Subcutaneous implantable cardioverter-defibrillator noise following left ventricular assist device implantation

Background

The incidence and impact of noise in a subcutaneous implantable cardioverter defibrillator (S-ICD) after left ventricular assist device (LVAD) implantation is not well established.

Methods

We performed a retrospective study of patients implanted with LVAD and with a pre-existing S-ICD between January 2005 and December 2020 at the three Mayo Clinic centers (Minnesota, Arizona, and Florida).

Results

Of the 908 LVAD patients, a pre-existing S-ICD was present in 9 patients (mean age 49.1 ± 13.7 years, 66.7% males), 100% with Boston Scientific third-generation EMBLEM MRI S-ICD, 11% with HeartMate II (HM II), 44% with HeartMate 3 (HM 3), and 44% with HeartWare (HW) LVAD. The incidence of noise from LVAD-related electromagnetic interference (EMI) was 33% and was only seen with HM 3 LVAD. Multiple measures attempted to resolve noise, including using alternative S-ICD sensing vector, adjusting S-ICD time zone, and increasing LVAD pump speed, were unsuccessful, necessitating S-ICD device therapies to be turned off permanently.

Conclusions

The incidence of LVAD-related S-ICD noise is high in patients with concomitant LVAD and S-ICD with significant impact on device function. As conservative management failed to resolve the EMI, the S-ICDs had to be programmed off to avoid inappropriate shocks. This study highlights the importance of awareness of LVAD-SICD device interference and the need to improve S-ICD detection algorithms to eliminate noise.

Artificial intelligence-augmented analysis of contemporary procedural, mortality, and cost trends in carcinoid heart disease in a large national cohort with a focus on the "forgotten pulmonic valve"

Background

Carcinoid heart disease is increasingly recognized and challenging to manage due to limited outcomes data. This is the largest known cohort study of valvular pathology, treatment (including pulmonary and tricuspid valve replacements [PVR and TVR]), dispairties, mortality, and cost in patients with malignant carcinoid tumor (MCT).

Methods

Machine learning-augmented propensity score-adjusted multivariable regression was conducted for clincal outcomes in the 2016-2018 U.S. National Inpatient Sample (NIS). Regression models were weighted by the complex survey design and adjusted for known confounders and the likelihood of undergoing valvular procedures.

Results

Among 101,521,656 hospitalizations, 55,910 (0.06%) had MCT. Patients with MCT vs. those without had significantly higher inpatient mortality (2.93 vs. 2.04%, p = 0.002), longer mean length of stay (12.20 vs. 4.62, p < 0.001), and increased mean total cost of stay ($70,252.18 vs. 51,092.01, p < 0.001). There was a step-wise increased rate of TVR and PVR with each subsequent year, with significantly more TV (0.16% vs. 0.01, p < 0.001) and PV (0.03 vs. 0.00, p = 0.040) diagnosed with vs. without MCT for 2016, with comparable trends in 2017 and 2018. There were no significant procedural disparities among patients with MCT for sex, race, income, urban density, or geographic region, except in 2017, when the highest prevalence of PV procedures were performed in the Western North at 50.00% (p = 0.034). In machine learning and propensity score augmented multivariable regression, MCT did not significantly increase the likelihood of TVR or PVR. In sub-group analysis restricted to MCT, neither TVR nor PVR significantly increased mortality, though it did increase cost (respectively, $141,082.30, p = 0.015; $355,356.40, p = 0.012).

Conclusion

This analysis reflects a favorable trend in recognizing the need for TVR and PVR in patients with MCT, with associated increased cost but not mortality. Our study also suggests that pulmonic valve pathology is increasingly recognized in MCT as reflected by the upward trend in PVRs. Further research and updated societal guidelines may need to focus on the "forgotten pulmonic valve" to improve outcomes and disparities in this understudied patient population.

Anterior-Posterior versus anterior-lateral electrodes position for electrical cardioversion of atrial fibrillation: A meta-analysis of randomized controlled trials

Background

The optimal electrodes position for elective direct current (DC) cardioversion of patients with atrial fibrillation (AF) remains uncertain.

Methods

An electronic search of MEDLINE, EMBASE and COCHRANE databases was performed through March 2022 for randomized trials that examined the outcomes of anterior-posterior (AP) versus anterior-lateral (AL) electrodes position during cardioversion of (AF). The main outcome was the success rate of cardioversion. Data were pooled using random effects model.

Results

The final analysis included 10 RCTs with a total of 1677 patients. There was no difference in the rate of successful cardioversion between the AP versus AL groups (86.6 vs 87.9 %; RR 1.00; 95 % Confidence Interval (CI) 0.95 to 1.06). Subgroup analysis by the shock waveform showed no significant interaction between monophasic and biphasic waveforms (P_intercation = 0.23). meta-regression analyses showed no effect modification of primary outcome according to body mass index (p = 0.15), left atrial diameter (p = 0.64), valvular heart disease (p = 0.34), lone AF (p = 0.58), or the duration of AF (p = 0.70). There was no significant difference between the AP and AL electrode position groups in successful cardioversion at low energy (RR 0.94; 95 % CI 0.74 to 1.19), the number of the delivered shocks (standardized mean difference [SMD] −0.03; 95 % CI −0.32 to 0.26) or the mean energy of the delivered shocks (SMD −0.11 and 95 % CI −0.30 to 0.07). There was lower transthoracic impedance with AP versus AL electrode position (SMD −0.28; 95 %CI −0.47 to −0.10).

