First-in-man report of transsubclavian venous implantation of the Aveir leadless cardiac pacing system

INTRODUCTION

Transsubclavian venous implantation of the Aveir leadless cardiac pacemaker (LCP) has not been previously reported.

METHODS AND RESULTS

Three cases of transsubclavian implantation of the Aveir LCP are reported. Two cases were postbilateral orthotopic lung transplant, without appropriate femoral or jugular access due to recent ECMO cannulation and jugular central venous catheters. In one case, there was strong patient preference for same-day discharge. Stability testing confirmed adequate fixation and electrical testing confirmed stable parameters in all cases. All patients tolerated the procedure well without significant immediate complications.

CONCLUSIONS

We demonstrate the feasibility of transsubclavian implantation of the Aveir LCP.

Longitudinal analysis of the skin microbiome in association with hand eczema, hand hygiene practices and moisturizer use

BACKGROUND

The skin microbiota maintains a physical and immunological barrier to the environment. Little is known about how the microbiome changes over time or the effect of hand hygiene practices and moisturizer use.

OBJECTIVES

To assess sex-specific changes in skin bacteria over time, and how the microbiome is related to self-reported hand eczema, hand hygiene practices and use of moisturizers.

METHODS

Swab samples from the dorsal hand were collected at baseline and 6.5 years later during the COVID-19 pandemic, in 168 participants from the RHINESSA study in Bergen, Norway. The skin samples were analysed by 16S rRNA amplicon sequencing.

RESULTS

The alpha diversity of the hand microbiome increased from baseline to follow-up, and beta diversity differed by sex at both time points. The relative abundance increased for several bacteria from baseline to follow-up, with sex-specific differences. Current hand eczema and aggravating hand eczema during the COVID-19 pandemic were associated with an increase in Staphylococcus. High hand washing frequency at home was associated with lower alpha diversity and with higher abundance of Staphylococcus, Corynebacterium, Finegoldia, and Pseudomonas and lower abundance of Propionibacterium and Pelomonas. The alpha diversity increased with increasing time passing between hand washing and sampling, whereas more frequent moisturizer use was associated with significantly lower alpha diversity, and a change in abundance for some bacteria, such as more Pseudomonas.

CONCLUSIONS

This longitudinal study revealed an overall increase in skin microbial diversity over a 6-year period, which was unexpected since follow-up was performed during the COVID-19 pandemic when vigorous hand hygienic practices were introduced. Sex-specific differences were identified at both time points. Individuals with hand eczema seem to develop a more dysbiotic skin bacterial community over time. Hand washing and use of moisturizers, with typically gender-specific habitual patterns, may lead to change in bacterial composition.

Can artificial intelligence fill in the gaps in heart failure guidelines by providing precision medicine in medication advice?

Background

The treatment of heart failure (HF) consists of many different types of medication. It is not yet known which patients benefit most from which medication type. Artificial intelligence (AI) may be helpful to predict the best individual combination of drugs and dosages, but such a model is lacking.

Purpose

We present an AI model that can predict optimal medication regimen per patient based on mortality and hospitalisation risk.

Methods

A total of 620 patients of the Randomized controlled multicenter Trial of Intensified vs Standard Medical Therapy in Elderly Patients With Congestive Heart Failure (TIME-CHF) study were divided into a training and a test population across different sections of patients. They were evaluated by a fixed multi-layer combination of different AI/machine learning models. The steps of the model include; (1) making segmentation by medication treatment: optimal or not optimal; (2) evaluation by general prognostic model and model optimised for patients with non-optimal medication (3); finding optimal medication recommendation for all outcomes of step 2. After optimising the model with the training population, the model was validated retrospectively on the test population. Prognosis was based on mortality and hospitalisation during up to 5 years follow-up.

Results

Of the 620 patients, 59% were male, age 76.9±7.6 years, and median follow-up was 2.2 years. The optimised model identified variables that are important to generate an accurate medication recommendation. These included biomarkers, symptoms, and patient characteristics. In the first step of clustering, data showed that at T0, 68% of the patients were not in optimal medical therapy range, and their outcome prediction was poor (Figure 1). During the follow-up period, this group decreased to 36%, and was almost equal in size to the group with good prognosis despite not optimal medication range (38%). Furthermore, the group with a good medical therapy range and good prognosis increased during the study.

Finally, validation of the medication prediction model showed that model-based therapy adjustments could significantly reduce hospitalisation rate and death. For patients who had therapy according to the AI model recommendation, the death rate and hospitalisation rate were three times lower (Table 1).

Conclusion

The AI model was successful in predicting the optimal medication regimen in the validation population. Where HF guidelines are ambiguous about optimal treatment, the model may fill these knowledge gaps. Furthermore, the model emphasises the hypothesis that a standard approach to HF treatment is not beneficial for all patients. There is a group outside the optimal medication range that has a poor outcome, but there is also a group that has a good outcome despite a non-optimal medication range. Therefore, the latter group would possibly be better off with less medication. These findings need to be validated prospectively in further research.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): INTERREG-NWE

Quality of Life, Risk and Recovery in a National Forensic Mental Health Service: A D-FOREST study from DUNDRUM Hospital

Introduction

Secure forensic mental health services have a dual role, to treat mental disorder and reduce violent recidivism. Quality of life is a method of assessing an individual patients’ perception of their own life and is linked to personal recovery. Placement in secure forensic hospital settings should not be a barrier to achieving meaningful quality of life. The WHO-QuOL measure is a self-rated tool, internationally validated used to measure patients own perception of their quality of life.

