Multicenter analysis to assess risk of major adverse cardiac events in patients undergoing high-sensitivity troponin testing in the emergency department

Study hypothesis

Our objective was to evaluate 30-day major adverse cardiac events (MACE) in emergency department (ED) patients with normal high-sensitivity troponins (hs-trop). We hypothesized that MACE rates would be <1% in patients with (1) two normal troponins regardless of change in troponin (delta) and (2) index hs-trop below the limit of quantitation (LOQ) regardless of the institution modified HEART score.

Methods

This was a multicenter, retrospective, cohort study of adult patients who presented to 1 of 18 EDs between July 2020 and April 2021 with acute coronary syndrome as defined by an institutional-modified HEART score completed by their treating physician or midlevel, no evidence of ST-elevation myocardial infarction, and an index or serial gender-adjusted hs-trop within normal limits. The primary outcome was MACE within 30 days of index ED encounter. A detailed case review was then performed for those patients experiencing a MACE.

Results

Of the 9084 patients who had single or serial normal troponins, 31 (0.34%; confidence interval [CI] 0.23%-0.48%) experienced MACE. Of the 6140 patients with 2 normal hs-trop and a delta (change in troponin) <4, 27 patients (0.44%; CI 0.29%-0.64%) experienced MACE. Only 1 of the 69 patients with 2 normal hs-trop results but delta (change in troponin) ≥ 4 (1.45%; CI 0.04%-7.81%) suffered MACE. This patient was classified as non-low risk by our institutional HEART score. Of 7498 patients with an index hs-trop 

Conclusion

Patients with 2 normal hs-trop values in the ED are unlikely to suffer 30-day MACE. Although it remains unclear whether patients with delta (change in troponin) ≥4 despite normal troponins will have a 30-day MACE, this situation is rare. Additionally, a single index hs-trop <6 ng/L demonstrated a low risk for 30-day MACE independent of the institutional HEART score.

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Affiliation(s)

Victoria Serven Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
Kamala Swayampakala Sanger Heart & Vascular InstituteAtrium HealthCharlotteNorth CarolinaUSA
Christy Lesassier Sanger Heart & Vascular InstituteAtrium HealthCharlotteNorth CarolinaUSA
Tyler Siekmann Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
Gabriel Rivera‐Camacho Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
Santosh Rao Sanger Heart & Vascular InstituteAtrium HealthCharlotteNorth CarolinaUSA
David Matthew Sullivan Information and Analytics ServicesAtrium HealthCharlotteNorth CarolinaUSA
Harvey Pendell Meyers Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
David Pearson Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA

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A 20-Year Analysis of Medicare Reimbursement for Abdominal Wall Reconstruction (2000 to 2020)

BACKGROUND

The purpose of this study was to evaluate monetary trends in Medicare reimbursement rates for 30 abdominal wall reconstruction surgical procedures over a 20-year period (2000 to 2020).

METHODS

The Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services was used for each of the 30 included current CPT codes, and reimbursement data were extracted. Monetary data were adjusted for inflation to 2020 U.S. dollars using changes to the United States consumer price index. The R 2 values for the average annual percentage change and the average total percentage change in reimbursement were calculated based on these adjusted trends for all included procedures.

RESULTS

After adjusting for inflation, the average reimbursement for all procedures decreased by 17.1% from 2000 to 2020. The greatest mean decrease was observed for CPT code 49568 (the implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of débridement for necrotizing soft-tissue infection, -34.4%). The only procedure with an increased adjusted reimbursement rate throughout the study period was CPT code 20680 (+3.9%). From 2000 to 2020, the adjusted reimbursement rate for all included procedures decreased by an average of 0.85% each year, with an average R 2 value of 0.78, indicating a stable decline throughout the study period.

CONCLUSIONS

Reimbursement rates are declining when adjusted for inflation. Increased awareness of these trends is helpful to maintain access to optimal abdominal reconstruction care in the United States.

Effect of Nanoparticle Weight on the Cellular Uptake and Drug Delivery Potential of PLGA Nanoparticles

Biodegradable and biocompatible polymeric nanoparticles (NPs) stand out as a key tool for improving drug bioavailability, reducing the inherent toxicity, and targeting the intended site. Most importantly, the ease of polymer synthesis and its derivatization to add functional properties makes them potentially ideal to fulfill the requirements for intended therapeutic applications. Among many polymers, US FDA-approved poly(l-lactic-co-glycolic) acid (PLGA) is a widely used biocompatible and biodegradable co-polymer in drug delivery and in implantable biomaterials. While many studies have been conducted using PLGA NPs as a drug delivery system, less attention has been given to understanding the effect of NP weight on cellular behaviors such as uptake. Here we discuss the synthesis of PLGA NPs with varying NP weights and their colloidal and biological properties. Following nanoprecipitation, we have synthesized PLGA NP sizes ranging from 60 to 100 nm by varying the initial PLGA feed in the system. These NPs were found to be stable for a prolonged period in colloidal conditions. We further studied cellular uptake and found that these NPs are cytocompatible; however, they are differentially uptaken by cancer and immune cells, which are greatly influenced by NPs' weight. The drug delivery potential of these nanoparticles (NPs) was assessed using doxorubicin (DOX) as a model drug, loaded into the NP core at a concentration of 7.0 ± 0.5 wt % to study its therapeutic effects. The results showed that both concentration and treatment time are crucial factors for exhibiting therapeutic effects, as observed with DOX-NPs exhibiting a higher potency at lower concentrations. The observations revealed that DOX-NPs exhibited a higher cellular uptake of DOX compared to the free-DOX treatment group. This will allow us to reduce the recommended dose to achieve the desired effect, which otherwise required a large dose when treated with free DOX. Considering the significance of PLGA-based nanoparticle drug delivery systems, we anticipate that this study will contribute to the establishment of design considerations and guidelines for the therapeutic applications of nanoparticles.

