Pop-up Langmuir probe diagnostic in the water cooled divertor of Wendelstein 7-X

The design, development, and successful implementation of pop-up Langmuir probes installed in the water-cooled divertor of W7-X are described. The probes are controlled by drive coils (actuators) installed behind the divertor plates. These drive coils make use of the magnetic field in W7-X to move the probe tips into and out of the plasma. The drive coils were installed in the vacuum vessel after extensively testing the durability of the coils and analyzing the criteria for safe operation. The probe design is carefully tailored for each of the 36 probe tips in order to be suitable for the different magnetic field configurations used in W7-X and ensure that the probes do not present leading edges to the magnetic flux tubes. An electronic bridge circuit is used for measurement to compensate for the effects of signal propagation time on the long cable lengths used. The diagnostic is integrated with the segment control of W7-X for automated operation and control of the diagnostic. The evaluation of the results from the plasma operation is presented after accounting for appropriate sheath expansion for negative bias voltage on the probes.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Myiasis of open great toe fracture wound: a rare case report

Introduction and importance

Myiasis of an open fracture wound is very rare but can occur due to neglect of wound care.

Case presentation

A 12-year-old boy from a low socio-economic background, following an impact injury in his right great toe 10 days back presented with complaints of pain, swelling, and a foul-smelling odor from his right great toe. On examination, a swollen, tender puncture wound was noted over the dorsal aspect of the great toe revealing part of live larvae and serosanguinous discharge. Management was done with the complete removal of maggots, wound debridement, wound lavage, administration of systemic antibiotics, and toe guard slab application.

Clinical discussion

Wound myiasis results from a facultative or obligatory parasite that is initiated when flies oviposit in hemorrhagic, necrotic, or pus-filled lesions. The possible complications of myiasis include local destruction, invasion into deep tissues, and secondary infection, which could result in amputation of the affected area, especially where obligatory parasites are concerned.

Conclusion

Myiasis commonly occurs due to poor hygiene and neglect of wound care along with many other risk factors. Early proper wound care prevents the development of wound myiasis and early diagnosis and treatment of myiasis prevent complication of local tissue destruction and amputation of affected parts.

Cellulose nanofibers (CNFs) in the recycling of nickel and cadmium battery metals using electrodeposition

Cellulose nanofibers (CNFs) were employed in the aqueous electrodeposition of nickel and cadmium for battery metal recycling. The electrowinning of mixed Ni-Cd metal ion recycling solutions demonstrated that cadmium with a purity of over 99% could be selectively extracted while leaving the nickel in the solution. Two types of CNFs were evaluated: negatively charged CNFs (a-CNF) obtained through acid hydrolysis (-75 μeq. g-1) and positively charged CNFs (q-CNF) functionalized with quaternary ammonium groups (+85 μeq. g-1). The inclusion of CNFs in the Ni-Cd electrolytes induced growth of cm-sized dendrites in conditions where dendrites were otherwise not observed, or increased the degree of dendritic growth when it was already present to a lesser extent. The augmented dendritic growth correlated with an increase in deposition yields of up to 30%. Additionally, it facilitated the formation of easily detachable dendritic structures, enabling more efficient processing on a large scale and enhancing the recovery of the toxic cadmium metal. Regardless of the charged nature of the CNFs, both negatively and positively charged CNFs led to a significant formation of protruding cadmium dendrites. When deposited separately, dendritic growth and increased deposition yields remained consistent for the cadmium metal. However, dendrites were not observed during the deposition of nickel; instead, uniformly deposited layers were formed, albeit at lower yields (20%), when positively charged CNFs were present. This paper explores the potential of utilizing cellulose and its derivatives as the world's largest biomass resource to enhance battery metal recycling processes.

AAV-based gene therapy prevents and halts the progression of dilated cardiomyopathy in a mouse model of phosphoglucomutase 1 deficiency (PGM1-CDG)

Phosphoglucomutase 1 (PGM1) deficiency is recognized as the third most common N-linked congenital disorders of glycosylation (CDG) in humans. Affected individuals present with liver, musculoskeletal, endocrine, and coagulation symptoms; however, the most life-threatening complication is the early onset of dilated cardiomyopathy (DCM). Recently, we discovered that oral D-galactose supplementation improved liver disease, endocrine, and coagulation abnormalities, but does not alleviate the fatal cardiomyopathy and the associated myopathy. Here we report on left ventricular ejection fraction (LVEF) in 6 individuals with PGM1-CDG. LVEF was pathologically low in most of these individuals and varied between 10% and 65%. To study the pathobiology of the cardiac disease observed in PGM1-CDG, we constructed a novel cardiomyocyte-specific conditional Pgm2 gene (mouse ortholog of human PGM1) knockout (Pgm2 cKO) mouse model. Echocardiography studies corroborated a DCM phenotype with significantly reduced ejection fraction and left ventricular dilation similar to those seen in individuals with PGM1-CDG. Histological studies demonstrated excess glycogen accumulation and fibrosis, while ultrastructural analysis revealed Z-disk disarray and swollen/fragmented mitochondria, which was similar to the ultrastructural pathology in the cardiac explant of an individual with PGM1-CDG. In addition, we found decreased mitochondrial function in the heart of KO mice. Transcriptomic analysis of hearts from mutant mice demonstrated a gene signature of DCM. Although proteomics revealed only mild changes in global protein expression in left ventricular tissue of mutant mice, a glycoproteomic analysis unveiled broad glycosylation changes with significant alterations in sarcolemmal proteins including different subunits of laminin-211, which was confirmed by immunoblot analyses. Finally, augmentation of PGM1 in KO mice via AAV9-PGM1 gene replacement therapy prevented and halted the progression of the DCM phenotype.