Conclusion

Meta-analysis of randomized data showed no difference between AP and AL electrode positions in the success rate of DC cardioversion of AF. Either AP or AL electrode positions should be acceptable approaches for elective DC cardioversion of patients with AF.

Abiotrophia defectiva Endocarditis of Bicuspid Aortic Valve: a Case Report

Background

Patients with a bicuspid aortic valve have increased risk of infective endocarditis, but common organisms are not always the culprit. We describe a case of an otherwise healthy young gentleman with bicuspid aortic valve who experienced Abiotrophia defectiva endocarditis. The aim of this case report is to highlight an uncommon cause of endocarditis associated with significant morbidity and mortality in order to improve the care provided by trainees and clinicians.

Case summary

A 37-year-old male presented with a 1-month history of fever, weight loss, myalgia, and night sweats. On transoesophageal echocardiography, he was found to have a bicuspid aortic valve with large vegetation and severe aortic insufficiency. Blood cultures were positive for A. defectiva. The endocarditis was successfully treated with surgical aortic valve replacement and 6 weeks of antibiotic therapy.

Discussion

Bicuspid valves are known to have increased susceptibility to endocarditis. The difficulty of isolating A. defectiva typically leads to delayed diagnosis and significant complications. This case is a reminder to have a high degree of suspicion for organisms which are rare and difficult to isolate because prompt recognition and surgical intervention may improve the outcome of care.

Heat stress develops with increased total-tract gut permeability, and dietary organic acid and pure botanical supplementation partly restores lactation performance in Holstein dairy cows

To evaluate the effects of heat stress (HS) conditions and dietary organic acid and pure botanical (OA/PB) supplementation on gut permeability and milk production, we enrolled 46 multiparous Holstein cows [208 ± 4.65 dry matter intake (DMI; mean ± SD), 3.0 ± 0.42 lactation, 122 ± 4.92 d pregnant, and 39.2 ± 0.26 kg of milk yield] in a study with a completely randomized design. Cows were assigned to 1 of 4 groups: thermoneutral conditions (TN-Con, n = 12), HS conditions (HS-Con, n = 12), thermoneutral conditions pair-fed to HS-Con (TN-PF, n = 12), or HS supplemented with OA/PB [75 mg/kg of body weight (BW); 25% citric acid, 16.7% sorbic acid, 1.7% thymol, 1.0% vanillin, and 55.6% triglyceride; HS-OAPB, n = 10]. Supplements were delivered twice daily by top-dress; all cows not supplemented with OA/PB received an equivalent amount of the triglyceride used for microencapsulation of the OA/PB supplement as a top-dress. Cows were maintained in thermoneutrality [temperature-humidity index (THI) = 68] during a 7-d acclimation and covariate period. Thereafter, cows remained in thermoneutral conditions or were moved to HS conditions (THI: diurnal change 74 to 82) for 14 d. Cows were milked twice daily. Clinical assessments and BW were recorded, blood was sampled, and gastrointestinal permeability measurements were repeatedly evaluated. The mixed model included fixed effects of treatment, time, and their interaction. Rectal and skin temperatures and respiration rates were greater in HS-Con and HS-OAPB relative to TN-Con. Dry matter intake, water intake, and yields of energy-corrected milk (ECM), protein, and lactose were lower in HS-Con relative to HS-OAPB. Nitrogen efficiency was improved in HS-OAPB relative to HS-Con. Compared with TN-Con and TN-PF, milk yield and ECM were lower in HS-Con cows. Total-tract gastrointestinal permeability measured at d 3 of treatment was greater in HS-Con relative to TN-Con or TN-PF. Plasma total fatty acid concentrations were reduced, whereas insulin concentrations were increased in HS-Con relative to TN-PF. We conclude that exposure to a heat-stress environment increases total-tract gastrointestinal permeability. This study highlights important mechanisms that might account for milk production losses caused by heat stress, independent of changes in DMI. Our observations also suggest that dietary supplementation of OA/PB is a means to partly restore ECM production and improve nitrogen efficiency in dairy cattle experiencing heat stress.