Absorption, distribution, metabolism, and excretion of [14C]iptacopan in healthy male volunteers and in in vivo and in vitro studies

Iptacopan (LNP023) is an oral, small-molecule, first-in-class, highly potent proximal complement inhibitor that specifically binds factor B and inhibits the alternative complement pathway. Iptacopan is currently in development as a targeted treatment for PNH and multiple other complement-mediated diseases. In this study, the absorption, distribution, metabolism, and excretion (ADME) of iptacopan was characterized in six healthy volunteers after a single 100 mg oral dose of [¹⁴C]iptacopan. This was supplemented with an in vivo rat ADME study and metabolite exposure comparisons between human, rat and dog, in addition to in vitro assays, to better understand the clearance pathways and enzymes involved in the metabolism of iptacopan. The fraction of [¹⁴C]iptacopan absorbed was estimated to be about 71%, with a time to maximum concentration (T_max) of 1.5 h and elimination half-life from plasma of 12.3 h. Following a single dose of [¹⁴C]iptacopan, 71.5% of the radioactivity was recovered in feces and 24.8% in urine. [¹⁴C]iptacopan was primarily eliminated by hepatic metabolism. The main biotransformation pathways were oxidative metabolism via CYP2C8, with M2 being the major oxidative metabolite, and acyl glucuronidation via UGT1A1. The two acyl glucuronide metabolites in human plasma, M8 and M9, each accounted for {less than or equal to}10% of the total circulating drug-related material; systemic exposure was also observed in toxicology studies in rat and dog, suggesting a low risk associated with these metabolites. Binding of iptacopan to its target, factor B, in the bloodstream led to a concentration-dependent blood:plasma distribution and plasma protein binding of [¹⁴C]iptacopan. Significance Statement We characterized the pharmacokinetics, excretion, metabolism and elimination of [¹⁴C]iptacopan (an oral, selective small-molecule inhibitor of factor B) - in healthy human subjects. [¹⁴C]iptacopan was primarily eliminated by metabolism. The primary biotransformation pathways were oxidative metabolism via CYP2C8 and acyl glucuronidation via UGT1A1. Direct secretion of iptacopan into urine and potentially bile represented additional elimination mechanisms. Binding of iptacopan to its target, factor B, in the bloodstream led to a concentration-dependent blood:plasma distribution and plasma protein binding of [¹⁴C]iptacopan.

Why people are bad at leftover food management? A systematic literature review and a framework to analyze household leftover food waste generation behavior

Food waste is a significant global problem. In the global north, households are a major driver of food waste generation and also a key enabler of solutions to address the issue. Leftover food management is identified as one of the key areas that can be targeted to reduce food waste at home. Although a large body of literature exists on household food waste and its drivers, managing food leftovers has received less attention. This state-of-the-art review focuses on leftover food management practices with the view of supporting practitioners in designing and prioritizing behavioral interventions to reduce leftover food waste in households. It uses the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework to select articles for the review. Based on 42 primary studies, this systematic review identifies a range of psycho-social, socio-demographic and lifestyle factors influencing leftover food waste generation behavior at home. Moreover, household food handling skills and knowledge, and availability and accessibility to infrastructure facilities affect leftover food waste generation behavior. Based on the synthesized literature, Leftover Food Waste Generation Behavior (LFWGB) Framework has been developed. The framework conceptualizes psycho-social, personal and lifestyle factors driving leftover food management behaviors at home. Reducing food leftovers must be given top priority along with consumer meal planning and food preparation skills in household food waste reduction interventions and campaigns.

Has the COVID-19 pandemic changed household food management and food waste behavior? A natural experiment using propensity score matching

Household food management behavior changed considerably during the COVID-19 pandemic. A growing body of work has quantified the impact of lockdowns on household food waste. Yet, previous studies used a retrospective study design which undermines the accuracy of the causal effect on household food waste. This paper investigates the causal impact of the COVID-19 pandemic on household food management and food waste using a natural experiment approach. Using two large national-scale longitudinal data sets (n = 8157), this study quantifies the impact of COVID-19 on food waste and food behavior of Australian households. Propensity score matching (PSM) was carried out to address potential endogeneity issues and to select control and treatment groups for analysis. Findings reveal that Australian households reduced food waste by 9% on average in 2020 (during COVID-19) compared to the pre-pandemic (2019) level. The use of a grocery list, discount purchases, and 'just-in-case' purchases, and food refrigeration have recorded a marked increase during the pandemic compared to pre-pandemic times. The changes to food management and food discard behavior during the pandemic offer important insights for behavior change campaigns to reduce household food waste. Interventions to sustain good food planning and storage practices and involving food retailers are promising entry points in addressing household food waste. The study also highlights the considerable challenge in achieving SDG 12.3 target by 2030.

Multidisciplinary perceptions on robotic surgical training: the robot is a stimulus for surgical education change

BACKGROUND

It is unclear how to best establish successful robotic training programs or if subspecialty robotic program principles can be adapted for general surgery practice. The objective of this study is to understand the perspectives of high-volume robotic surgical educators on best practices in robotic surgery training and to provide recommendations transferable across surgical disciplines.

METHODS

This multi-institutional qualitative analysis involved semi-structured interviews with high-volume robotic educators from academic general surgery (AGS), community general surgery (CGS), urology (URO), and gynecology (GYN). Purposeful sampling and snowballing ensured high-volume status and geographically balanced representation across four strata. Interviews were transcribed, deidentified, and independently, inductively coded. A codebook was developed and refined using constant comparative method until interrater reliability kappa reached 0.95. A qualitative thematic, framework analysis was completed.