Reversal of Solvent Migration in Poroelastic Folds

Polymer networks and biological tissues are often swollen by a solvent such that their properties emerge from a coupling between swelling and elastic stress. This poroelastic coupling becomes particularly intricate in wetting, adhesion, and creasing, for which sharp folds appear that can even lead to phase separation. Here, we resolve the singular nature of poroelastic surface folds and determine the solvent distribution in the vicinity of the fold tip. Surprisingly, two opposite scenarios emerge depending on the angle of the fold. In obtuse folds such as creases, it is found that the solvent is completely expelled near the crease tip, according to a nontrivial spatial distribution. For wetting ridges with acute fold angles, the solvent migration is reversed as compared to creasing, and the degree of swelling is maximal at the fold tip. We discuss how our poroelastic fold analysis offers an explanation for phase separation, fracture, and contact angle hysteresis.

Awareness and perception of an Indian dental professional in context to the process and their role in disaster victim identification as a taskmaster

Forensic odontology is a young area in India. However, it has been used as an integral component in a various medicolegal cases in India. However, the involvement of a dentist in mass disasters still needs to be well recognized. The role of the dentists in any unforeseen circumstances is to contribute as an adjunct hand in Disaster Victim Identification (DVI) which is in an emergent stage in India. This study aimed to assess an Indian dental professional's knowledge and awareness of their role in DVI. A pre-tested, self-administered anonymous questionnaire consisting of 6 open-ended and 14 close-ended questions was mailed to the participants. A total of 441 responses were recorded. The study indicated adequate knowledge and awareness among dental practitioners. Conversely, only a handful of people had first-hand autopsy experience. Thus, to supplement the skills needed to work at ground zero, it is recommended to develop hands-on training programs for dentists in each state of India. Also, creating a pool of experts in each state of India can strengthen the task force.

Sustained usage of an app-based clinical-decision making aid for the management of atherosclerotic cardiovascular disease

Background

Complexity of therapies for atherosclerotic cardiovascular disease (ASCVD) risk reduction represents a challenge for clinicians and may lead to poor uptake of these therapies.

Purpose

The goal of this project was to design an easy-to-use, point-of-care tool to risk stratify ASCVD patients and provide individualized guidance for clinicians to incorporate these agents.

Methods

Based on the REACH registry trial and predictive modeling (including 49,689 patients with ASCVD in 44 countries), we designed and implemented an app for secondary risk assessment. Using demographic and comorbidity profiles, this tool was used to calculate an individual's 20-month risk of cardiovascular events and mortality. It also provided graphical comparison to an age-matched control with optimized cardiovascular risk profile to illustrate the modifiable residual risk. The app then utilized the patient's risk profile to provide specific guidance for possible therapeutic interventions SGLT2-inhibitors, GLP1-agonists, PCSK9-inhibitors, Vascular-dose Rivaroxaban, and Icosapent Ethyl. Additionally, it identified individuals who qualified for cardiac rehabilitation or may benefit from smoking cessation interventions, including counselling or pharmacological therapies.

We launched a pilot test of the “Residual Cardiovascular Risk: Assessment and Management Guide” app at a regional cardiac center. 240 referring physicians (including family doctors, emergency physicians, internists, and cardiologists) were invited by email or fax to utilize the app. Feedback was solicited from all users three months into the test period. Following this, no further marketing of the app was performed for all users. Usage data was recorded using Google Analytics over a 12-month period and analyzed in 4-month increments.

Results

From January to December 2021, our app was used to risk stratify 1576 patients. A total of 47 individual users utilized the app over this period. From January to April, the app was used on average 160 times monthly. From May to August, it was used 115 times monthly. From September to December, it was used 118 times monthly. Twenty-four physicians provided feedback; 100% affirmed the functionality, ease of use, and utility of the tool. The app was described as “useful for discussions with patients”, “helpful to optimize patients” and “similar to a mini-cardiology consult”. User suggestions resulted in further improvements to the app, including integration of reports into Electronic Medical Records.

Conclusions

The early success of this app demonstrates a need for simple, accessible, and individualized guidance for management of ASCVD patients to improve uptake of guideline-based medical therapies. This tool demonstrates sustained usage among clinicians, as well as subjective utility in aiding therapeutic decision making. Future clinical research will focus on the ability of this tool to impact physician prescribing patterns and clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

A novel algorithm for rapid sequence optimization of guideline directed medical therapy for heart failure with reduced ejection fraction

Introduction

Current guidelines for management of Heart Failure with Reduced Ejection Fraction (HFrEF) recommend Beta-blockers, Angiotensin Receptor Neprilysin Inhibitors (ARNI), Mineralocorticoid Receptor Antagonists (MRA) and SGLT2 inhibitors. However, guideline-directed medical therapies (GDMT) remain underutilized. The 2018 CHAMP-HF registry of HFrEF patients demonstrated that only 1% of patients were treated with target doses of Beta-blockers, MRA and ACE-inhibitors (ACE-I) and Angiotensin Receptor Blocker (ARB) or ARNI. Historically, HFrEF therapies were initiated and up-titrated sequentially. Recent expert commentary has suggested a more aggressive approach of initiating all 4 classes of therapy at low doses after which patients should be up-titrated to target dose

Purpose

This study tested a novel, virtual HFrEF optimization program with the goal of achieving GDMT using a novel “rapid sequence” algorithm.