Objectives

This aim of this study was to assess self-reported quality of life in a complete National cohort of forensic in-patients, and ascertain the associations between quality of life and measures of violence risk, recovery and functioning.

Methods

This is a cross sectional study, set in Dundrum Hospital, the site of Ireland’s National Forensic Mental Health Service. It therefore includes a complete national cohort of forensic in-patients. The WHO-QuOL was offered to all 95 in-patients in Dundrum Hospital during December 2020 – January 2021, as was PANSS (Positive and Negative Symptoms for Schizophrenia Scale). During the study period the researchers collated the scores from HCR-20 (violence risk), therapeutic programme completion (DUNDRUM-3) and recovery (DUNDRUM-4). Data was gathered as part of the Dundrum Forensic Redevelopment Evaluation Study (D-FOREST).

Results

Lower scores on dynamic violence risk, better recovery and functioning scores were associated with higher self-rated quality of life.

Conclusions

The quality of life scale was meaningful in a secure forensic hospital setting. Further analysis will test relationships between symptoms, risk and protective factors and global function.

Disclosure

No significant relationships.

AB0623 A review of the evidence behind the recommendation of rituximab for ANCA associated vasculitis

Background

Cyclophosphamide (CYC) is currently used to induce remission in patients with ANCA-associated vasculitis (AAV). Once remission induction is successful Azathioprine (AZA) is given as maintenance (1). Concerns surround the use of cyclophosphamide which has an undesirable safety profile, limiting its use in patients. AZA has shown to be effective at maintenance, however rates of relapse on AZA are high.

Rituximab (RTX) is a biologic with a high specificity to B cells. Its mechanism of action (B cell apoptosis) may mean that it can be used for both the induction and maintenance of remission, with a superior long-term safety profile.

Objectives

To conduct a systematic review of literature to determine the efficacy of rituximab as a remission inducing and maintaining agent.

Methods

A systematic review of literature was conducted by searching PubMed and Cochrane library with the search phrase “rituximab AND ANCA-associated vasculitis”. The following criteria was then applied: randomised controlled trial (RCT) in the English language. Only original papers were accepted if it pertained to RTX for either induction or maintenance of remission.

Results

1008 papers were initially identified and after the search strategy was applied 9 RCTs were analysed.

The RAVE trial compared RTX to CYC in 197 patients with AAV in a double-blind double-dummy trial. The result of the RAVE trial indicated that RTX was as effective as CYC at maintaining remission. The RITUXVAS trial, which was partially blinded and had a sample of 44 patients also came to the same conclusion. Both the RAVE and RITUXVAS trials also showed that an initial dose of RTX was as effective as continuous immunosuppression over the trial length.

Further RCTs were published from the RAVE and RITUXVAS studies including a follow up of patients from the RITUXVAS trial at 24 months which showed no increased rates of relapse or adverse events between the groups. The RAVE study also showed that RTX was effective to be used on multiple occasions to induce remission irrespective of the initial remission inducing agent.

The MAINRITSAN1 study was a non-blinded randomised trial which compared RTX with azathioprine for maintenance in 115 patients with AAV. The results of this trial showed that RTX was superior than AZA at maintenance with only 5% on RTX compared with 29% on AZA relapsing. The long-term follow up of patients in the trial, showed that at 60 months, patients who received RTX were less likely to have relapsed.

The MAINRITSAN2 trial indicated that there was no difference between a fixed vs tailored RTX dose, meaning that a lower tailored dose was as effective as a higher fixed dose. The MAINRITSAN 3 paper was a double-blind trial that indicated that biannual RTX for maintenance was superior than placebo at maintaining remission.

Conclusion

RTX is as effective as CYC at inducing remission, with both the RAVE and RITUXVAS trials sharing similar conclusions.

Currently the research indicates that an initial dose of RTX can maintain remission at similar rates as continuous AZA, however its superiority is yet to be determined. The MAINRITSAN 1 trial was unblinded in its protocol with the data indicating it drastically overestimated the efficacy of both RTX and AZA. Therefore, more research is needed to validate the claim that RTX is superior than AZA at maintenance.

References

[1]Yates, M, et al. 2016. EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Annals of the Rheumatic Diseases 75, 1583–1594. doi:10.1136/annrheumdis-2016-209133

Acknowledgements

I would like to thank Dr Marwan Bukhari for his continued support and feedback during this project.

Disclosure of Interests

None declared

Acute aortic dissection in the Marfan syndrome during the COVID-19 epidemic

A 17-year-old boy with a recent diagnosis of COVID-19 infection was admitted with acute chest pain due to type A aortic dissection and was subsequently diagnosed with the Marfan syndrome. Literature shows an increased rate of aortic dissection during flu season. The hypothesis is that a cytokine storm triggers the dissection.

Range of factors in the reduction of hyperhydricity associated with in vitro shoots of Salvia santolinifolia Bioss

Hyperhydricity is a serious physiological disorder and affects In vitro propagation of many plants and as well of Salvia santolinifolia. The donor material to initiate the in vitro culture was the callus taken from the in vitro shoots produced on Murashig and Skoogs (MS) medium at 4.0 mg/l BA. This callus formed numerous hyperhydric shoots on culturing upon the medium of the same composition. The aim was to systematically evaluate the effect of cytokinins (Benzyladnine (BA) and N6-(-2-isopentenyl) adenine (2iP), culture vessels magnitude, medium solidification, source of nitrogen and calcium chloride for the alleviation of hyperhydricity. In the tissue cultures of S. santolinifolia BA and 2iP induced severe hyperhydricity, when other factors i.e. culture vessels magnitude and a suitable concentration of agar, ammonium nitrate (NH4NO3), potassium nitrate (KNO3) & calcium chloride (CaCl2.2H2O) were not optimized. After 30 days' culture, we observed 83.82% hyperhydric shoots at increased level (1.5 mg/l 2iP) and 81.59% at decreased levels (1.0 mg/l 2iP). On the other hand, hyperhydricity percentage at decreased (0.4%) and at increased (0.8%) levels of agar were 72.37% and 39.08%, respectively. MS medium modification with NH4NO3 (412 mg/l), KNO3 (475 mg/l) and CaCl2.2H2O (880 mg/l) was found the best medium to reduced hyperhydricity (23.6%).