RESULTS

Thirty-four interviews were completed: AGS (n = 9), CGS (n = 8), URO (n = 9), and GYN (n = 8) resulting in 40 codes and four themes. Theme 1: intangibles of culture, resident engagement, and faculty and administrative buy-in are as important as tangibles of robot and simulator access, online modules, and case volumes. Theme 2: robotic OR integration stresses the trainee-autonomy versus patient-safety balance. Theme 3: trainees acquire robotic skills along individual learning curves; benchmark assessments track progress. Theme 4: AGS can learn from URO and GYN through multidisciplinary collaboration but must balance pre-existing training program use with context-specific curricular needs.

CONCLUSIONS

Robotic surgical experts emphasize the importance of universal training paradigms, such as a strong educational culture that balances autonomy and patient safety, collaboration between disciplines, and routine assessments for continuous growth. Often, introduction and acceptance of the robot serves as a stimulus to discuss broader surgical education change.

Diverse aging rates in ectothermic tetrapods provide insights for the evolution of aging and longevity

Comparative studies of mortality in the wild are necessary to understand the evolution of aging; yet, ectothermic tetrapods are underrepresented in this comparative landscape, despite their suitability for testing evolutionary hypotheses. We present a study of aging rates and longevity across wild tetrapod ectotherms, using data from 107 populations (77 species) of nonavian reptiles and amphibians. We test hypotheses of how thermoregulatory mode, environmental temperature, protective phenotypes, and pace of life history contribute to demographic aging. Controlling for phylogeny and body size, ectotherms display a higher diversity of aging rates compared with endotherms and include phylogenetically widespread evidence of negligible aging. Protective phenotypes and life-history strategies further explain macroevolutionary patterns of aging. Analyzing ectothermic tetrapods in a comparative context enhances our understanding of the evolution of aging.

AB0444 ENPATORAN: PRECLINICAL EVIDENCE SUPPORTING GLUCOCORTICOID DOSE REDUCTION AND PHASE II STUDY DESIGN IN PATIENTS WITH SLE AND/OR CLE (WILLOW)

Background

Enpatoran is a potent selective dual inhibitor of toll-like receptor (TLR) 7 and TLR8, aberrant activation of which may be involved in systemic lupus erythematosus (SLE) pathogenesis and glucocorticoid resistance.1,2,3 Enpatoran suppressed disease development in lupus mouse models, improving survival and reducing proteinuria, autoantibodies, and the interferon (IFN) gene signature.1 In healthy participants and patients hospitalized with COVID-19 pneumonia, enpatoran was well tolerated and demonstrated effective TLR7/8 engagement.4 Enpatoran is potentially glucocorticoid sparing and may help avoid the detrimental effects of long-term corticosteroid use in SLE management.5,6

Objectives

To evaluate the glucocorticoid-sparing effect of enpatoran and design a basket trial to assess its efficacy and safety in patients with SLE and/or cutaneous lupus erythematosus (CLE).

Methods

Cytokine concentrations and gene expression changes were measured in stimulated human peripheral blood mononuclear cells (PBMCs) from healthy donors after treatment with dexamethasone, TLR7/8 inhibitor, or both. A Phase II, basket design proof-of-concept, dose-finding study in patients with SLE and/or CLE (WILLOW) was designed.

Results

In healthy donor PBMCs, synergy was observed between TLR7/8 inhibitor and dexamethasone. Combination treatment inhibited cytokine release (IL-6) with greater potency than either treatment alone and reduced the expression of nuclear factor-kappa B and IFN-regulated genes. WILLOW is a Phase II, basket proof-of-concept, dose-finding, randomized, double-blind, placebo (PBO)-controlled 24-week study with two cohorts (NCT05162586, Figure 1). The primary objectives of WILLOW are to evaluate the dose–response relationship of enpatoran in reducing disease activity based on Cutaneous Lupus Erythematosus Disease Area and Severity Index-A (CLASI-A) or BILAG-Based Composite Lupus Assessment (BICLA) response rate. The secondary objectives are to investigate effects on both BICLA response and clinically meaningful corticosteroid reduction and evaluate disease control (including clinically meaningful corticosteroid reduction) in patients with predominantly active CLE or SLE. Cohort A will enroll patients with CLE (active subacute CLE and/or discoid LE) or SLE with predominantly active lupus rash. Cohort B, in two parts, will enroll SLE patients with moderate to severe systemic disease activity. Part 1 will assess clinical signal and Part 2 may be adapted to improve dose finding. Glucocorticoid-sparing will be evaluated by mandatory tapering to a prednisone-equivalent dose of ≤5 mg/day.

Figure 1.

WILLOW study design.

Cohort A and Cohort B Part 1 will start in parallel.

*Part 2 will be initiated after a pre-specified number of patients are enrolled in Part 1; enpatoran doses in Part 2 may be adapted to improve dose finding (dashed boxes).

BILAG, British Isles Lupus Assessment Group; CLASI-A, Cutaneous Lupus Erythematosus Disease Area and Severity Index-A; CLE, cutaneous lupus erythematosus; CS, corticosteroid; DBPC, double-blind placebo-controlled; DLE, discoid lupus erythematosus; PBO, placebo; SCLE, Subacute cutaneous lupus erythematosus; SLE, systemic lupus erythematosus; SLEDAI, Systemic Lupus Erythematosus Disease Activity Index.

Conclusion

Enpatoran is a novel TLR7/8 inhibitor and may enable glucocorticoid dose reduction in patients with SLE and CLE. The WILLOW study incorporates multiple novel elements including a basket design and evaluation of glucocorticoid-sparing.

References

[1]Vlach, et al. J Pharmacol Exp Ther. 2021;376:397–409;

[2]Northcott, et al. Lancet Rheumatol. 2021;5:e357–e370;

[3]Guiducci, et al. Nature. 2010;465:937–941;

[4]Port, et al. Pharmacol Res Perspect. 2021;9:e00842;

[5]Thamer, et al. J Rheumatol. 2009;36:560–564;

[6]Ruiz-Irastorza, et al. Rheumatology. 2012;51:1145–1153.