Methods

We conducted a single center study at a regional cardiovascular centre using a prospective pre-post design. NYHA class II/III HFrEF patients referred from both inpatient and outpatient settings were enrolled in a virtual 3-month HFrEF optimization program. All participants underwent an initial consult with a program nurse and cardiologist. After this, all patients were seen remotely by a nurse every two weeks for adjustment of HFrEF medications. At week 1, patients started on ARNI and SGLT2i. After week 3, Beta-Blocker was initiated. After week 5, MRA was initiated. Following this, medications were up-titrated every two weeks, based on clinical judgement of the overseeing cardiologist. Vital signs and bloodwork were obtained after all medication adjustments. In addition, all patients were seen once weekly by a kinesiologist for lifestyle optimization and counselling.

Results

From April 2020 to January 2021, 297 NYHA class II/III HFrEF patients enrolled in the virtual HFrEF optimization program. Mean age was 69 and 63% were male. Mean ejection fraction was 28% and 54% had ischemic cardiomyopathy. At intake, the proportion of patients prescribed maximally-tolerated dosage was 64% for Beta-Blockers, 7% for MRA, 1% for ARNI and 1% for SGLT2i. At 3-month follow-up, maximally-tolerated dose was prescribed in 84% of patients for beta-blockers (p&lt;0.01), 58% for MRA (p&lt;0.01), 77% for SGLT2i (p&lt;0.01) and 96% for ARNI (p&lt;0.01). 39% of patients achieved maximal doses of all 4 classes of medications at follow-up. No medication-related adverse events were reported and 18 patients were hospitalized for HF exacerbation during study follow-up.

Conclusions

This study demonstrates that a program using aggressive GDMT initiation can safely and effectively improve uptake of therapy in HFrEF patients. Future research should examine HFrEF “rapid sequence” optimization on patient outcomes in a randomized setting.

Funding Acknowledgement

Type of funding sources: None.

Impact of diabetes and glucose-lowering therapy on post-operative atrial fibrillation after cardiac surgery: secondary analysis of the SEARCH-AF CardioLink-1 randomized clinical trial

Background

Diabetes mellitus is an important risk factor for atrial fibrillation (AF) and is associated with an increased risk of complications for patients with AF. The impact of diabetes on post-operative AF after cardiac surgery is not well-defined.

Purpose

We sought to characterize the effect of diabetes, insulin, and oral hypoglycemic agents on the incidence of post-operative atrial fibrillation (POAF) after cardiac surgery. Accordingly, we conducted a secondary analysis of the Post-Surgical Enhanced Monitoring for Cardiac Arrhythmias and Atrial Fibrillation (SEARCH-AF) CardioLink-1 randomized trial.

Methods

In the SEARCH-AF trial, 336 patients with risk factors for stroke (CHA2DS2-VASc score ≥2) and no history of preoperative AF were randomized to usual care or continuous cardiac rhythm monitoring for 30 days after discharge from cardiac surgery with a wearable, patched-based device. The primary outcome was occurrence of cumulative atrial fibrillation/flutter (AF/AFL) lasting for ≥6 minutes detected by continuous monitoring or AF/AFL documented by a 12-lead electrocardiogram within 30 days of randomization. We assessed the association between diabetes and occurrence of post-operative AF. In addition, we examined the association between POAF and glucose-lowering therapy among patients with diabetes.

Results

Among the 176 (52%) patients with diabetes in the study cohort, 80 (45%) patients were treated with at least 1 oral hypoglycemic agent and 44 (25%) patients were treated with insulin. The incidence of POAF occurring within 30 days after discharge from surgery was similar between patients with or without diabetes (cumulative incidence: 10.8% vs. 10.0%, log-rank p=0.77). Among patients with diabetes, the incidence of POAF was highest in those who were not treated with glucose-lowering therapy (17.3%) when compared with those treated with oral hypoglycemic agents (10.0%) or insulin (4.5%) (log-rank ptrend=0.045 among the 3 groups). In an exploratory analysis, we observed a trend suggesting a lower incidence of POAF among cardiac surgical patients who were treated with SGLT-2 inhibitors (log-rank ptrend=0.084).

Conclusion

The incidence of POAF occurring after discharge from cardiac surgery is equally high among patients with or without diabetes. Our results suggest a potential association between specific glucose-lowering therapies and risk of POAF after cardiac surgery, meriting further investigations.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Heart and Stroke Foundation of Canada

Valvular surgery is associated with an increased risk of post-operative atrial fibrillation: secondary analysis of the SEARCH-AF CardioLink-1 randomized trial

Background

Patients undergoing valve surgery have a higher risk of developing post-operative atrial fibrillation (POAF) relative to those undergoing isolated coronary artery bypass grafting (CABG). Whether this risk extends beyond hospital discharge is unknown.