Reclassification of Treatment Strategy with Fractional Flow Reserve in Cancer Patients with Coronary Artery Disease

Background and Objectives: Cancer and coronary artery disease (CAD) often coexist. Compared to quantitative coronary angiography (QCA), fractional flow reserve (FFR) has emerged as a more reliable method of identifying significant coronary stenoses. We aimed to assess the specific management, safety and outcomes of FFR-guided percutaneous coronary intervention (PCI) in cancer patients with stable CAD. Materials and Methods: FFR was used to assess cancer patients that underwent coronary angiography for stable CAD between September 2008 and May 2016, and were found to have ≥50% stenosis by QCA. Patients with lesions with an FFR > 0.75 received medical therapy alone, while those with FFR ≤ 0.75 were revascularized. Procedure-related complications, all-cause mortality, nonfatal myocardial infarction, or urgent revascularizations were analyzed. Results: Fifty-seven patients with stable CAD underwent FFR on 57 lesions. Out of 31 patients with ≥70% stenosis as measured by QCA, 14 (45.1%) had an FFR ≥ 0.75 and lesions were reclassified as moderate and did not receive PCI nor DAPT. Out of 26 patients with <70% stenosis as measured by QCA, 6 (23%) had an FFR < 0.75 and were reclassified as severe and were treated with PCI and associated DAPT. No periprocedural complications, urgent revascularization, acute coronary syndromes, or cardiovascular deaths were noted. There was a 22.8% mortality at 1 year, all cancer related. Patients who received a stent by FFR assessment showed a significant association with decreased risk of all-cause death (HR: 0.37, 95% CI 0.15−0.90, p = 0.03). Conclusions: Further studies are needed to define the optimal therapeutic approach for cancer patients with CAD. Using an FFR cut-off point of 0.75 to guide PCI translates into fewer interventions and can facilitate cancer care. There was an overall reduction in mortality in patients that received a stent, suggesting increased resilience to cancer therapy and progression.

Psychotic-like Experiences during COVID-19 Outbreak: A survey from Pakistan

Introduction

Despite the fact that adolescents have been at higher risk of distress during the COVID-19 pandemic, the effect of pandemic on psychotic-like experiences (PLEs) is not well described.

Objectives

The study’s objective is to evaluate if PLEs are induced in young individuals aged 18-24 during the pandemic.

Methods

A total of 201 college students from Pakistan (ages 18-24) were recruited for a cross-sectional research. We investigated the incidence of PLEs in Pakistan during the pandemic, their links to socio-demographic factors, COVID-19-related characteristics, depression, anxiety, and sleep difficulties. Community Assessment of Psychic Experience’s positive symptom component (CAPE), Patient Health Questionnaire, Generalized Anxiety Disorder Scale, and IBM SPSS 25 were used.

Results

CAPE-Frequency and CAPE-stress were positively associated with PHQ total (p<0.0010); GAD total (p<0.001); time spent indoors due to COVID-19 (p<0.001). Psychiatric disorder other than bipolar disorder or psychosis (p<0.001 for CAPE-frequency and stress), family history of psychiatric disorders (p<0.001 for CAPE-frequency and stress), chronic medical disease (p=0.021 CAPE-frequency and p=0.026 CAPE-stress), illegal drug usage (p<0.001 for CAPE-frequency and stress) were associated with CAPE-Frequency and CAPE-stress. In linear stepwise regression analysis, the best model predicted CAPE-Frequency explained 77.4% of variance with the following variables: PHQ total (B=0.552, SE= 0.08, t=6.909, p<0.001), GAD total (p<0.001), duration at home (p<0.001), and psychiatric disorder in family (p<0.001).

Conclusions

PLEs have been linked with anxiety and depression during the pandemic. Individuals with a mental condition, family history of psychiatric disorder, chronic medical illness, illicit drug use, and increased time spent at home experienced more PLEs and stress.

Disclosure

No significant relationships.

Percutaneous Coronary Intervention in Patients With Gynecological Cancer: Machine Learning-Augmented Propensity Score Mortality and Cost Analysis for 383,760 Patients

Background

Despite the growing number of patients with both coronary artery disease and gynecological cancer, there are no nationally representative studies of mortality and cost effectiveness for percutaneous coronary interventions (PCI) and this cancer type.

Methods

Backward propagation neural network machine learning supported and propensity score adjusted multivariable regression was conducted for the above outcomes in this case-control study of the 2016 National Inpatient Sample (NIS), the United States' largest all-payer hospitalized dataset. Regression models were fully adjusted for age, race, income, geographic region, cancer metastases, mortality risk, and the likelihood of undergoing PCI (and also with length of stay [LOS] for cost). Analyses were also adjusted for the complex survey design to produce nationally representative estimates. Centers for Disease Control and Prevention (CDC)-based cost effectiveness ratio (CER) analysis was performed.

Results

Of the 30,195,722 hospitalized patients meeting criteria, 1.27% had gynecological cancer of whom 0.02% underwent PCI including 0.04% with metastases. In propensity score adjusted regression among all patients, the interaction of PCI and gynecological cancer (vs. not having PCI) significantly reduced mortality (OR 0.53, 95%CI 0.36–0.77; p = 0.001) while increasing LOS (Beta 1.16 days, 95%CI 0.57–1.75; p &lt; 0.001) and total cost (Beta $31,035.46, 95%CI 26758.86–35312.06; p &lt; 0.001). Among gynecological cancer patients, mortality was significantly reduced by PCI (OR 0.58, 95%CI 0.39–0.85; p = 0.006) and being in East North Central, West North Central, South Atlantic, and Mountain regions (all p &lt; 0.03) compared to New England. PCI reduced mortality but not significantly for metastatic patients (OR 0.74, 95%CI 0.32–1.71; p = 0.481). Eighteen extra gynecological cancer patients' lives were saved with PCI for a net national cost of $3.18 billion and a CER of $176.50 million per averted death.