Acknowledgements

This study was sponsored by the healthcare business of Merck KGaA, Darmstadt, Germany (CrossRef Funder ID: 10.13039/100009945), who funded medical writing support by Bioscript Stirling Ltd.

Disclosure of Interests

Eric F. Morand: None declared, Andrew Bender Shareholder of: Shares in Merck KGaA, Employee of: EMD Serono Research & Development institute (an affiliate of Merck KGaA), Aditee Deshpande Employee of: EMD Serono Research & Development institute (an affiliate of Merck KGaA), Bharat Vaidyanathan Employee of: EMD Serono Research & Development institute (an affiliate of Merck KGaA), cristina vazquez mateo Employee of: EMD Serono Research & Development institute (an affiliate of Merck KGaA), Melinda Przetak Employee of: EMD Serono Research & Development institute (an affiliate of Merck KGaA), Flavie Moreau Employee of: EMD Serono Research & Development institute (an affiliate of Merck KGaA), Mukhy Khursheed Employee of: Merck Serono Ltd (an affiliate of Merck KGaA), Sanjeev Roy Employee of: Ares Trading SA (an affiliate of Merck KGaA), David Pearson Consultant of: Biogen Inc.

Discovery of the Clinical Candidate MAK683: An EED-Directed, Allosteric, and Selective PRC2 Inhibitor for the Treatment of Advanced Malignancies

Polycomb Repressive Complex 2 (PRC2) plays an important role in transcriptional regulation during animal development and in cell differentiation, and alteration of PRC2 activity has been associated with cancer. On a molecular level, PRC2 catalyzes methylation of histone H3 lysine 27 (H3K27), resulting in mono-, di-, or trimethylated forms of H3K27, of which the trimethylated form H3K27me3 leads to transcriptional repression of polycomb target genes. Previously, we have shown that binding of the low-molecular-weight compound EED226 to the H3K27me3 binding pocket of the regulatory subunit EED can effectively inhibit PRC2 activity in cells and reduce tumor growth in mouse xenograft models. Here, we report the stepwise optimization of the tool compound EED226 toward the potent and selective EED inhibitor MAK683 (compound 22) and its subsequent preclinical characterization. Based on a balanced PK/PD profile, efficacy, and mitigated risk of forming reactive metabolites, MAK683 has been selected for clinical development.

A retrospective study to establish recommendations for plan quality metrics in Lung SBRT

The increased use of Stereotactic body radiation therapy (SBRT) has warranted a new method of plan evaluation. The crucial component of SBRT is the precise, conformal delivery of radiation dose to the target with rapid dose fall-off in the surrounding normal tissues.In this study, we retrospectively evaluated plan quality in lung SBRT patients by calculating conformity, homogeneity, and gradient parameters using an in-house script. The goal of this study was to establish achievable, size-dependent recommendations for these plan quality metrics such that they may be used as a guideline in our clinic. Seventy-three patients treated with lung SBRT at The University of Toledo Medical Center during the period 2017-2020 were retrospectively reviewed for this study. Plans were evaluated using dosimetric indices from respective The Radiation Therapy Oncology Group (RTOG) and International Commission on Radiation Units and Measurements (ICRU) protocols. Average values for each of the following indices were calculated: RTOG conformity index = 1.12 ± 0.13; Paddick conformity index = 0.82 ± 0.07; gradient index = 4.63 ± 0.71; and Homogeneity index = 0.3 ± 0.07, for all studied lung lesions with a mean volume of 23.2 cc. Our final recommendations are based on clinically approved plans, after having removed statistical outliers that we may not have approved had the metrics been calculated. Additionally, we observed that a sharper dose fall-off and a more homogeneous plan were found using 6 FFF compared to 10 FFF energy. Comparison between our results and RTOG0915 data shows no deviation or minor deviation for the RTOG conformity index and the ratio of 50% prescription isodose volume to the target volume. Furthermore, no statistically significant correlation between RTOG conformity index and target volume was observed which is in agreement with RTOG0915. Using various dosimetric indices to characterize dose distributions in lung SBRT is a powerful tool to assess plan quality. We recommend that these values be calculated for all plans, utilizing a script or program so as to improve clinical workflow.

Thriving in adversity: Do life skills programs work for developing world children? A pragmatic randomized controlled trial

The severe adversity experienced by millions of children in the developing world leads to failure to thrive associated with cognitive deficits, emotional management problems, and social impairment. In this pragmatic randomized controlled trial, 909 children (aged 8–15 years) in India with disadvantaged backgrounds took part in a semistructured program involving sports or creative arts activities. The Life Skills Assessment Scale was used to assess the children's life skills before and after taking part in the program. Children who took part in the program showed significant increases in life skills following participation, compared to a control group. This study demonstrates the impact of simple, low-budget programs on cognitive, emotional, and social life skills that are typically delayed by severe adversity. The findings have clear implications for children in other adverse environments, such as conflict zones and settlements for displaced children resulting from war, natural disasters, and emergency events.

Thriving in adversity: Do brief milieu interventions work for young adults in the developing world? A pragmatic randomized controlled trial

Adolescence may be a window of opportunity to attenuate the effects of early social adversity, which impedes cognitive, emotional, and social development, and increases risk of psychopathology into adulthood. We ran a pragmatic randomized controlled trial to assess the impact of a brief intervention designed to facilitate life skills for psychosocial competence. Socially disadvantaged young people living in South India who had experienced early adversity (N = 645; age range = 17–22 years) participated in the intervention or were assigned to a wait-list control group. The intervention led to large differences in life skills between the two groups. This brief, scalable intervention can be made available to address the impact of early social adversity on young people's development.