Purpose

We examined the association between surgery type (isolated CABG vs. valve repair/replacement) on the incidence of post-operative atrial fibrillation (POAF) by conducting a secondary analysis of the Post-Surgical Enhanced Monitoring for Cardiac Arrhythmias and Atrial Fibrillation (SEARCH-AF) CardioLink-1 randomized trial.

Methods

In the SEARCH-AF trial, 336 patients with risk factors for stroke (CHA2DS2-VASc score ≥2) and no history of preoperative AF were randomized to usual care or continuous cardiac rhythm monitoring for 30 days after discharge from cardiac surgery with a wearable, patched-based device. The primary outcome was occurrence of cumulative atrial fibrillation/flutter (AF/AFL) lasting for ≥6 minutes detected by continuous monitoring or AF/AFL documented by a 12-lead ECG within 30 days of randomization. We compared the risk of POAF between patients who underwent CABG vs. valve repair/replacement. Patients who experienced post-operative AF during hospitalization were excluded from this analysis.

Results

The overall cohort consisted of 255, 39, and 42 patients who underwent isolated CABG, isolated valve replacement/repair, and CABG + valve repair/replacement, respectively. Baseline characteristics were similar among the groups except for younger age (p=0.0014), higher prevalence of preoperative myocardial infarction (p=0.002) and lower ejection fraction (p=0.025) in the isolated CABG group. Eighteen patients experienced post-operative AF during hospitalization. Patients who underwent CABG + valve surgery or isolated valve surgery were more likely to experience post-operative AF compared with those who underwent isolated CABG (Log-Rank ptrend=0.0096). Among patients who were randomized to continuous cardiac rhythm monitoring, the probability of post-operative AF among patients who underwent isolated CABG, valve surgery, and CABG + valve surgery was 15.8%, 29.4%, and 35.0%, respectively (Log-Rank ptrend=0.017). After multivariable adjustment, the risk of developing post-operative AF within 30 days after discharge remained higher among patients who underwent valve surgery compared with those who underwent isolated CABG (hazard ratio (HR) 2.22, 95% CI 1.01–4.87. Patients who underwent CABG + repair/replacement had the highest risk of experiencing post-operative AF when compared to patients who underwent isolated CABG (HR 2.78, 95% CI 1.12–6.86).

Conclusion

Patients undergoing valve repair or bioprosthetic valve replacement have a substantial risk of post-operative AF within 30 days after discharge from surgery. An aggressive cardiac rhythm monitoring strategy during this vulnerable period should be considered for this high-risk patient population.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Heart and Stroke Foundation of Canada

The impact of statin on post-operative atrial fibrillation after discharge from cardiac surgery: secondary analysis of the SEARCH-AF CardioLink-1 randomized trial

Background

There is conflicting evidence regarding the use of statins to reduce the risk of post-operative atrial fibrillation (POAF) in patients undergoing cardiac surgery.

Purpose

We sought to determine the effects of statin use on the burden of new-onset post-discharge POAF in the Post-Surgical Enhanced Monitoring for Cardiac Arrhythmias and Atrial Fibrillation (SEARCH-AF) CardioLink-1 randomized controlled trial.

Methods

In the SEARCH-AF trial, 336 patients with risk factors for stroke (CHA2DS2-VASc score ≥2) and no history of preoperative AF were randomized to usual care or continuous cardiac rhythm monitoring for 30 days after discharge from cardiac surgery with a wearable, patched-based device. The primary endpoint was the occurrence of cumulative atrial fibrillation/flutter (AF/AFL) lasting for ≥6 minutes detected by continuous monitoring or AF/AFL documented by a 12-lead electrocardiogram within 30 days of randomization. Using time-to-event analysis and Cox regression, we evaluated the association between the risk of post-operative AF in relation to statin use and dosing intensity (low, moderate, high) at the time of discharge. We excluded patients who experienced post-operative AF during hospitalization in this analysis.

Results

In the overall cohort (n=336), 260 (77.4%) patients were treated with statins at the time of hospital discharge. There were 18 (5.4%) patients who experienced post-operative AF during hospitalization. Patients prescribed with statins were more likely to be male (p=0.018), had lower CHA2DS2-VASc scores (p=0.011), and were more likely to undergo isolated coronary artery bypass grafting (CABG) (p=0.083). Baseline characteristics were otherwise similar between the 2 groups. Patients treated with statins at discharge had a 2-fold lower rate of post-operative AF than those who were not treated with statins in the overall cohort (17.6% vs. 8.2%, Log-Rank p=0.017) and among those who were randomized to continuous cardiac rhythm monitoring (31.6% vs. 16.0%, Log-Rank p=0.027) (Figure). After adjusting for surgery type (CABG vs. valve surgery) and the CHA2DS2-VASc score, statin use at discharge was associated with a lower risk of post-operative AF within 30 days after surgery (hazard ratio 0.48, 95% CI 0.24–0.97). Furthermore, increasing intensity of statin therapy was associated with lower risk of POAF (ptrend=0.0012) (Figure 1)