Conclusion

This large propensity score analysis suggests that PCI may cost inefficiently reduce mortality for gynecological cancer patients, amid income and geographic disparities in outcomes.

Noninvasive Imaging for Patients with COVID-19 and Acute Chest Pain

Acute chest pain is a common presentation in patients with COVID-19. Although noninvasive cardiac imaging modalities continue to be important cornerstones of management, the pandemic has brought forth difficult and unprecedented challenges in the provision of timely care while ensuring the safety of patients and providers. Clinical practice has adapted to these challenges, with several recommendations and societal guidelines emerging on the appropriate use of imaging modalities. In this review, we summarize the current evidence base on the use of noninvasive cardiac imaging modalities in COVID-19 patients with acute chest pain, with a focus on acute coronary syndromes.

Isolation and characterization of bacteria associated with silkworm gut under antibiotic-treated larval feeding

The impact of antibiotics on growth, cocoon production was assessed in addition to isolation and characterization of bacteria associated with silkworm gut of infected larvae. Larval rearing was maintained at recommended conditions of temperature and humidity. Silkworm larvae showing abnormal symptoms were collected from the control group and dissected for gut collection. Bacteria were isolated from the gut content by spreading on agar plates and incubated at 37 °C for 48 hrs. Bacterial identification and phylogenetic analysis were carried out by 16S rRNA gene sequencing. The isolated bacteria were subjected to antimicrobial susceptibility test (disc diffusion methods) by using Penicillin (10 µg/mL), Tetracycline (30 µg/mL), Amoxicillin (25 µg/mL), Ampicillin (10 µg/mL), and Erythromycin (15 µg/mL). All isolated strains showed positive results for the catalase test. We isolated and identified bacterial strains (n = 06) from the gut of healthy and diseased silkworm larvae. Based on the 16S rRNA gene sequence, isolated bacteria showed close relation with Serratia, Bacillus, and Pseudomonas spp. Notably, 83.3% of strains were resistant to Penicillin, Tetracycline, Amoxicillin, Ampicillin, and Erythromycin but 16.6% showed antibiotic susceptibility to the above-mentioned commonly used antibiotics. Silkworm larvae fed on penicillin-treated leaves showed significant improvement in larval weight, larval length, and cocoon production. Significantly higher larval weight (6.88g), larval length (5.84cm), and cocoon weight (1.33g) were recorded for larvae fed on leaves treated with penicillin as compared to other antibiotics. Isolated bacterial strains showed close relation with Serratia spp., Bacillus spp. and Pseudomonas spp.

Trends in hospitalized patients with cancer and stress cardiomyopathy

Introduction

Although cardiovascular disease (CVD) and cancer remain the top two causes of death worldwide, novel therapeutics have resulted in a decreased mortality rate in both groups. Accordingly, there has been a heightened awareness of patients with cancer experiencing stress cardiomyopathy (SC). In patients with cancer, the emotional stress of the diagnosis of cancer is compounded by the physical stress of treatments such as surgery, chemotherapy, immunotherapy, and radiotherapy. Previous studies have shown that SC in patients with cancer is associated with higher odds of in-hospital mortality when compared to patients with SC alone. No studies have examined the differences between patients with active cancer and SC compared to patients with active cancer without SC.

Purpose

To explore the unique impact that a diagnosis of SC has on patients with specific types of cancer, so that clinicians may recognize these phenomena and reduce morbidity associated with this disease.

Methods

We queried the 2016 United States National Inpatient Sample, which is the largest publicly available all-payer inpatient healthcare database, to identify demographic characteristics and outcomes in patients with active cancer and SC.

Results

Of 30,195,722 adult hospitalized patients, 4,719,591 (15.63%) had active cancer of whom 568,239 (12.04%) had SC. Among patients with active cancer, patients with SC versus those without SC were significantly more likely to have the following characteristics: female sex, white race, commercial insurance, hypertension, anemia, thrombocytopenia, and coagulation disorder (p&lt;0.003 for all variables). The five most common primary malignancies in patients with SC were breast (13.4%), lung (10.2%), skin (9.5%), colon (8.1%), and leukemia (4.8%) (Figure 1).

In machine learning-augmented propensity score-adjusted multivariable regression fully adjusting for age, race, income, and presence of metastases, the only primary malignancies that significantly increased the likelihood of SC were lung cancer (OR 1.25; p=0.003) and breast cancer (OR 1.81; p&lt;0.001) (Table 1). In separate regression, neither SC alone nor having both SC and cancer was significantly associated with mortality. The presence of concomitant SC and breast cancer was significantly associated with reduced mortality (OR 0.48; p=0.032).

Conclusion

In patients with active cancer, SC was not associated with in-hospital mortality. In addition, patients with both SC and breast cancer had significantly reduced mortality when compared to all patients with cancer. Further investigation will be necessary to confirm these findings and determine the possible protective factors in patients with SC and breast cancer. Furthermore, clinicians should be aware, early during hospitalization, of the increased likelihood of SC in patients with lung cancer and breast cancer, in order to reduce morbidity associated with these diagnoses.