A guide to diagnosing and managing ascites in cirrhosis

Combined serum and ascites fluid measurements point to the cause of ascites. For patients with modest edema, a reduced weight-loss target with diuresis may be acceptable.

Impact of the Miocene orogenesis on Kaloula spp. radiation and implication of local refugia on genetic diversification

The phylogeography of the Kaloula genus in East Asia is still poorly understood. One of the difficulties is the absence of fossils to corroborate molecular dating estimates. Here, we examined the mitochondrial structure of Kaloula spp. in East Asia and focused on the impact of glaciations on the northernmost species: Kaloula borealis. We determined the phylogenetic relationships, molecular dating, and genetic connectivity assessments within the genus from 1211 bp of concatenated mitochondrial 12S and 16S. The relaxed clock analyses reveal the emergence of Kaloula spp. common ancestor in East and Southeast Asia between the Eocene and Oligocene, c. 38.47 Ma (24.69-53.65). The genetic diversification of lineages then increased on the East Asian Mainland during the Lower Miocene, c. 20.10 (8.73-30.65), most likely originating from the vicariance and radiation triggered by the orogeny of the Qinghai-Tibetan Plateau. Later, the dispersal towards the North East Asian Mainland during the Upper Miocene drove the population diversification of K. borealis c. 9.01 Ma (3.66-15.29). Finally, the central mainland population became isolated following orogenesis events and diverged into K. rugifera during the Pliocene, c. 3.06 Ma (0.02-10.90). The combination of population genetic and barrier analyses revealed a significant genetic isolation between populations of Kaloula spp. matching with the massive Qinling-Daba Mountain chain located in south-central China. Finally, we highlight a young divergence within the Eastern Mainland population of K. borealis, possibly attributed to refugia in south eastern China from which populations later expanded.

Compliance of atrial fibrillation treatment with the ABC pathway in patients with concomitant diabetes mellitus in the Middle East based on the Gulf SAFE registry

Introduction

Atrial fibrillation (AF) and diabetes mellitus (DM) constitute a heavy burden on healthcare expenditure due to their negative impact on clinical outcomes in patients. DM is highly prevalent in the Middle East. The Atrial fibrillation Better Care (ABC) pathway provides a simple step-by-step strategy with an integrated, holistic approach to AF management: A, Avoid stroke (Anticoagulation); B, Better symptom management; C, Cardiovascular and comorbidity risk management.

Aim

Evaluation of the AF treatment compliance to ABC pathway regimen in patients with DM based on a large real-world registry from the Middle East region. We assessed the impact of ABC-pathway compliance on all-cause mortality and the composite outcome of stroke or systemic embolism, all-cause death and cardiovascular hospitalizations.

Methods

From 2043 patients in the Gulf SAFE registry, 603 patients with DM were included in an analysis of compliance with components of the ABC pathway: A, oral anticoagulation (OAC) use in patients with CHA2DS2-VASc score ≥1 (≥2 in females); B, AF symptoms according to the European Heart Rhythm Association (EHRA) score; C, Optimized management of cardiovascular comorbidities e.g. blood pressure control, statins for vascular disease, etc.

Results

From 606 patients, 86 (14.3%) patients were treated in compliance with the ABC pathway. During 1-year follow-up, 207 composite outcome events and 87 deaths occurred. Mortality was significantly lower in the ABC-adherent group vs non-ABC compliant (5.8% vs 15.9%, p=0.0014, respectively) (Figure). On multivariate analysis, ABC-adherent management was associated with a lower risk of all-cause death and the composite outcome after 6 months (OR 0.18; 95% CI, 0.42–0.75 and OR 0.54; 95% Cl, 0.30–1.00, respectively) and at 1 year (OR 0.30; 95% Cl,0.11–0.76 and OR 0.57; 95% Cl, 0.33–0.97, respectively) vs the non-ABC group (Table).

Conclusions

Integrated AF care, according to ABC pathway, was independently associated with a lower risk of all-cause death and the composite outcome, in DM patients with AF. This highlights the importance of a comprehensive and holistic approach to AF management.

Events rates and outcomes odds ratio

Funding Acknowledgement

Type of funding source: None

Pharmacological inhibition of C-C chemokine receptor 4 aggravates atherosclerosis through prevention of regulatory T cell recruitment to the lesions

Background

Regulatory T cells (Tregs) are demonstrated to play a protective role in the development of atherosclerosis. However, their sites of action in atherosclerosis remain unclear. Although C-C chemokine receptor 4 (CCR4) has been shown to contribute to the accumulation of Tregs in inflamed tissues and prevention of experimental autoimmune diseases, the role of CCR4 in Treg migration to atherosclerotic lesions and suppression of plaque formation remains unknown.