Conclusion

Among cardiac surgery patients with risk factors for stroke and no history of pre-operative AF, the use of statins was associated with a reduction in post-operative AF risk within 30 days of discharge. The routine use of high-intensity statin to prevent post-operative AF after cardiac surgery deserves further study.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Heart and Stroke Foundation of Canada

A Point Prevalence Study of the Use of Antibiotics in Six Tertiary Care Hospitals in the Kathmandu Valley, Nepal

Background Point prevalence survey (PPS) on antibiotic use developed by the WHO has already been used in many hospitals globally. Objective To obtain information on antibiotic prescribtion using point prevalence survey methodology in six private hospitals in the Kathmandu valley. Method This descriptive cross-sectional study was completed during 20th July to 28th July 2021 using point prevalence survey methodology. The study was conducted among inpatients admitted at or before 8:00 AM on the day of survey in various wards. Data was presented as frequencies and percentages. Result Maximum number of patients were above 60 years [34 (18.7%)]. Number of male and female participants were equal [91 (50%)]. Only one antibiotic was used in 81 patients (44.5%) followed by two antibiotics in 71 (39%) patients. Duration of prophylactic antibiotic use was one day in 66 (63.7%) patients. Blood, urine, sputum, and wound swabs were the common samples for culture. Cultures were positive for 17 (24.7%) samples. The common organisms isolated were E. Coli, Pseudomonas aeruginosa and Klebsiella pneumoniae. Ceftriaxone was the most used antibiotic. Drug and therapeutics, infection control committee and pharmacovigilance activities were present in 3/6 (50%) study sites. Antimicrobial stewardship was present in 3/6 (50%) and microbiological services was present in all hospitals. Antibiotic formulary and antibiotic guideline were present in 4/6 sites and facilities to audit or review surgical antibiotic prophylaxis choice in 2/6 (33.3%) sites, facility to monitor antibiotic use in 4/6 (66.6%) and cumulative antibiotic susceptibility reports in 2/6 (33.3%) study sites. Conclusion Ceftriaxone was the most used antibiotic. E. Coli, Pseudomonas aeruginosa and Klebsiella pneumonia were the commonly isolated organisms. Not all parameters for infrastructure, policy and practice and monitoring and feedback were present at the study sites. KEY WORDS.

Aryl hydrocarbon receptor and Krüppel like factor 10 mediate a transcriptional axis modulating immune homeostasis in mosquitoes

Immune responses require delicate controls to maintain homeostasis while executing effective defense. Aryl hydrocarbon receptor (AhR) is a ligand-activated transcription factor. The Krüppel-like factor 10 (KLF10) is a C2H2 zinc-finger containing transcription factor. The functions of mosquito AhR and KLF10 have not been characterized. Here we show that AhR and KLF10 constitute a transcriptional axis to modulate immune responses in mosquito Anopheles gambiae. The manipulation of AhR activities via agonists or antagonists repressed or enhanced the mosquito antibacterial immunity, respectively. KLF10 was recognized as one of the AhR target genes in the context. Phenotypically, silencing KLF10 reversed the immune suppression caused by the AhR agonist. The transcriptome comparison revealed that silencing AhR and KLF10 plus challenge altered the expression of 2245 genes in the same way. The results suggest that KLF10 is downstream of AhR in a transcriptional network responsible for immunomodulation. This AhR–KLF10 axis regulates a set of genes involved in metabolism and circadian rhythms in the context. The axis was required to suppress the adverse effect caused by the overactivation of the immune pathway IMD via the inhibitor gene Caspar silencing without a bacterial challenge. These results demonstrate that the AhR–KLF10 axis mediates an immunoregulatory transcriptional network as a negative loop to maintain immune homeostasis.

Prognostic significance of polyvascular disease in patients admitted with acute decompensated heart failure: the ARIC Study Community Surveillance

Introduction

The prevalence and outcomes of polyvascular disease (PVD) in patients admitted with acute decompensated heart failure (ADHF) have not been previously reported, nor is it known whether associations differ for heart failure (HF) with reduced vs. preserved ejection fraction (HFrEF vs HFpEF, respectively).

Purpose

To investigate the relationship between atherosclerotic involvement of multiple arterial territories and mortality in patients hospitalized with ADHF.

Methods

The Atherosclerosis Risk in Communities (ARIC) study conducted hospital surveillance of adjudicated heart failure in 4 US areas from 2005–2014, with events verified by physician review. Medical histories were abstracted from the hospital record. PVD was defined by coexisting disease in ≥2 arterial beds, identified by prevalent coronary artery disease, peripheral arterial disease, and cerebrovascular disease. Mortality hazards of PVD vs. no PVD were analyzed separately for HFpEF and HFrEF, with adjustment for age, race, sex, year of admission and geographic region. All analyses were weighted by the inverse of the sampling probability.

Results

Of 24,936 ADHF hospitalizations (52% female, 32% Black, mean age 75 years), 19% had PVD (22% among HFrEF hospitalizations, 17% among HFpEF hospitalizations), Figure 1. There was an increasing trend in 1-year mortality with 0, 1 and ≥2 arterial bed involvement, both for patients with HFrEF (29% to 32% to 38%; P-trend=0.0006) and HFpEF (26% to 32% to 37%; P-trend &lt;0.0001). After adjustments, PVD was associated with a 20% higher hazard of 1-year mortality in patients with HFrEF (HR=1.23; 95% CI: 1.06–1.44) and a 30% higher hazard in patients with HFpEF (HR=1.33; 95% CI: 1.09–1.63), with no significant interaction by HF type (P-interaction = 0.5).