Funding Acknowledgement

Type of funding sources: None.

Clinical course and surgical outcomes in middle-age adults with anomalous aortic origin of a coronary artery

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with anomalous aortic origin of a coronary artery (AAOCA) present with a wide range of clinical manifestations, including ischemic symptoms (chest pain or dyspnea) and sudden cardiac death (SCD). Studies have identified coronary anatomic characteristics associated with a higher risk of SCD. However, most of the published literature consists of studies in adolescents and young adults. There is a paucity of data regarding outcomes in middle-aged patients. Current guidelines reveal gaps in evidence for identification of adults are at risk for SCD, and for whom surgery is beneficial.

Purpose

To study the clinical course and rate of major adverse cardiac events (MACE) in middle-aged adults with AAOCA based on presenting symptoms, coronary anatomy on coronary computed tomography angiography (CCTA), stress test results, and surgical management.

Methods

We included all patients from January 2013 to December 2019 age &gt; 18 at our institution who were found to have AAOCA.  Patients with the following were excluded to minimize confounding factors which could cause MACE: coronary artery disease (CAD) with &gt;50% stenosis in any coronary vessel, CAD requiring revascularization, heart failure with ejection fraction &lt;40%, history of heart transplant, and non-AAOCA congenital heart disease. All patient charts were reviewed for demographics, coronary anatomy on CCTA, presenting symptoms, rationale for pursuing stress testing and CCTA, nature of surgical interventions, post-surgical course, and MACE (cardiovascular death, myocardial infarction, and need for coronary revascularization). All patients underwent PET as well as treadmill stress testing.

Results

Of 19,367 patients who underwent CCTA, 47 met inclusion criteria, with median age at diagnosis of 54 and median follow-up of 48 months. No patients suffered MACE. Twenty-five patients had AAORCA and 22 had AAOLCA (Table 1). Ten patients with AAORCA and 8 patients with AAOLCA presented with ischemic symptoms and had coronary anatomy characteristics associated with higher risk of SCD, as well as ischemia corresponding to the anomalous artery on stress testing and did not undergo surgery due to personal preference. Five symptomatic patients with stress-induced ischemia corresponding to the anomalous artery underwent surgery and all achieved symptom relief over a median follow up of 5 years.

Conclusion

As AAOCA is a significant cause of SCD in young adults, it is compelling to observe this adult cohort in which no patients experienced MACE, including 18 symptomatic patients with high-risk anatomy and stress-induced ischemia, as well as a Class I recommendations for surgery.  The results suggest that although surgery may be beneficial for symptom relief, it does not necessarily improve mortality over an intermediate follow-up period.  Future studies should examine surgical outcomes in middle-aged cohorts with larger sample sizes.

Prevalence and risk factors of Syphilis among blood donors of Punjab, Pakistan

Syphilis is a sexually transmitted disease and its actual prevalence among Pakistani blood donors is currently unknown. A cross sectional study was conducted at different district healthcare hospitals of Punjab, Pakistan with an aim to evaluate the prevalence and risk factors associated with syphilis in blood donors using immunochromatographic test (ICT) and enzyme linked immunosorbent assay (ELISA). A total (n=1200) blood samples were collected from donors aged 18-65 years. All the information regarding personal data, demographic data and risk factors was collected via structured questionnaire. On the basis of ICT and ELISA, the overall prevalence of syphilis was 3.91% among blood donors. The demographic factors positively linked with syphilis were age (P= 0.000; Odds ratio, OR= 7.18; 95% confidence interval CI= 2.816-18.295) and education status (P= 0.000; Odds ratio, OR= 12.33; 95% confidence interval CI= 3.469-43.849) of donors. Similarly among the risk factors analyzed, marital status (P= 0.012; Odds ratio OR= 2.251; 95% confidence interval CI= 1.206- 4.202) and blood transfusion history (P= 0.030; Odds ratio OR= 1.981; 95% confidence interval CI= 1.083-3.623) were also strongly associated with syphilis. We emphasized the importance of promoting preventive measures for syphilis. The syphilis diagnosis should not be based on a single test. The present study indicates that higher prevalence is alarming for blood donors in Pakistan. Stringent donor screening is highly recommended to ensure maximum safe blood transfusion.

Effects of abomasal infusions of fatty acids and 1-carbon donors on apparent fatty acid digestibility and incorporation into milk fat in cows