Methods and results

We intraperitoneally injected 8-week-old apolipoprotein E–deficient mice fed a normal diet with vehicle (n=9) or a 4-μg dose of a CCR4 antagonist (n=10) 3 times weekly for 8 weeks and evaluated atherosclerotic lesions at 16 weeks old. Administration of the CCR4 antagonist significantly aggravated atherosclerotic plaque formation (aortic sinus plaque area: 2.91±0.87×104 μm2 versus 5.41±0.98×104 μm2 in control vehicle-treated and CCR4 antagonist-treated mice, respectively; P<0.05), associated with increased accumulation of macrophages and CD4+T cells in the plaques. Flow cytometric analysis revealed a decrease in Foxp3+ Tregs in the para-aortic lymph nodes and thoracoabdominal aortas of CCR4 antagonist-treated mice, along with a tendency toward increase in CD44highCD62Lloweffector T cells in para-aortic lymph nodes, indicating CCR4-dependent migration of Tregs to atherosclerotic lesions and their possible atheroprotective role. We observed no changes in splenic Foxp3+ Tregs and effector T cells following CCR4 antagonist treatment. We also investigated the effect of CCR4 blockade on advanced atherosclerosis using LDL receptor–deficient mice fed a high-cholesterol diet. Although 8-week treatment with the CCR4 antagonist led to a decrease in Foxp3+ Tregs in the atherosclerotic lesions, atherosclerotic lesion formation was not significantly affected, suggesting that CCR4-dependent Treg accumulation in atherosclerotic lesions is not critical for prevention of advanced atherosclerosis.

Conclusions

Our findings indicate an important role for CCR4 in promotion of Treg recruitment into atherosclerotic lesions and subsequent prevention of early atherosclerosis and suggest CCR4 as a novel therapeutic target for atherosclerosis.

Funding Acknowledgement

Type of funding source: None

Increased Prevalence of Obesity and Metabolic Syndrome in Patients with Alcoholic Fatty Liver Disease

BACKGROUND AND AIMS

Obesity and diabetes are risk factors for advanced alcoholic liver disease, and both are components of the metabolic syndrome. We aimed to assess the prevalence of metabolic syndrome and its components in a contemporary US cohort of adults with alcoholic liver disease and compare it to a historic cohort to assess changes over time.

METHOD

Individuals 18 years or older who participated in the National Health and Nutrition Examination Survey during 2009-2014 and 1999-2001 were used as the contemporary and historic cohort, respectively. Alcoholic liver disease was defined as excessive alcohol consumption (men: ≥ 3 drinks/day; women: ≥ 2 drinks/day) and elevated alanine aminotransferase. Metabolic syndrome definition was based on the updated International Diabetes Federation criteria. Data are presented as mean ± standard error or unweighted frequency. A logistic regression analysis was performed to assess differences in metabolic syndrome components between the two period cohorts while adjusting for central obesity.

RESULTS

The mean age for our contemporary cohort was 41.9, 66.1% being male. Central obesity was present in 66.3%, type 2 diabetes in 18.7%, low high-density lipoprotein in 28.3%, hypertriglyceridemia in 44.8%, and hypertension in 54.7%. 36.9% met the criteria for metabolic syndrome. Compared to the historic cohort, patients in the contemporary cohort were more likely to have central obesity (50% vs. 66%, p = 0.002), metabolic syndrome (26% vs. 37%, p = 0.044), and type 2 diabetes (12% vs. 19%, p = 0.099).

CONCLUSIONS

Prevalence of both obesity and metabolic syndrome is increasing in alcoholic liver disease patients. Further studies are required to investigate effective interventions to avoid disease progression in these high-risk patients.

Role of platelet-albumin-bilirubin score in predicting re-bleeding after band ligation for acute variceal hemorrhage

Platelet-albumin-bilirubin (PALBI) score was proposed by Roayaie et al with modification of previously studied albumin-bilirubin score to include platelet as an indicator of portal hypertension in 2015. Predictive value of this score was recently tested by Elshaarawy et al for re-bleeding in patients presenting with acute variceal hemorrhage. We did a similar study at our center (n = 170) to look at incidence of re-bleeding after band ligation defined as drop in 2 units of hemoglobin and witnessed melena or hematemesis within 2 wk of the procedure. We calculated PALBI scores for all patients based on lab values prior to the procedure. Of 25.3% had re-bleeding episodes, area under receiver operating characteristic curve for PALBI as predictor of re-bleeding was 0.601 (95% confidence interval: 0.502-0.699). PALBI score showed moderate accuracy at predicting re-bleeding in our population.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Medications in type-2 diabetics and their association with liver fibrosis

BACKGROUND

The prevalence of nonalcoholic fatty liver disease (NAFLD) is significantly rising worldwide. Type-2 diabetes (T2D) is a major risk factor for NAFLD progression.

AIM

To assess the association of commonly used medications to advanced fibrosis (AF) in patients with biopsy-proven NAFLD and T2D.

METHODS

We used the International Classification of Disease 9^th Revision Clinical Modification coding system to identify patients with T2D and included patients who underwent liver biopsy for suspected NAFLD between January 1, 2000 to December 31, 2015. We compared demographics, clinical characteristics, and differences in pattern of medication use in patients who had biopsy-proven AF to those without it. A univariate and multivariate analysis was performed to assess the association of different classes of medication with the presence of AF.

RESULTS

A total of 1183 patients were included in the final analysis, out of which 32% (n = 381) had AF on liver biopsy. Mean age of entire cohort was 52 years and majority were females (65%) and Caucasians (85%). Among patients with AF, 51% were on oral hypoglycemics, 30% were on insulin, 66% were on antihypertensives and 27% were on lipid lowering agents for the median duration of 19 mo, 10 mo, 26 mo, and 24 mo respectively. Medications associated with decreased risk of AF included metformin, liraglutide, lisinopril, hydrochlorothiazide, atorvastatin and simvastatin while the use of furosemide and spironolactone were associated with higher prevalence of AF.