Conclusion

Patients hospitalized with ADHF and coexisting PVD have an increased risk of death, irrespective of HF type. Clinical attention should be directed toward PVD, with secondary prevention strategies enacted to improve the prognosis of this vulnerable population.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National Institutes of Health Distributions of arterial diseaseTrends in 1-year mortality outcomes

Mediators of the effect of ertugliflozin on a composite kidney outcome in patients with type 2 diabetes and atherosclerotic cardiovascular disease: analyses from VERTIS CV

Introduction

Sodium–glucose cotransporter 2 (SGLT2) inhibitors have been shown to slow the decline of kidney function in outcome trials, but the biological mediator(s) underlying the therapeutic benefit are not well established.

Purpose

We performed a post-hoc analysis exploring potential mediators of the effects of the SGLT2 inhibitor ertugliflozin on the VERTIS CV exploratory kidney composite outcome (sustained 40% decrease from baseline in estimated glomerular filtration rate [eGFR], chronic kidney replacement therapy or kidney death).

Methods

In VERTIS CV, 8246 participants with type 2 diabetes mellitus and established atherosclerotic cardiovascular disease were randomised to placebo, ertugliflozin 5 mg or 15 mg (pooled for analyses, as prospectively planned), and were followed for a mean of 3.5 years. The hazard ratio (HR; 95% confidence interval) for the pre-specified exploratory kidney composite outcome was 0.66 (0.50, 0.88). Cox regression models were used to evaluate covariates that were significantly differentially changed from baseline with ertugliflozin treatment as candidate mediators, with a mediator identified as a covariate when added to an unadjusted model of randomised treatment assignment a) yielded a larger hazard ratio; and b) the mediator retained P&lt;0.05 in the model (eGFR was excluded as a covariate). The percentage of mediation was determined by the proportional increase in the HR between the unadjusted and adjusted models for each post-randomisation period: early (first change from baseline measurement) and average (weighted average of change from baseline from all post-baseline measurements). Each potential mediator was tested individually, so across analyses, mediation % sums to &gt;100%.

Results

Of 22 covariates significantly changed by ertugliflozin, nine were identified as potential mediators (Table). The covariates with a high percentage of mediation were those related to changes in blood erythrocytes (haemoglobin, haematocrit and red blood cell mass), with average changes in haemoglobin having the highest percentage of mediation (61.8%). Serum uric acid was associated with a mediation of 29.4% and 50.0% for the early and average post-randomisation effect periods, respectively. Early changes in glycated haemoglobin had a large mediation (50%), but the average change during the trial was not significant. Average change in serum albumin had a large mediation (29.4%). Average changes in body weight and systolic blood pressure had percentages of mediation of 41.2% and 14.7%, respectively.

Conclusion

Multiple factors may be involved in the reduction of the kidney composite outcome observed with ertugliflozin. In the short-term, changes in glycaemia had a high mediation effect. Over the long-term, changes suggestive of haemoconcentration and/or haematopoiesis (natriuresis-related effects), showed the highest percentage of mediation, followed by changes in serum uric acid and body weight (glucosuria-related effects).

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Sponsored by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA in collaboration with Pfizer Inc., New York, NY, USA

Mediation analyses of the effect of ertugliflozin on hospitalisation for heart failure in patients with type 2 diabetes and atherosclerotic cardiovascular disease from the VERTIS CV trial

Introduction

Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce risk of hospitalisation for heart failure (HHF) in outcome trials, but the biological mediators underlying the therapeutic benefit are not well established.

Purpose

To identify potential biological mediators through which ertugliflozin reduces risk of HHF.

Methods

In VERTIS CV, 8246 patients with type 2 diabetes and atherosclerotic cardiovascular disease were randomised to ertugliflozin 5 or 15 mg (observations pooled as prospectively planned) or placebo. Cox regression models were used to evaluate the associations between changes in 26 potential mediators with outcomes. Potential mediators were selected based on proposed mechanisms and/or differential change from baseline with SGLT2 inhibitors. Mediation criteria required 1) significant (P&lt;0.05 for change from baseline) effects of ertugliflozin vs placebo on each potential mediator; and 2) significant (P&lt;0.05) association of change in post-randomisation levels of the potential mediator with risk of HHF when added to an unadjusted model of randomised treatment assignment. Percent mediation was determined by comparing the unadjusted hazard ratio and hazard ratio adjusted for change in the potential mediator of interest. Each covariate was tested individually, such that percent mediation across the analyses summed to &gt;100%. Time-dependent models were used to evaluate associations between early (change from baseline for the first post-baseline measurement) and average (weighted average of change from baseline using all post-baseline measurements) changes in covariates with clinical outcomes.