Our primary objective was to determine the effects of the abomasal infusion of 16-carbon (16C) and 22-carbon (22C) fatty acids (FA) on apparent FA digestibility, plasma FA concentrations, and their incorporation into milk fat in cows. Our secondary objective was to study the effects of 1-carbon donors choline and l-serine on these variables. Five rumen-cannulated Holstein cows (214 ± 4.9 d in milk; 3.2 ± 1.1 parity) were enrolled in a 5 × 5 Latin square experiment with experimental periods lasting 6 d. Abomasal infusates consisted of (1) palmitic acid (PA; 98% 16:0 of total fat), (2) PA + choline chloride (PA+CC; 50 g/d of choline chloride), (3) PA + l-serine (PA+S; 170 g/d of l-serine), (4) behenic acid (BA; 92% 22:0 of total fat), and (5) docosahexaenoic acid algal oil (DHA; 47.5% DHA of total fat). Emulsions were formulated to provide 301 g/d of total FA and were balanced to provide a minimum of 40 and 19 g/d of 16:0 and glycerol, respectively, to match the content found in the infused algal oil. Apparent digestibility of FA was highest in DHA, intermediate in PA, and lowest in BA. Digestibility of 16C FA was lowest in BA and highest in PA. The digestibility of 22C FA was highest in DHA relative to BA (99 vs. 58%), whereas 1-carbon donors had no effect on 22C FA digestibility. Plasma 16C FA concentrations were greatest with PA treatment, and 22C FA concentrations were ~3-fold greater in DHA-treated cows relative to all other treatments. Milk fat 16:0 content was highest in PA relative to BA and DHA (e.g., 37 vs. 27% in PA and DHA), whereas the milk yield of 16:0 was higher in PA relative to DHA (i.e., 454 vs. 235 g/d). Similarly, milk 22:0 content and yield were ~10-fold higher in BA relative to all other treatments, whereas DHA treatment resulted in higher content and yield of 22:6 in milk fat relative to all other treatments (41- and 38-fold higher, respectively). Consequently, the content of FA >16C (i.e., preformed) was higher in milk fat from cows infused with BA and DHA relative to PA. De novo FA content in milk did not differ between PA, PA+CC, and PA+S (~16% of milk fat) but was higher in BA and DHA treatments (19 and 21%, respectively). We conclude that FA carbon chain length and degree of saturation affected FA digestibility and availability for absorption as well as their incorporation into milk fat. The abomasal infusion of choline chloride and l-serine did not modify these variables relative to infusing palmitic acid alone.

Abstract 328: Heart Failure Quality Improvement at the Las Vegas VA

Background: Recently there has been a push to prevent patients admitted with acute decompensated heart failure from being readmitted to the hospital within 30 days. At the VA Southern Nevada Healthcare System, we found that congestive heart failure was the most common cause of hospital admission from January 2017 to June 2018, as well as the diagnosis with the highest 30-day readmission rate to the hospital.

Objective: The goal of this project was to research the cause of heart failure readmissions at the VA Southern Nevada Healthcare System and recommend solutions to reduce the readmission rate.

Methods: We obtained a list of all patients at the VA who were documented as being readmitted within 30 days for heart failure from January 2017 to June 2018. We compared each patient’s hospital management to recommendations from the American Heart Association’s (AHA) “Get with the Guidelines” heart failure quality improvement program, which lays out a specific set of evidence-based benchmarks that should be achieved for patients with heart failure before hospital discharge.

Results: We identified 36 patients and analyzed their hospital courses for compliance with AHA quality improvement measures. There were ten patients who did not receive pharmacologic guideline directed medical therapy for heart failure on discharge, who were not found to have any contraindications. There were eight patients who did not have a transthoracic echocardiogram performed in the previous six months who may have benefitted from repeat left ventricular function assessment. Importantly, 16 patients were not seen at a follow up appointment within one month of discharge from the hospital.

Conclusion: We presented our findings to the Chief of Medicine, nursing staff, and residents at the VA Southern Nevada Healthcare System and worked with the Systems Redesign staff to determine how to improve adherence to guidelines and obtain close follow up for patients. An acute care transition clinic was created for patients at high risk for readmission on discharge, and a cardiology nurse practitioner was asked to make follow up appointments for all patients before discharge. We also created a heart failure order set in the electronic medical record, so that providers will be more likely to follow AHA recommendations from the beginning of each admission. We plan to conduct a follow up study to determine whether 30-day readmission rates improve after our recommended measures are instituted. Our objective is to reduce 30-day readmission rates and improve patient morbidity and mortality.ve patient morbidity and mortality.

Three-valve endocarditis in a patient with bioprosthetic aortic valve replacement and intravenous drug use: a case report

Background

Here, we outline the case of a US Veteran’s Health Administration (VA) patient with a history of recent bioprosthetic aortic valve replacement (AVR) and recent intravenous drug use (IVDU) who was found to have three-valve infective endocarditis (IE) resulting in septic shock. We highlight this case because it represents an uncommon case of three-valve IE in the setting of recent bioprosthetic valve replacement and IVDU, and it raises the need for continued awareness of mental health and drug rehabilitation in the US military veteran population.

Case summary

A 62-year-old gentleman with recent bioprosthetic AVR presented with dyspnoea and lower extremity oedema and was found to have a heart failure exacerbation. He developed sepsis and was found to have three-valve endocarditis, as well as aortic root abscess and pacemaker lead infection. He was treated with broad-spectrum antibiotics and evaluated for surgical intervention. After discussion with the surgical team, the patient decided not to pursue surgery due to prohibitively high perioperative mortality risk. The patient was transferred to hospice and expired within 2 weeks.

Discussion

Three-valve IE is sparingly documented in published literature and can be difficult to treat. Providers must be cognizant of prosthetic valve endocarditis as an uncommon but known complication of valve replacement surgery. Intravenous drug use is a common risk factor for endocarditis and is prevalent in the US military veteran population. Prosthetic valve endocarditis should be treated with broad-spectrum antibiotics, and in general, if it leads to new significant valvular abnormalities, the valve should be replaced.