CONCLUSION

In our cohort of T2D with biopsy proven NAFLD, the patients who were receiving metformin, liraglutide, lisinopril, hydrochlorothiazide, atorvastatin and simvastatin were less likely to have AF on biopsy, while patients who were receiving furosemide and spironolactone had a higher likelihood of having AF when they underwent liver biopsy. Future studies are needed to confirm these findings and to establish measures for prevention of NAFLD progression in patients with T2D.

Lambl's Excrescences: An Enigma of Modern Diagnostic Cardiology

Lambl's excrescences were first described in 1856 by a Bohemian physician, Vilém Dušan Lambl, and since then have gained widespread attention and controversy within the medical literature. Despite numerous case reports and observational studies, consensus on the significance and management of Lambl’s excrescences remains sparse. We describe the case of a 48-year-old male who presented with recurrent embolic strokes. No underlying paroxysmal arrhythmia or inter-atrial shunt was identified, and the only pathological finding was a 1-mm aortic valve strand. We managed this patient successfully using a novel oral anticoagulant.

Resection of early esophageal neoplasms: The pendulum swings from surgical to endoscopic management

Esophageal cancer is a highly lethal disease and is the sixth leading cause of cancer related mortality in the world. The standard treatment is esophagectomy which is associated with significant morbidity and mortality. This led to development of minimally invasive, organ sparing endoscopic therapies which have comparable outcomes to esophagectomy in early cancer. These include endoscopic mucosal resection and endoscopic submucosal dissection. In early squamous cell cancer, endoscopic submucosal dissection is preferred as it is associated with cause specific 5-year survival rates of 100% for M1 and M2 tumors and 85% for M3 and SM1 tumors and low recurrence rates. In early adenocarcinoma, endoscopic resection of visible abnormalities is followed by ablation of the remaining flat Barrett’s mucosa to prevent recurrences. Radiofrequency ablation is the most widely used ablation modality with others being cryotherapy and argon plasma coagulation. Focal endoscopic mucosal resection followed by radiofrequency ablation leads to eradication of neoplasia in 93.4% of patients and eradication of intestinal metaplasia in 73.1% of patients. Innovative techniques such as submucosal tunneling with endoscopic resection are developed for management of submucosal tumors of the esophagus. This review includes a discussion of various endoscopic techniques and their clinical outcomes in early squamous cell cancer, adenocarcinoma and submucosal tumors. An overview of comparison between esophagectomy and endoscopic therapy are also presented.

1436Overexpression of Cytotoxic T-Lymphocyte Associated Antigen-4 suppresses aortic immunoinflammatory responses and prevents angiotensin II-induced abdominal aortic aneurysm formation in mice

Aims

Vascular inflammation via T-cell-mediated immune responses has been shown to be critically involved in the pathogenesis of abdominal aortic aneurysm (AAA). T-cell coinhibitory molecule cytotoxic T-lymphocyte–associated antigen-4 (CTLA-4) is known to act as a potent negative regulator of immune responses. However, the role of this molecule in the development of AAA remains completely unknown. In the present study, we determined the effects of CTLA-4 overexpression on experimental AAA.

Methods and results

We continuously infused 12-week-old CTLA-4 transgenic (CTLA-4-Tg)/apolipoprotein E–deficient (Apoe−/−) mice (n=35) or control Apoe−/− mice (n=40) fed a high-cholesterol diet with angiotensin II by implanting osmotic mini-pumps and evaluated the development of AAA. Ninety percent of angiotensin II-infused mice developed AAA, with 50% mortality because of aneurysm rupture. Overexpression of CTLA-4 significantly reduced the incidence (66%), mortality (26%), and diameter (18%) of AAA (incidence: P=0.0104; mortality: P=0.031; diameter: P=0.011). These protective effects were associated with a decreased number of effector CD4+ T cells and the downregulated expression of costimulatory molecules CD80 and CD86, ligands for CTLA-4, on CD11c+ dendritic cells in lymphoid tissues. In addition, by performing in situ zymography of the abdominal aortic aneurysm lesions, we observed a trend toward a decrease in MMP activity in the aneurysmal lesion following overexpression of CTLA-4. Finally, CTLA-4-Tg/Apoe−/− mice had reduced macrophage and CD4+ T cell accumulation and MMP activity in the aneurysmal lesion, leading to attenuated aortic inflammation, preserved vessel integrity, and decreased susceptibility to AAA and aortic rupture.

Conclusion

Our findings suggest that CTLA-4 protects against AAA by suppressing immunoinflammatory responses and could be an attractive therapeutic target for AAA.

A Large Pericardial Effusion Culminating in Left Lung Collapse

Pericardial effusion is characterized by excess fluid accumulation in the pericardium. It can be asymptomatic or silent when the effusion is trivial in size or develops slowly. On the other hand, large rapidly developing effusions may present with hemodynamic instability or tamponade. In rare circumstances when a large effusion develops over a period of time, it may cause compression atelectasis of the surrounding bronchi and lung. We describe the case of a 70-year-old female who presented with acute respiratory insufficiency due to left lung collapse secondary to large pericardial effusion. To our knowledge, this is an extremely rare complication of large pericardial effusion.