Results

Over a mean of 3.5 years, the incidence rate of HHF was 0.7 and 1.1 per 100 patient-years with ertugliflozin and placebo, respectively. Among 26 candidate mediators, 9 and 13 met the mediation criteria based on early and average changes, respectively. The 3 covariates with the largest mediating effects of early changes included haematocrit (40%), haemoglobin (27%) and HDL-C (23%) (Table); other significant biomarkers included urine albumin/creatinine ratio, and serum albumin, uric acid, chloride, protein and sodium. The 3 biomarkers with the largest mediating effects in average changes included haemoglobin (63%), albumin (50%) and uric acid (47%) (Table); other significant biomarkers included haematocrit, urine albumin/creatinine ratio, body weight, serum protein and chloride, systolic blood pressure, ALT, BUN, eGFR and heart rate.

Conclusions

In these analyses from the VERTIS CV trial, potential markers of volume status and haemoconcentration and/or haematopoiesis were the strongest mediators of the effect of ertugliflozin on reducing risk of HHF in the early and average change periods. Other potential mediators included uric acid, lipid markers and kidney parameters. These findings provide insights into potential mechanisms through which ertugliflozin, and potentially the SGLT2 inhibitor class, may prevent HHF.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Sponsored by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, and Pfizer Inc., New York, NY, USA.

Knowledge and Practices of Child Protection among the School Health Nurses of Nepal

Background Child protection is burning issues in developing countries including Nepal. Child protection is one of the key works of the school health nurses. Objective To find out about the existing knowledge and practices of child protection among the school health nurses. Method This descriptive cross-sectional study was conducted among 130 school health nurses working in different schools throughout Nepal. The participants were selected using purposive sampling technique and were invited to participate via various online networks. Self-administered questionnaire was used to collect data. Duration of data collection was 20 December 2020 to 10 February 2021. Descriptive statistics was used to analyze and interpret the data. Result Among the 130 Participants, 88.5% belonged to less than 29 years age group and 67.7% had Proficiency Certificate Level in Nursing education. None of them has received training related to child protection recognition and response and 90.8% had work experience of less than 5 years. Eighty percent and 96.9% participants had knowledge regarding the meaning of child right and child abuse respectively. But 45.4% had knowledge on meaning of child neglect; 53.1% and 72.3% had the knowledge of physical abuse and noncontact sexual abuse respectively. Majority (86.9%) of the participants reported as relatives were the abuser and 63.8% replied as home is the common place for abuse. Similarly, 85.4% had received the information regarding child protection via television radio and newspaper. Only 36.1% has already been involved in child protection. The participants who went to local government (Palika), police and Non-government Organizations for coordination for child right issues were 9(19.1%), 7(14.8%) and 8(17.0%) respectively. Conclusion Most of the school health nurses are young without having experience of childhood abuse and received any child protection training before joining the job. They have good knowledge of child right, physical, sexual abuse except child neglect and existing legal arrangements. There is gap in knowledge and practice.

Trained Immunity in Anopheles gambiae: Antibacterial Immunity Is Enhanced by Priming via Sugar Meal Supplemented With a Single Gut Symbiotic Bacterial Strain

Mosquitoes have evolved an effective innate immune system. The mosquito gut accommodates various microbes, which play a crucial role in shaping the mosquito immune system during evolution. The resident bacteria in the gut microbiota play an essential role in priming basal immunity. In this study, we show that antibacterial immunity in Anopheles gambiae can be enhanced by priming via a sugar meal supplemented with bacteria. Serratia fonticola S1 and Enterobacter sp. Ag1 are gut bacteria in mosquitoes. The intrathoracic injection of the two bacteria can result in an acute hemocoelic infection in the naïve mosquitoes with mortality of ∼40% at 24 h post-infection. However, the Enterobacter orSerratia primed mosquitoes showed a better 24 h survival upon the bacterial challenge. The priming confers the protection with a certain degree of specificity, the Enterobacter primed mosquitoes had a better survival upon the Enterobacter but not Serratia challenge, and the Serratia primed mosquitoes had a better survival upon the Serratia but not Enterobacter challenge. To understand the priming-mediated immune enhancement, the transcriptomes were characterized in the mosquitoes of priming as well as priming plus challenges. The RNA-seq was conducted to profile 10 transcriptomes including three samples of priming conditions (native microbiota, Serratia priming, and Enterobacter priming), six samples of priming plus challenges with the two bacteria, and one sample of injury control. The three priming regimes resulted in distinctive transcriptomic profiles with about 60% of genes affected by both bacteria. Upon challenges, different primed mosquitoes displayed different transcriptomic patterns in response to different bacteria. When a primed cohort was challenged with a heterogenous bacterium, more responsive genes were observed than when challenged with a homogenous bacterium. As expected, many canonical immune genes were responsive to the priming and challenge, but much more non-immune genes with various functions were also responsive in the contexts, which implies that the prior priming triggers a delicately coordinated systemic regulation that results in an enhanced immunity against the subsequent challenge. Besides the participation of typical immune pathways, the transcriptome data suggest the involvement of lysosome and metabolism in the context. Overall, this study demonstrated a trained immunity via priming with bacteria in diet.

Experience Sharing: Final Year MBBS Journey

Studying medicine is tough. The saying: It is hard to enter medical school but easier later is a myth. All the semesters and years have their trials and tribulations but the final year is known among students to be a terror. Here we share our experience of the final year hoping it could give insight to the medical students about what to expect in the ultimate year and prepare themselves mentally as well as academically beforehand.