Prehospital ECG with ST-depression and T-wave inversion are associated with new onset heart failure in individuals transported by ambulance for suspected acute coronary syndrome

BACKGROUND

Prehospital electrocardiogram(s) (ECG) can improve early detection of acute coronary syndrome (ST-segment elevation myocardial infarction [STEMI], non-STEMI, and unstable angina) and inform prehospital activation of cardiac catheterization lab; thus, reducing total ischemic time and improving patient outcomes. Less is known, however, about the association of prehospital ECG ischemic findings and long term adverse clinical events. With this in mind, this study was designed to examine the: 1) frequency of prehospital ECGs for acute myocardial ischemia (ST-elevation, ST-depression, and/or T-wave inversion); and, 2) whether any of these specific ECG features are associated with adverse clinical events within 30 day of initial presentation to the emergency department (ED).

METHODS

We included consecutive patients ≥ 21 years during a five-year period (2013-2017), who were transported by ambulance to the ED with non-traumatic chest pain and/or anginal equivalent(s) and had a prehospital 12‑lead ECG. Two cardiologists (LG, EC), blinded to clinical data, interpreted the 12‑lead ECGs applying current guideline based ischemia criteria. Adverse clinical events, return to ED, and rehospitalization evaluated at 30-days.

RESULTS

We identified 3646 patients (mean age, 59.7 years ±15.7; 45% female) with ECGs, of which N = 3587 had data on the three ischemic markers of interest. Of these, 1762 (49.1%) had ECG evidence of ischemia. In adjusted logistic regression models, those with T-wave inversion had a higher odds (OR = 1.59) of new onset heart failure, while ST-elevation was associated with lower odds (OR = 0.69). Patients with ST-depression had higher odds of new onset heart failure and death within 30 days (OR = 1.29, 1.49 respectively), but this association attenuated after controlling for other ECG features.

CONCLUSIONS

ST-depression and/or T-wave inversion are independent predictors of new onset heart failure, within 30 days of initial ED presentation. Our study in a large cohort of patients, suggests that using ECG ST-elevation alone may not capture patients with ischemia who may benefit from aggressive anti-ischemic therapies to reduce myocardial damage with resultant heart failure.

The way to a man's heart is through his stomach: a case of myocardial infarction mimic and pseudo-tamponade in a polytrauma patient

Background

There exists a therapeutic conflict between haemorrhage control and prevention of thromboembolic events following polytrauma and complications are not uncommon. Such opposing therapies can result in unexpected pathophysiology and there is a real risk of misdiagnosis resulting in harm. This case presents a previously unreported complication of prevention and management of thromboembolism- STEMI (ST elevation myocardial infarction) and tamponade mimic secondary to retroperitoneal haematoma.

Case presentation

We present a 50-year-old male polytrauma patient who following treatment for presumed pulmonary embolus demonstrated classical clinical findings of myocardial infarction and pericardial tamponade secondary to a retroperitoneal haematoma. This is an event not previously reported in the literature. The risk of adverse outcome by management along the standard lines of STEMI (ST elevation myocardial infarction) was averted through awareness for alternative aetiology via a multi-team approach which resulted in percutaneous drainage of the haematoma and complete resolution of symptoms.

Conclusions

This manuscript highlights the therapeutic conflict between haemorrhage control and prevention of thromboembolic events in critically injured, the importance of high index of suspicion in this patient cohort and the benefits of multidisciplinary decision making in the complex patient through a not previously published pathophysiologic phenomenon.

Untangling the influence of biotic and abiotic factors on habitat selection by a tropical rodent

Understanding how animal populations respond to environmental factors is critical because large-scale environmental processes (e.g., habitat fragmentation, climate change) are impacting ecosystems at unprecedented rates. On an overgrazed floodplain in north-western Australia, a native rodent (Pale Field Rat, Rattus tunneyi) constructs its burrows primarily beneath an invasive tree (Chinee Apple, Ziziphus mauritiana) rather than native trees. The dense thorny foliage of the Chinee Apple may allow high rat densities either because of abiotic effects (shade, in a very hot environment) or biotic processes (protection from trampling and soil compaction by feral horses, and/or predation). To distinguish between these hypotheses, we manipulated Chinee Apple foliage to modify biotic factors (access to horses and predators) but not shade levels. We surveyed the rat population with Elliott traps under treatment and control trees and in the open woodland, in two seasons (the breeding season—January, and the nesting season—May). In the breeding season, we ran giving-up density experiments (GUD) with food trays, to assess the perceived risk of predation by rats across our three treatments. Selective trimming of foliage did not affect thermal regimes underneath the trees but did allow ingress of horses and we observed two collapsed burrows as a consequence (although long term impacts of horses were not measured). The perceived predation risk also increased (GUD values at food trays increased) and was highest in the open woodland. Our manipulation resulted in a shift in rat sex ratios (indicating female preference for breeding under control but not foliage-trimmed trees) and influenced rat behaviour (giving-up densities increased; large dominant males inhabited the control but not treatment trees). Our data suggest that the primary benefit of the Chinee Apple tree to native rodents lies in physical protection from predators and (potentially) feral horses, rather than in providing cooler microhabitat.

Multidisciplinary Approach to Robotic Resection of Abdominal Wall Endometriosis and Mesh Repair

STUDY OBJECTIVE

To demonstrate a technique for robot-assisted laparoscopic excision of abdominal wall endometriosis and mesh reinforcement of the subsequent defect.

DESIGN

Description and demonstration of surgical technique.

SETTING

Abdominal wall endometriosis most commonly takes hold after seeding of a previous cesarean scar [1-5]. As of 2018, 31.9% of deliveries in the United States were accomplished by cesarean section [6]. With endometriosis at an estimated incidence of 11% in the United States, evaluation for, and minimally invasive management of, abdominal wall endometriosis is becoming an essential skillset for the gynecologic surgeon [7].