Stress Cardiomyopathy in Association with Severe Agitation in Dementia

Stress cardiomyopathy is a reversible left ventricular systolic dysfunction in the setting of intense emotional and physical trauma. It has rarely been described in association with the agitated state of dementia. We describe the case of a 78-year-old female with dementia who was diagnosed with stress cardiomyopathy in the setting of worsening agitation. This case underscores the importance of recognizing the non-specific manifestations of stress cardiomyopathy in this subset of patient population.

Stage IV Non-small Cell Lung Cancer Presenting as Supraventricular Tachycardia

Despite numerous advancements in diagnostics and treatment, lung cancer carries a high mortality rate. This is primarily attributable to the fact that the majority of patients present with stage III or IV disease and otherwise non-specific symptoms. In this article, we discuss a rare case of stage IV lung cancer presenting as supraventricular tachycardia secondary to cardiomediastinal involvement. Unfortunately, by the time the tumor had involved the mediastinum, surgical options were limited and treatment was largely palliative.

SAT-578 Hashimoto's Encephalopathy: An Underreported Syndrome: A Case Report

Introduction Hashimoto’s encephalopathy (HE) is an immune-mediated encephalopathy associated with Hashimoto’s thyroiditis (HT). Unlike encephalopathy associated with clinical hypothyroidism, HE can arise in euthyroid states as well. We describe a case of subacute encephalopathy in a patient with known Hashimoto’s thyroiditis. Case report A 57 year old male with a history of Hashimoto’s thyroiditis was brought to the hospital with new onset psychosis (delusions, olfactory and auditory hallucinations) and seizure like apneic episodes. He had a tick bite 3 weeks prior but did not demonstrate rash, joint pain, fever, headache or focal neurologic symptoms. He did not have meningismus on exam and demonstrated intact anterograde and retrograde memory. His initial work up including CBC, BMP was unremarkable. Metabolic work up including B1, B12 and ammonia levels were within range and urine toxicology was normal. TSH was elevated up to 7.930 (Ref: 0.27-4.2 Units/ml) while free T4 was 1.39 (Ref: 0.93-1.7 ng/dl). Infectious processes including HIV and syphilis (RPR) were excluded. LP was performed and revealed normal CSF chemistry, microbiology and cell count. CSF Lyme PCR and autoimmune panel was negative. MRI and EEG did not show any structural lesion or epileptic activity, respectively. Given history of Hashimoto’s thyroiditis, we obtained serum anti-thyroid peroxidase level which was elevated at 3,721.5 (Ref: <9 IU/ml). Serum thyroglobulin antibody level was 3.0 (Ref: <2.3 IU/ml). Patient was started on steroids for Hashimoto’s encephalopathy and his symptoms improved within the next 48 hours. Discussion Hashimoto’s encephalopathy was first defined in 1960’s but has been subject to controversy. Its exact pathophysiology is unknown, however majority of evidence points towards an autoimmune process. The disease can manifest years before the clinical onset of Hashimoto’s thyroiditis and may represent a separate or parallel disease process. HE has a variable clinical presentation however two syndromes have been commonly described. 1) Stroke-like subtype with acute or sub-acute focal deficits 2) Diffuse progressive subtype with encephalopathy, rapidly progressive dementia, psychosis and seizures. Elevated TPO antibodies are the mainstay of diagnosis and demonstrate high specificity in the appropriate setting. Other diagnostic modalities (CSF analysis, brain MRI/CT and EEG) may demonstrate non-specific abnormalities. The syndrome carries a benign prognosis and is largely reversible with steroids thus highlighting the importance of timely diagnosis. Conclusion Hashimoto’s encephalopathy is an underdiagnosed etiology of encephalopathy. HE should be strongly considered in a patient with unexplained neurologic symptoms and psychosis once relevant etiologies have been ruled out. Anti-thyroid antibodies should be included as first tier investigation in encephalopathy work up.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Reprogramming of Molecular Switching Events in UPR Driven ER Stress: Scope for Development of Anticancer Therapeutics

The incitement of unfolded protein response (UPR) during endoplasmic reticulum (ER) stress by diverse intracellular (hypoxia, nutrient deprivation, etc.) or extracellular (environmental or drug induced) stimuli is considered a major threat for perturbing cellular homeostasis leading to the aggregation of unfolded proteins inside the cell. The catastrophic UPR events emerge as a prime cellular adaptation by remodeling cancer cell signaling and restoring ER homeostasis in favor of tumor growth. The transient ER stress protects cancer cells from undergoing apoptosis, whereas the prolonged stress response further activates many cell death pathways. The present review summarizes the UPR mediated triggering of transcriptional and translational reprogramming, which will provide novel therapeutic strategies towards pro-death mechanisms rather than a cellular adaptation in tumorigenesis. Nonetheless, the current topic also points out the reprogramming of emerging molecular switching events by complex UPR-mediated signaling to trigger apoptosis. The novel agents from various natural, semi-synthetic and synthetic sources that target ER stress signaling pathway to modulate selectively the UPR phenomena with preclinical efficacy are outlined. Since major emphasis on ER stress-induced transcriptional and translational reprogramming remains to be explored, we believe that the current subject will instigate more attention from the biomedical researchers in this certain research direction.

De novo transcriptome analysis shows differential expression of genes in salivary glands of edible bird's nest producing swiftlets

BACKGROUND

Edible bird's nest (EBN), produced from solidified saliva secretions of specific swiftlet species during the breeding season, is one of the most valuable animal by-products in the world. The composition and medicinal benefits of EBN have been extensively studied, however, genomic and transcriptomic studies of the salivary glands of these birds have not been conducted.

