significant associations with treatment status and indices of bone remodeling or sclerostin although sclerostin tended to be increased in untreated versus treated (p = 0.06). In contrast to previous histomorphometric studies suggesting a low remodeling activity in XLH, these biochemical indices suggest high osteoblast and osteoclast activity. Further studies are needed to ascertain if the higher sclerostin level in XLH is related to osteocyte dysfunction or represents a secondary phenomenon.