INTERVENTIONS

Robot-assisted laparoscopic evaluation of size and location of lesion in relation to anatomic landmarks. Demonstration of techniques to identify borders of endometriotic lesion including clinical and microscopic. Minimally invasive resection of lesion with preservation of vital structures. Placement of abdominal wall mesh for reinforcement of rectus muscle and fascial defect. Peritoneal closure to minimize adhesions and herniation into defect. Brief review of alternative approaches to surgical management.

CONCLUSION

Minimally invasive resection of abdominal wall endometriosis with subsequent mesh reinforcement provides a surgical option with less morbidity while still accomplishing successful treatment.

A multi-centre analysis of a decade of endoscopic pharyngeal pouch surgery in Cheshire and Merseyside

BACKGROUND

There are sparse data on the outcomes of endoscopic stapling of pharyngeal pouches. The Mersey ENT Trainee Collaborative compared regional practice against published benchmarks.

METHODS

A 10-year retrospective analysis of endoscopic pharyngeal pouch surgery was conducted and practice was assessed against eight standards. Comparisons were made between results from the tertiary centre and other sites.

RESULTS

A total of 225 procedures were performed (range of 1.2-9.2 cases per centre per year). All centres achieved 90 per cent resumption of oral intake within 2 days. All centres achieved less than 2-day hospital stays. Primary success (84 per cent (i.e. abandonment of endoscopic stapling in 16 per cent)), symptom resolution (83 per cent) and recurrence rates (13 per cent) failed to meet the standard across the non-tertiary centres.

CONCLUSION

Endoscopic pharyngeal pouch stapling is a procedure with a low mortality and brief in-patient stay. There was significant variance in outcomes across the region. This raises the question of whether this service should become centralised and the preserve of either tertiary centres or sub-specialist practitioners.

Cutaneous T-cell lymphoma is associated with increased risk of lymphoma, melanoma, lung cancer, and bladder cancer: A systematic review and meta-analysis

BACKGROUND

Patients with cutaneous T-cell lymphoma (CTCL) are at a higher risk of developing second malignancies. However, rates of incidence vary significantly across studies.

METHODS

A systematic review and meta-analysis of articles published between 1950 and 2019 was performed to evaluate the risk of second malignancies in patients with CTCL.

RESULTS

We identified 10 eligible studies, including 12 patient cohorts, with 5.9% to 16.8% of patients developing second malignancies. All studies showed a male predominance for patients developing second malignancies. The mean age across the studies ranged from 44.6 to 68.0 years. The time between the diagnosis of CTCL and second malignancy ranged from 2.1 to 5.4 years (mean, 3.29 y; 95% confidence interval [CI], 2.69-5.15). Meta-analysis showed a standardized incidence ratio of 2.18 (95% CI, 1.43-2.93) for all malignancies. The standardized incidence ratios were 15.25 (95% CI, 7.70-22.79) for Hodgkin lymphoma, 4.96 (95% CI, 3.58-6.33) for non-Hodgkin lymphoma, 1.69 (95% CI, 1.18-2.21) for lung cancer, 1.72 (95% CI, 1.18-2.21) for bladder cancer, and 3.09 (95% CI, 1.77-6.43) for melanoma.

CONCLUSIONS

We find that patients with CTCL are at increased risk of second malignancies, especially Hodgkin and non-Hodgkin lymphoma, lung cancer, bladder cancer, and melanoma. These findings provide evidence of a population at increased risk of malignancy. Early detection may decrease the morbidity burden of second malignancies, thus providing a strong rationale for prospective screening studies.

Mycosis fungoides: developments in incidence, treatment and survival

BACKGROUND

Prior studies have demonstrated improved disease-specific survival of mycosis fungoides (MF) patients over the last 50 years.

OBJECTIVE

To analyse patterns of survival and incidence from 1973 to 2016 and determine whether apparent improvements in MF-specific survival are due to lead-time bias rather than improvements in treatment.

METHODS

We performed an analysis of 10 155 patients diagnosed with MF from 1973 to 2016 in the United States cancer registries of SEER-18. We also performed a literature review of papers including stage data for unselected populations of MF patients prior to 2000.

RESULTS

Incidence of MF increased from 3.0 per million person-years in the 1970s to 5.9 in the 2010s. For all cohorts, non-Hodgkin lymphoma (including MF) was the leading cause of death. Survival analysis demonstrated marked improvement in disease-specific and overall survival from the 1970s to 2010s. Based on systematic review of the literature, 32%-73% of patients diagnosed prior to 2000 were diagnosed with early-stage disease, as opposed to 81% of patients in the SEER 2000-2016 cohort (P < 0.035 for all cohorts).

CONCLUSIONS

Although there have been improvements in MF-related survival over the last 50 years, these may reflect improvements in our ability to diagnose early-stage disease rather than improved treatment.

The Life Skills Assessment Scale: Norms for young people aged 17–19 and 20–22 years

Severe poverty, adversity, and malnutrition have irrefutable negative effects on the development and mental health of children and young people. The Life Skills Assessment Scale (LSAS), is a 5-item impact assessment scale developed in India, that provides a simple, yet valid and reliable, instrument to assess life skills of disadvantaged children and young people, with age norms of 8–16 years. In the present study, in Bengaluru, India, we used observational data obtained from 656 disadvantaged young people to extend the LSAS age norms to 17–19 and 20–22 years age groups, resulting in a simple, valid, and reliable assessment tool for children and young people aged from 8 to 22 years.

ST-Segment Elevation Myocardial Infarction and Out-of-Hospital Cardiac Arrest: Contemporary Management From the Multicenter START Registry

BACKGROUND

Recent studies suggest that primary percutaneous coronary intervention (PCI) and targeted temperature management (TTM) improve outcome in ST-segment elevation myocardial infarction (STEMI) complicated by out-of-hospital cardiac arrest (OHCA). The objective of this study was to evaluate a contemporary series of patients with STEMI and OHCA to characterize treatment approaches and predictors of neurologic outcome.