RESULTS

The study described the transcriptomes of salivary glands from three swiftlet species (28 samples) generated by RNASeq. A total of 14,835 annotated genes and 428 unmapped genes were cataloged. The current study investigated the genes and pathways that are associated with the development of salivary gland and EBN composition. Differential expression and pathway enrichment analysis indicated that the expression of CREB3L2 and several signaling pathways involved in salivary gland development, namely, the EGFR, BMP, and MAPK signaling pathways, were up-regulated in swiftlets producing white EBN (Aerodramus fuciphagus) and black EBN (Aerodramus maximus) compared with non-EBN-producing swiftlets (Apus affinis). Furthermore, MGAT, an essential gene for the biosynthesis of N-acetylneuraminic acid (sialic acid), was highly expressed in both white- and black-nest swiftlets compared to non-EBN-producing swiftlets. Interspecies comparison between Aerodramus fuciphagus and Aerodramus maximus indicated that the genes involved in N-acetylneuraminic and fatty acid synthesis were up-regulated in Aerodramus fuciphagus, while alanine and aspartate synthesis pathways were up-regulated in Aerodramus maximus. Furthermore, gender-based analysis revealed that N-glycan trimming pathway was significantly up-regulated in male Aerodramus fuciphagus from its natural habitat (cave) compared to their female counterpart.

CONCLUSIONS

Transcriptomic analysis of salivary glands of different swiftlet species reveal differential expressions of candidate genes that are involved in salivary gland development and in the biosynthesis of various bioactive compounds found in EBN.

Inhibition of Twist1-mediated invasion by Chk2 promotes premature senescence in p53-defective cancer cells

Twist1, a basic helix-loop-helix transcription factor is implicated as a key mediator of epithelial-mesenchymal transition (EMT) and metastatic dissemination in p53-deficient cancer cells. On the other hand, checkpoint kinase 2 (Chk2), a major cell cycle regulatory protein provides a barrier to tumorigenesis due to DNA damage response by preserving genomic stability of the cells. Here we demonstrate that Chk2 induction proficiently abrogates invasion, cell scattering and invadopodia formation ability of p53-mutated invasive cells by suppressing Twist1, indicating Chk2 confers vital role in metastasis prevention. In addition, ectopic Chk2, as well as its (Chk2) induction by natural podophyllotoxin analog, 4'-demethyl-deoxypodophyllotoxin glucoside (4DPG), strongly restrain Twist1 activity along with other mesenchymal markers, for example, ZEB-1, vimentin and Snail1, whereas the epithelial markers such as E-cadherin and TIMP-1 expression augmented robustly. However, downregulation of endogenous Chk2 by siRNA as well as Chk2 selective inhibitor PV1019 implies that 4DPG-mediated inhibition of Twist1 is Chk2-dependent. Further, mechanistic studies unveil that Chk2 negatively regulates Twist1 promoter activity and it (Chk2) interacts steadily with Snail1 protein to curb EMT. Strikingly, Chk2 overexpression triggers premature senescence in these cells with distinctive increase in senescence-associated β-galactosidase (SA-β-gal) activity, G2/M cell cycle arrest and induction of senescence-specific marker p21^waf1/Cip1. Importantly, stable knockdown of Twist1 by shRNA markedly augments p21 expression, its nuclear accumulation, senescence-associated heterochromatin foci (SAHF) and amplifies the number of SA-β-gal-positive cells. Moreover, our in vivo studies also validate that 4DPG treatment significantly abrogates tumor growth as well as metastatic lung nodules formation by elevating the level of phospho-Chk2, Chk2 and suppressing Twist1 activity in mouse mammary carcinoma model. In a nutshell, this report conceives a novel strategy of Twist1 suppression through Chk2 induction, which prevents metastatic dissemination and promotes premature senescence in p53-defective invasive cancer cells.

Twenty-four-hour in-house neonatologist coverage and long-term neurodevelopmental outcomes of preterm infants

Objectives

To compare short- and long-term neurodevelopmental outcomes at 3 years of corrected age of preterm infants cared for by 24-hour in-house staff neonatologists and those cared for by staff neonatologists during daytime only.

Methods

Retrospective analysis of prospectively collected follow-up data on all nonanomalous preterm infants from 1998 to 2004 excluding year 2001 as a washout period. Infants were divided into two groups based on care provided by staff neonatologists: 24-hour in-house coverage (24-hour coverage 1998-2000) and daytime coverage (day coverage 2002-2004). Short- and long-term outcomes were compared.

Results

A total of 387 (78%) of the screened infants were included. Twenty-four-hour coverage (n=179) and day coverage (n=208) groups had a median birth weight (BW) of 875 g (range 470-1250) and 922 g (480-1530; P=0.028), respectively, and both had a median gestational age of 27 weeks. In the day coverage group, a smaller proportion of mothers had chorioamnionitis (20% vs. 30%; P=0.025), received less antibiotics (62% vs. 73%; P=0.023), and infants had fewer cases of confirmed sepsis (14% vs. 23%; P=0.022). In the day coverage group, a larger number of infants had respiratory distress syndrome (87% vs. 77%; P=0.011) and required prolonged mechanical ventilation (median 31 vs. 21 days; P=0.002). The incidence of major neurodevelopmental impairment was not significantly different between the two groups (odds ratio 0.76; 95% confidence interval 0.34-1.65).

Conclusions

Duration of mechanical ventilation was reduced with 24-hour in-house coverage by staff neonatologists. However, 24-hour coverage was not associated with any difference in neurodevelopmental (ND) outcomes at 3-year corrected age.