Observation of an Unusual Upward-Going Cosmic-Ray-like Event in the Third Flight of ANITA

We report on an upward traveling, radio-detected cosmic-ray-like impulsive event with characteristics closely matching an extensive air shower. This event, observed in the third flight of the Antarctic Impulsive Transient Antenna (ANITA), a NASA-sponsored long-duration balloon payload, is consistent with a similar event reported in a previous flight. These events could be produced by the atmospheric decay of an upward-propagating τ lepton produced by a ν_{τ} interaction, although their relatively steep arrival angles create tension with the standard model neutrino cross section. Each of the two events have a posteriori background estimates of ≲10^{-2} events. If these are generated by τ-lepton decay, then either the charged-current ν_{τ} cross section is suppressed at EeV energies, or the events arise at moments when the peak flux of a transient neutrino source was much larger than the typical expected cosmogenic background neutrinos.

Energy Spectrum of Cosmic-Ray Electron and Positron from 10 GeV to 3 TeV Observed with the Calorimetric Electron Telescope on the International Space Station

First results of a cosmic-ray electron and positron spectrum from 10 GeV to 3 TeV is presented based upon observations with the CALET instrument on the International Space Station starting in October, 2015. Nearly a half million electron and positron events are included in the analysis. CALET is an all-calorimetric instrument with total vertical thickness of 30 X_{0} and a fine imaging capability designed to achieve a large proton rejection and excellent energy resolution well into the TeV energy region. The observed energy spectrum over 30 GeV can be fit with a single power law with a spectral index of -3.152±0.016 (stat+syst). Possible structure observed above 100 GeV requires further investigation with increased statistics and refined data analysis.

Assessment of allelic diversity among drought-resistant cotton genotypes using microsatellite markers

Drought, in conjunction with high temperature, is an important environmental constraint to cotton production. Development of cotton varieties with increased tolerance against adverse environmental conditions has been proposed as effective strategy for ensuring reliable yields. In the present study, 30 simple sequence repeat (SSR) primers were used to estimate genetic divergence among 22 cotton genotypes for drought stress tolerance. Genetic diversity is a prerequisite for developing drought resistant cotton genotypes. Eleven SSR primers out of 30 were able to discriminate among the cotton genotypes, implying that 37% of the primers were informative. In total, 41 alleles were detected, with an average of 3.72 alleles per primer. The number of alleles per locus ranged from one (JESPR-284) to six (JESSPR-302), and the allelic diversity in the experimental material was 0.40. Genetic similarity coefficients ranged from 0.87-1.00. The result of principal component analysis confirmed the clustering of 21 cotton genotypes in two groups leaving one genotype (CIM-109) ungrouped. Overall, genetic diversity among the 22 cotton genotypes was low. More polymorphic SSR markers are needed to explore the workable genetic variation among the screened cotton genotypes in future studies.

Pattern of first- and second-line drug resistance among pulmonary tuberculosis retreatment cases in Pakistan

BACKGROUND

Drug resistance in general, and multidrug-resistant tuberculosis (MDR-TB) in particular, threatens global tuberculosis (TB) control efforts. Population-based estimates of drug resistance are needed to develop strategies for controlling drug-resistant TB in Pakistan.

OBJECTIVE

To obtain population-based data on Mycobacterium tuberculosis drug resistance in Pakistan.

METHODS

To obtain drug resistance data, we conducted a population-based study of TB cases in all provinces of Pakistan. We performed culture and drug susceptibility testing on M. tuberculosis isolates from patients with a prior history of anti-tuberculosis treatment (retreatment cases) from all over the country.

RESULTS

Of 544 isolates from previously treated cases, 289 (53.1%) were susceptible to all first-line drugs, 255 (46.9%) were resistant to at least one anti-tuberculosis drug and 132 (24.3%) were MDR-TB. Among MDR-TB isolates, 47.0% were ofloxacin (OFX) resistant. Extensively drug-resistant TB was found in two (0.4%) isolates.

CONCLUSION

Prevalence of drug resistance in retreatment isolates was high. The alarmingly high prevalence of OFX resistance among MDR-TB isolates may threaten the success of efforts to control and treat MDR-TB.

Characteristics of Four Upward-Pointing Cosmic-Ray-like Events Observed with ANITA

We report on four radio-detected cosmic-ray (CR) or CR-like events observed with the Antarctic Impulsive Transient Antenna (ANITA), a NASA-sponsored long-duration balloon payload. Two of the four were previously identified as stratospheric CR air showers during the ANITA-I flight. A third stratospheric CR was detected during the ANITA-II flight. Here, we report on characteristics of these three unusual CR events, which develop nearly horizontally, 20-30 km above the surface of Earth. In addition, we report on a fourth steeply upward-pointing ANITA-I CR-like radio event which has characteristics consistent with a primary that emerged from the surface of the ice. This suggests a possible τ-lepton decay as the origin of this event, but such an interpretation would require significant suppression of the standard model τ-neutrino cross section.