METHODS

From January 2009 through November 2012, a total of 239 patients who underwent emergent coronary angiography at 10 medical centers across the United States were enrolled. All patients suffered OHCA with STEMI on either the prehospital or post-resuscitation electrocardiogram. Neurologic outcome was assessed using the cerebral performance category (CPC) score. Predictors of neurologic outcome were determined using multivariate logistic regression analysis. The primary endpoint was in-hospital survival with good neurologic function (CPC score 1 or 2).

RESULTS

Mean age was 60 ± 13 years, 72% were male, and the majority of patients had a history of cardiovascular event. Initial rhythm was ventricular fibrillation in 72%. At hospital presentation, 76% of patients were intubated, 37% were in cardiogenic shock, and 33% were receiving vasopressors. Primary PCI was performed in 74%, with an average door-to-balloon time of 95 ± 77 minutes, and TTM was used in 51%. Forty-four percent of patients had full neurologic recovery (CPC score 1) and 55% had good neurologic function. Overall in-hospital survival rate was 66%. Independent predictors of in-hospital survival with good neurologic function were: receiving bystander cardiopulmonary resuscitation, location of arrest, receiving drug-eluting stents, and not experiencing a recurrent cardiac arrest.

CONCLUSIONS

Short-term survival for patients with STEMI and OHCA undergoing emergent coronary angiography and revascularization with TTM in this contemporary, multicenter registry was high and neurologic outcome was good in more than half of patients.

Simultaneous Determination of Multiple Tetracycline Residues in Milk by Metal Chelate Affinity Chromatography: Collaborative Study

To meet federal and state regulatory needs, a liquid chromatographic (LC) method with ultraviolet (UV) detection was developed for determination of 7 tetracyclines at 30 ng/mL in milk. Raw milk samples are defatted, acidified, and centrifuged to remove proteins, and tetracyclines are specifically absorbed from the milk by chelation with metal ions bound to small Chelating Sepharose Fast Flow columns. Tetracyclines are removed from these columns with EDTA-containing buffer, and extracts are further cleaned by ultrafiltration. Finally, extracts are concentrated and analyzed simultane ously by using on-line concentration. This method was validated in a collaborative study that involved 11 laboratories, including the authors’ laboratory. Each laboratory was asked to prepare and analyze known control and fortified milk samples, as well as 18 coded blind samples. Eight laboratories completed all analyses. Average interlaboratory recoveries for the known fortified samples ranged from 59% (methacycline at 15 ng/mL) to 78% (oxytetracy cline at 60 ng/mL). Average recovery for each of 7 residues at 30 ng/mL were between 60 and 110%, meeting single-residue guidelines for accuracy set by the U.S. Food and Drug Administration. Reproducibility relative standard deviation (RSDR) for the known fortified samples varied from 11 to 39%, with 6 of 7 residues at the 30 ng/mL level having RSDR values at or below 20%. Seven of 8 laboratories correctly identified blind control milk samples and all 28 residues present in blind samples. The metal chelate affinity—LC method for determination of multiple tetracycline residues in milk has been adopted first action by AOAC INTERNATIONAL.

Analysis of Milk-Based Infant Formula. Phase IV. Iodide, Linoleic Acid, and Vitamins D and K: U.S. Food and Drug Administration-Infant Formula Council: Collaborative Study

In 1982, the U.S. Food and Drug Administration, the Infant Formula Council and its member companies, contract laboratories, and other government laboratories began a study of analytical methods for the nutrients listed in the Infant Formula Act of 1980. Phases I, II, III, and V have been completed. The present report provides data on Phase IV, in which 13 laboratories collaboratively studied an ion-selective electrode method for analyzing iodide, a gas chromatographic method for linoleic acid, and 2 liquid chromatographic (LC) methods each for vitamins D and K. Data were insufficient to evaluate one each of the LC methods studied for vitamins K and D. The relative standard deviations (RSD) are sufficient for the nutrient levels found in infant formula. RSDs (%) for repeatability (RSDr) and reproducibility (RSDR), respectively, were as follows: iodide, 4.0-11.4 and 13.5-18.2; linoleic acid, 1.0-1.6 and 3.5-5.1; vitamin K1, 3.2-16.0 and 6.2-19.4; and vitamin D3,4.2 and 35.0. The recommendation to adopt the method for vitamin D was supported by the results of a ministudy. All laboratories were capable of using these methods with little training. The methods for determination of iodide, linoleic acid, and vitamins D and K in ready-to-feed milkbased infant formula have been adopted first action by AOAC International.

A rare case of a diverticular perforation associated with colo-urachal fistula presenting as anaphylaxis

Diverticular disease is a common clinical condition among Western populations, which increases with age. It can present in a variety of manners and has myriad of potential disease complications. We present a rare case of an adult patient with an extraperitoneal complications of a diverticular perforation presenting with facial swelling due to a colo-urachal fistula associated with a patent urachal remnant. Perforation should be considered in patients presenting with surgical emphysema with background of diverticular disease.

Evaluation of the use of abdominal compression of the lung in stereotactic radiation therapy