Differential regulation of NM23-H1 under hypoxic and serum starvation conditions in metastatic cancer cells and its implication in EMT

Multiple stresses are prevalent inside the tumor microenvironment rendering tumor growth, neighboring invasion and metastasis of the cancer cells to distant organs. NM23-H1 is the first metastasis suppressor gene identified and known to be implicated as an important regulator of stress-induced metastasis. Herein, we demonstrated that prototypical NM23-H1 expression diminished during hypoxia and serum starvation in Panc-1/MDA-MB-231 cells, but converse invasion patterns were obtained in these two diverse stresses. Supportingly, a compelling discrete difference in mRNA and protein levels of NM23-H1 was achieved in hypoxia as well as serum starvation. Knockdown of NM23-H1 activates EMT whereas the similar effects are subdued in serum starvation where NM23-H1 down-modulation prompted E-cadherin upregulation. Stable NM23-H1 expression augmented E-cadherin levels along with retardation in invadopodea formation and invasion. In hypoxia/serum starvation excess NM23-H1 effectively modulated the Twist1 promoter activity. Thus, differential regulation of NM23-H1 may corroborate/abrogate EMT depending on the nature of stress, tumor microenvironment and cellular context.

Cristacarpin promotes ER stress-mediated ROS generation leading to premature senescence by activation of p21(waf-1)

Stress-induced premature senescence (SIPS) is quite similar to replicative senescence that is committed by cells exposed to various stress conditions viz. ultraviolet radiation (DNA damage), hydrogen peroxide (oxidative stress), chemotherapeutic agents (cytotoxic threat), etc. Here, we report that cristacarpin, a natural product obtained from the stem bark of Erythrina suberosa, promotes endoplasmic reticulum (ER) stress, leading to sub-lethal reactive oxygen species (ROS) generation and which eventually terminates by triggering senescence in pancreatic and breast cancer cells through blocking the cell cycle in the G1 phase. The majority of cristacarpin-treated cells responded to conventional SA-β-gal stains; showed characteristic p21(waf1) upregulation along with enlarged and flattened morphology; and increased volume, granularity, and formation of heterochromatin foci-all of these features are the hallmarks of senescence. Inhibition of ROS generation by N-acetyl-L-cysteine (NAC) significantly reduced the expression of p21(waf1), confirming that the modulation in p21(waf1) by anti-proliferative cristacarpin was ROS dependent. Further, the elevation in p21(waf1) expression in PANC-1 and MCF-7 cells was consistent with the decrease in the expression of Cdk-2 and cyclinD1. Here, we provide evidence that cristacarpin promotes senescence in a p53-independent manner. Moreover, cristacarpin treatment induced p38MAPK, indicating the ROS-dependent activation of the MAP kinase pathway, and thus abrogates the tumor growth in mouse allograft tumor model.

Dual modulation of Ras-Mnk and PI3K-AKT-mTOR pathways: A Novel c-FLIP inhibitory mechanism of 3-AWA mediated translational attenuation through dephosphorylation of eIF4E

The eukaryotic translation initiation factor 4E (eIF4E) is considered as a key survival protein involved in cell cycle progression, transformation and apoptosis resistance. Herein, we demonstrate that medicinal plant derivative 3-AWA (from Withaferin A) suppressed the proliferation and metastasis of CaP cells through abrogation of eIF4E activation and expression via c-FLIP dependent mechanism. This translational attenuation prevents the de novo synthesis of major players of metastatic cascades viz. c-FLIP, c-Myc and cyclin D1. Moreover, the suppression of c-FLIP due to inhibition of translation initiation complex by 3-AWA enhanced FAS trafficking, BID and caspase 8 cleavage. Further ectopically restored c-Myc and GFP-HRas mediated activation of eIF4E was reduced by 3-AWA in transformed NIH3T3 cells. Detailed underlying mechanisms revealed that 3-AWA inhibited Ras-Mnk and PI3-AKT-mTOR, two major pathways through which eIF4E converges upon eIF4F hub. In addition to in vitro studies, we confirmed that 3-AWA efficiently suppressed tumor growth and metastasis in different mouse models. Given that 3-AWA inhibits c-FLIP through abrogation of translation initiation by co-targeting mTOR and Mnk-eIF4E, it (3-AWA) can be exploited as a lead pharmacophore for promising anti-cancer therapeutic development.

Inhibition of Invasion in Pancreatic Cancer Cells by Conjugate of EPA with β(3,3)-Pip-OH via PI3K/Akt/NF-kB Pathway

The present work describes the anti-invasive effect of conjugate BC06, a novel conjugate of EPA, (2E,4E)-4-(benzo[d][1,3]dioxol-5-ylmethylene) hex-2-enoic acid with β,β-disubstituted-β-amino acid, β(3,3)-Pip-OH (2-(4-aminopiperidin-4-yl)acetic acid), in human pancreatic carcinoma. The conjugate BC06 inhibited invasion and migration of PANC-1 cells in wound healing, matrigel invasion, and gelatin degradation assays. Apart from suppressing PI3K/Akt/NF-kB signaling, which is involved in the up-regulation of matrix metalloproteinases, our study also demonstrated that dose-dependent treatment of BC06 results in the upregulation of TIMP-1 and E-cadherin expression. Further, BC06 was found to be inhibiting the metastatic ability of PANC-1 cells by reducing MMP-2 and MMP-9 expression. These findings suggest that EPA conjugate with β(3,3)-Pip-OH, BC06, may be used as an anti-invasive agent against human pancreatic carcinoma.