A Current Review on Analytical Tools for Determination of New Oral Antidiabetic Drugs, Empagliflozin, Linagliptin and Biguanides in Bulk Materials, Pharmaceuticals & Biological Samples

Worldwide the R & D divisions of Pharma industry are actively involved in the development of new therapeutic agents. These agents may be either new entities or partial structural modification of the existing one. The recent FDA statistics represent that the average number of drug filings are increasing every year in the thrust areas like anti-cancer agents, anti-diabetic, antibiotics, cardio-vascular drugs, respiratory drugs etc. Sodium glucose co-transporter-2(SGLT-2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors and biguanides are effective oral anti-diabetic agents used in treatment of type 2 Diabetes Mellitus. Therefore, the necessity to explore and compare the existing analytical and bioanalytical assays used for determination of such drugs either single or in combination is crucial. Many methods were reported in the literature for the bio-analysis and analysis of four novel gliptins combinations, empagliflozin-linagliptin, empagliflozin-metformin HCl, linagliptin-metformin HCl, empagliflozin-linagliptin-metformin HCl combination with application on Glyxambi®, Synjardy®, Jentadueto®, Trijardy® XR tablets respectively. Furthermore, this review offered an overview of different methods used for determination of every drug alone as empagliflozin from SGLT-2 inhibitors, linagliptin from DPP-4 inhibitors and metformin from biguanides in a tabulated comparative way. Moreover, the current review emphasizes the most common stability indicating assays to be of interest to the analysts in the area of drug control. This review helps in understanding the further need for the development of analytical methods for the estimation of such drugs.

The relationship between viscoelasticity and elasticity

Soft materials that are subjected to large deformations exhibit an extremely rich phenomenology, with properties lying in between those of simple fluids and those of elastic solids. In the continuum description of these systems, one typically follows either the route of solid mechanics (Lagrangian description) or the route of fluid mechanics (Eulerian description). The purpose of this review is to highlight the relationship between the theories of viscoelasticity and of elasticity, and to leverage this connection in contemporary soft matter problems. We review the principles governing models for viscoelastic liquids, for example solutions of flexible polymers. Such materials are characterized by a relaxation time λ, over which stresses relax. We recall the kinematics and elastic response of large deformations, and show which polymer models do (and which do not) correspond to a nonlinear elastic solid in the limit λ → ∞. With this insight, we split the work done by elastic stresses into reversible and dissipative parts, and establish the general form of the conservation law for the total energy. The elastic correspondence can offer an insightful tool for a broad class of problems; as an illustration, we show how the presence or absence of an elastic limit determines the fate of an elastic thread during capillary instability.

Under-carboxylated osteocalcin regulates glucose and lipid metabolism during pregnancy and lactation in rats

PURPOSE

Under-carboxylated osteocalcin (UcOC), a bone-released hormone is suggested to regulate energy metabolism. Pregnancy and lactation physiological conditions that require high levels of energy. The current study attempts to examine whether UcOC is involved in regulating energy metabolism during these conditions using adult Wistar rats.

METHODS AND RESULTS

Insulin tolerance tests indicated insulin resistance during late pregnancy (day 19 of pregnancy; P19) and insulin sensitivity during early lactation (day 6 of lactation; L6). Gene expression analyses suggested that muscle glucose metabolism was downregulated during P19 and enhanced during L6. Concomitantly, circulatory UcOC levels were lower during pregnancy but higher during early lactation; the rise in UcOC levels was tightly linked to the lactation process. Altering endogenous UcOC levels pharmacologically with warfarin and alendronate in P19 and L6 rats changed whole-body insulin response and muscle glucose transporter (Glut4) expression. Glut4 expression can be increased by either UcOC or estrogen receptors (ERs), both of which act independent of each other. A high fat diet decreased UcOC levels and insulin sensitivity in lactating rats, suggesting that diet can compromise UcOC-established energy homeostasis. Gene expression of lipid metabolism markers and triglyceride levels suggested that UcOC suppression during early pregnancy is an essential step in maternal lipid storage.

CONCLUSION

Taken together, we found that UcOC plays an important role in energy homeostasis via regulation of glucose and lipid metabolism during pregnancy and lactation.

A Systematic Analysis of Mosquito-Microbiome Biosynthetic Gene Clusters Reveals Antimalarial Siderophores that Reduce Mosquito Reproduction Capacity

Advances in infectious disease control strategies through genetic manipulation of insect microbiomes have heightened interest in microbially produced small molecules within mosquitoes. Herein, 33 mosquito-associated bacterial genomes were mined and over 700 putative biosynthetic gene clusters (BGCs) were identified, 135 of which belong to known classes of BGCs. After an in-depth analysis of the 135 BGCs, iron-binding siderophores were chosen for further investigation due to their high abundance and well-characterized bioactivities. Through various metabolomic strategies, eight siderophore scaffolds were identified in six strains of mosquito-associated bacteria. Among these, serratiochelin A and pyochelin were found to reduce female Anopheles gambiae overall fecundity likely by lowering their blood-feeding rate. Serratiochelin A and pyochelin were further found to inhibit the Plasmodium parasite asexual blood and liver stages in vitro. Our work supplies a bioinformatic resource for future mosquito-microbiome studies and highlights an understudied source of bioactive small molecules.