Management and treatment outcomes of MDR-TB: results from a setting with high rates of drug resistance

SETTINGS

Although Pakistan has a high burden of multidrug-resistant tuberculosis (MDR-TB), little is known about the management and treatment outcomes of MDR-TB patients in Pakistan.

OBJECTIVE

To evaluate management and predictors of unsuccessful treatment outcomes among MDR-TB patients.

METHODS

In this observational cohort study, 196 MDR-TB patients enrolled at the Programmatic Management Unit for drug-resistant TB of Lady Reading Hospital, Peshawar, Pakistan, between 1 January 2012 and 28 February 2013 were included. Patients were followed until an outcome was recorded or 31 January 2015.

RESULTS

Extensive concurrent resistance to ofloxacin (OFX) and pyrazinamide (54.6%) was observed. Among 181 patients for whom treatment outcome was available, 135 (74.6%) were cured, 1 (0.6%) completed treatment, 35 (19.3%) died, 8 (4.4%) failed treatment and 2 (1.1%) defaulted. In multivariate analysis, predictors of unsuccessful treatment outcome (death, failure and default) were age >40 years (OR 3.412, P = 0.009), baseline body weight <40 kg (OR 2.966, P = 0.020), concurrent comorbidity (OR 3.785, P = 0.023), resistance to OFX (OR 2.777, P = 0.023), lung cavitations at baseline chest X-ray (OR 5.253, P < 0.001) and regimen modification due to adverse events (OR 3.492, P = 0.037).

CONCLUSION

The treatment outcome results were encouraging. Patients with identifiable predictors of poor treatment outcome should receive enhanced clinical management. Early detection and management of mild adverse effects can help prevent regimen modification and may improve treatment outcomes.

Ectopic Intrathymic Parathyroid adenoma demonstrated on Tc-99m Sestamibi SPECT-CT

Intrathymic parathyroid adenoma is a rare cause of primary hyperparathyroidism. In this case, Tc-99m Sestamibi SPECT-CT successfully localized abnormal tracer uptake in the mediastinum with corresponding low density lesion on CT images suggestive of mediastinal parathyroid adenoma which late on confirmed on histopathology. After the median sternotomy a large intrathymic parathyroid adenoma was identified and excised. With the help of gamma probe the surgeons detect the lesion early and with more confidence as well as reducing the total operation time. Tc-99m Sestamibi SPECT-CT scintigraphy and gamma probe localization is recommended for preoperative and intra operative localization of ectopic parathyroid adenomas.

Combining ability analysis for within-boll yield components in upland cotton (Gossypium hirsutum L.)

Cotton is an important cash crop worldwide, accounting for a large percentage of world agricultural exports; however, yield per acre is still poor in many countries, including Pakistan. Diallel mating system was used to identify parents for improving within-boll yield and fiber quality parameters. Combining ability analysis was employed to obtain suitable parents for this purpose. The parental genotypes CP-15/2, NIAB Krishma, CIM-482, MS-39, and S-12 were crossed in complete diallel mating under green house conditions during 2009. The F₀ seed of 20 hybrids and five parents were planted in the field in randomized complete block design with three replications during 2010. There were highly significant differences among all F₁ hybrids and their parents. Specific combining ability (SCA) variance was greater than general combining ability (GCA) variance for bolls per plant (9.987), seeds per boll (0.635), seed density (5.672), lint per seed (4.174), boll size (3.69), seed cotton yield (0.315), and lint percentage (0.470), showing predominance of non-additive genes; while seed volume (3.84) was controlled by additive gene action based on maximum GCA variance. Cultivar MS-39 was found to be the best general combiner for seed volume (0.102), seeds per boll (0.448), and lint per seed (0.038) and its utilization produced valuable hybrids, including MS-39 x NIAB Krishma and MS-39 x S-12. The parental line CIM-482 had high GCA effects for boll size (0.33) and seeds per boll (0.90). It also showed good SCA with S-12 and NIAB Krishma for bolls per plant, with CP- 15/2 for boll size, and with MS-39 for seeds per boll. The hybrids, namely, CP-15/2 x NIAB Krishma, NIAB Krishma x S-12, NIAB Krishma x CIM-482, MS-39 x NIAB Krishma, MS-39 x CP-15/2, and S-12 x MS-39 showed promising results. Correlation analysis revealed that seed cotton yield showed significant positive correlation with bolls per plant, boll size and seeds per boll while it showed negative correlation with lint percentage and lint per seed. Seed volume showed significant negative correlation with seed density. Seeds per boll were positively correlated with boll size and negatively correlated with bolls per plant lint percentage and lint per seed. Similarly, lint per seed exhibited positive correlation with lint percentage and boll size showed significantly negative correlation with bolls per plant. Presence of non-additive genetic effects in traits like bolls per plant, seeds per boll, lint per seed, seed cotton yield, and lint percentage is indicative of later generation selection or heterosis breeding may be adopted. For boll size, seed volume and seed density early generation selection may be followed because of the presence of additive gene action. The parental material used in this study and cross combinations obtained from these parents may be exploited in future breeding endeavors.