The goal of this retrospective study was to determine the benefit in using abdominal compression to reduce tumor motion for patients treated with lung stereotactic body radiotherapy. Forty-four lung lesions (n = 44) from 37 patients (N = 37) treated at the University of Toledo's Dana Cancer Center were assessed by determining the overall tumor displacement along with possible surrogates such as change in tidal volume and diaphragm displacement, with and without abdominal compression. Measurements of lung capacity were acquired from the 4DCT at maximum and minimum respiration in order to determine the tidal volume, with and without abdominal compression. Tumor centroid and diaphragm apex motion was then assessed in 3 dimensions from phase 0 to phase 50. This was measured in centimeters using the ruler method on MIM software, both with and without the compression belt. Change in overall tumor movement was 0.61 cm ± 0.09 cm with compression, and 0.60 cm ± 0.09 cm without the compression belt. Delta tumor motion was reduced in 5 cases, increased (made worse) in 6 cases, and did not clinically impact the remaining 33 cases. Average tidal volume with abdominal compression was 379.7 mL or 12.0% ± 0.724% of total lung volume while average tidal volume without abdominal compression was 337.7 mL or 10.5% ± 0.649% of total lung volume. Change in diaphragm position throughout the breathing cycle was 1.21 cm ± 0.10 cm with compression, and 1.28 ± 0.13 cm without the compression belt. These findings indicate that abdominal compression may not be an effective method in the reduction of respiratory motion, and can even negatively impact tumor motion by increasing its displacement. Compression decreased tumor motion in 5 out of the 44 cases studied. The 5 cases that benefitted tended to be lesions close to the diaphragm but these 5 corresponded to less than half of the inferior lesions, suggesting that even inferior lung lesions may not be prime candidates for abdominal compression.

Outcomes of implant-based oral rehabilitation in head and neck oncology patients-a retrospective evaluation of a large, single regional service cohort

Background

The study reports on implant survival outcomes in head and neck cancer patients who received implant-based oral rehabilitation in a regional service centre.

Methods

A retrospective analysis of implant survival outcomes in patients treated in a regional service from 2012 to 2017 was performed. The primary outcome measure was implant survival. The secondary outcome measure was to assess the effect of covariates associated with implant failure including bone type, radiotherapy, chemotherapy, gender and surgical implant complications. Kaplan-Meier survival curves were applied to compare differences in the survival rates of groups of variables. Cox proportional hazards models were applied to identify covariates associated with implant failure. p value was set at 0.05.

Results

The sample was composed of 167 head and neck cancer patients who had 779 dental implants placed. Implant survival estimates were calculated: 3 years, 95.7% [95%CI 94.3–97.2%] and 5 years, 95.5% [95%CI 93.9–97.0%], with a median follow-up of 38 months. Gender (p = 0.09), radiotherapy (p = 0.16) and chemotherapy (p = 0.17) did not significantly influence implant survival, whereas implant failure was higher in transported (reconstructed) bone sites in comparison with native bone (p < 0.01).

Conclusion

The result of this study suggests that overall implant survival as part of the routine oral rehabilitation is high in this patient cohort; however, implant failure was found to be statistically higher for implant placed into transported bone in comparison to native bone.

Fatigue in systemic lupus erythematosus and other autoimmune skin diseases

BACKGROUND

Fatigue is a well-established symptom in systemic lupus erythematosus (SLE), but has not been well characterized in other skin-limited autoimmune diseases such as cutaneous lupus erythematosus (CLE), amyopathic dermatomyositis (ADM) or autoimmune blistering diseases (AIBD).

OBJECTIVES

In this retrospective study, we compared fatigue in controls (n = 84) with that in patients enrolled in prospective longitudinal databases with SLE (n = 165), CLE (n = 226), ADM (n = 136) and AIBD (n = 79).

METHODS

We used the 36-Item Short Form Survey (SF-36) vitality scale to analyse median scores and the percentages of patients with clinically significant fatigue (defined as a score ≤ 35) between experimental groups and controls.

RESULTS

Median and interquartile range (IQR) vitality scores demonstrated greater fatigue in the experimental groups (SLE 35, IQR 20-55; CLE 50, IQR 30-70; ADM 50, IQR 30-65; AIBD 55, IQR 35-70) than in controls (73, IQR 65-85) (P < 0·05 for each experimental group vs. control). The SLE group had worse fatigue than all of the other groups (P < 0·05 SLE vs. each group), but there was no difference between the CLE, ADM or AIBD groups (all P > 0·05). In addition, the experimental groups had more clinically significant fatigue (score ≤ 35) (SLE 44·2%, CLE 25·2%, ADM 31·6%, AIBD 24·1%) than controls (2%) (P < 0·01 for each experimental group vs. control). The SLE group had more clinically significant fatigue than the CLE group (P < 0·01); however, there was no difference in clinically significant fatigue between SLE and either ADM (P = 0·17) or AIBD (P = 0·055).

CONCLUSIONS

These findings demonstrate that patients with skin-limited autoimmune disease experience more fatigue than controls. Fatigue is an important symptom that negatively affects quality of life for patients. It should be addressed by clinicians and measured in future clinical trials.

Retrospective dosimetric analysis of brain lesions planned in Pinnacle 9.8 via a HDMLC linac

The University of Toledo Medical Center's Eleanor N. Dana Cancer Center located in northwest Ohio currently utilizes the Edge Radiosurgery System (Varian Medical Systems Inc., Palo Alto, CA) to deliver stereotactic radiosurgery for the treatment of brain lesions. The purpose of this study is to determine the quality of conformal arc radiotherapy in treating patients with brain lesions at The University of Toledo Medical Center and to provide more data for conformity and gradient indices (due to a lack of current data) to hopefully improve national standards by allowing centers to compare among each other. Treatment plans were assessed using the Pinnacle³ v9.8 Radiation Therapy Planning System (Philips Healthcare, Amsterdam, Netherlands). For patients (n = 41) presenting with small brain lesions (n = 82) and treated with conformal arc radiotherapy via the Edge Radiosurgery System, the RTOG conformity index, Paddick conformity index, conformity gradient index, gradient index, and dose gradient index were determined for each plan. This study additionally provides data to suggest the more accurate method of volume derivation provided by the Pinnacle³ v9.8 software. Using this method, average values for each of the following indices were calculated: RTOG conformity index = 1.36 ± 0.29; Paddick conformity index = 0.72 ± 0.12; conformity gradient index = 214.67 ± 12.35; gradient index = 3.64 ± 1.09; dose gradient index = -0.11 ± 0.16. Thus, The University of Toledo Medical Center provides favorable conformity of dose to intracranial target lesions.