Very low event rate and few device implants in drug-induced brugada. A seven-year experience of ajmaline challenge at a district general hospital

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with a drug-induced Brugada electrocardiogram (ECG) are thought to have a lower risk of sudden cardiac death than those with a spontaneous type 1 ECG. Despite having a Brugada ECG, most patients do not need an implantable cardioverter defibrillator (ICD).

Purpose

To report a district general hospital experience on referral and outcomes of ajmaline challenge (AC) with medium term follow up.

Methods

92 consecutive patients (50 males, mean age 41 ±17) had an AC in a single centre from 2014-2021. High ventricular leads were used from 2015. Ajmaline (1m/kg) was administered intravenously over 10-minutes. Data were collected from the electronic health record.

Results

The AC was positive in 18 (20%) patients. The yield from high leads was higher (7% vs 22%) p=0.28) but not statistically significant. There were no deaths or documented ventricular arrhythmias (VA) in AC positive patients during a median follow up of 3.2 years (1.7-4.9).

The resting ECG was normal in 46.7%. A type 1 pattern had been provoked by fever or electrolyte derangements in 3.3%, type 2 pattern in 8.7% and a type 3 pattern in 5.4%. An RSR pattern (not in keeping with a BrS ECG) was seen in 26.4%. The test was stopped prematurely due to QRS widening >150ms in 1 patient. No adverse arrhythmic events occurred (table 1).

In our cohort, positive AC patients were older (48y vs 37y p= 0.05) and more likely to have a type 2 (28% vs 4% p=0.007) or type 3 ECG (17% vs 3% p=0.05). Asymptomatic patients were more likely to have a normal ECG (22% vs 78% p=0.05)

Of those with a positive AC, nine patients had symptoms of palpitations or syncope (table 2). A subcutaneous ICD (S-ICD) was implanted for syncope in two patients. No device therapies have occurred during a follow up of 2.5 years and 3.9 years respectively. Of those with a positive AC but asymptomatic, one S-ICD was initially implanted due to patient preference. A second S-ICD was implanted in a patient who experienced a collapse and brief seizure in the context of modest alcohol consumption.

In seven positive patients (39%) and 18 negative patients (23%) an ILR was implanted. 1 episode of complete heart block was detected in an ajmaline negative patient during a median follow up of 2.7 years (1.7-3.9).

There were no device related complications or adverse events.

Conclusion

AC is safe with a low number of device implants and ICD shocks. The yield from ILR implants was very low. A single patient had a potentially adverse outcome after consuming alcohol, a known trigger for VA in BrS. Our findings are in keeping with contemporary evidence that suggests the risk of adverse cardiac events in drug-induced BrS is low. However, time to first ICD shock may occur after ten years or more from diagnosis so long term follow up is required.

Measurement of the Fluctuations in the Number of Muons in Extensive Air Showers with the Pierre Auger Observatory

We present the first measurement of the fluctuations in the number of muons in extensive air showers produced by ultrahigh energy cosmic rays. We find that the measured fluctuations are in good agreement with predictions from air shower simulations. This observation provides new insights into the origin of the previously reported deficit of muons in air shower simulations and constrains models of hadronic interactions at ultrahigh energies. Our measurement is compatible with the muon deficit originating from small deviations in the predictions from hadronic interaction models of particle production that accumulate as the showers develop.

Features of the Energy Spectrum of Cosmic Rays above 2.5×10^{18} eV Using the Pierre Auger Observatory

We report a measurement of the energy spectrum of cosmic rays above 2.5×10^{18}  eV based on 215 030 events. New results are presented: at about 1.3×10^{19}  eV, the spectral index changes from 2.51±0.03(stat)±0.05(syst) to 3.05±0.05(stat)±0.10(syst), evolving to 5.1±0.3(stat)±0.1(syst) beyond 5×10^{19}  eV, while no significant dependence of spectral features on the declination is seen in the accessible range. These features of the spectrum can be reproduced in models with energy-dependent mass composition. The energy density in cosmic rays above 5×10^{18}  eV is [5.66±0.03(stat)±1.40(syst)]×10^{53}  erg Mpc^{-3}.

P14.30 Treatment outcomes of newly-diagnosed glioblastoma multiforme (GBM) by O6-methylguanine DNA methyltransferase promoter (MGMT) status: a multi-country study

INTRODUCTION

This study evaluated the relationship of MGMT status with first-line (1L) treatment outcomes of patients with newly-diagnosed GBM in France, Germany, Italy, Spain, the UK (EU5), and Canada.

MATERIALS AND METHODS

Medical oncologists and neuro-oncologists across EU5 and Canada completed a point in time, cross-sectional survey for the next 8 GBM patients seen between May and July 2016 within EU5 and Canada. All results apart from time to progression (TTP) were presented for patients receiving 1L active drug treatment. TTP was calculated from initiation of 1L treatment to initiation of second-line treatment. Results presented are statistically significant (p<0.05) unless otherwise specified. Bases vary depending on data availability.

RESULTS

A total of 241 physicians reported on 1747 patients with GBM. 875 were receiving 1L active drug treatment at time of survey. Mean age was 59.7 years (median=61) and 34.6% were women. Mean life expectancy was 14.9 months (median=12) at diagnosis and mean TTP was 8.5 months (median=7.3). Surgery was performed in 62% of patients (n=546) prior to 1L drug treatment; 38% of patients (n=329) had no surgery. Patients with surgery had a higher life expectancy at diagnosis vs patients with no surgery prior to 1L (mean=16.4 vs 12.2 months; median=15.0 vs 12.0). Patients who received corticosteroids (n=524) vs no corticosteroids during radiotherapy (n=64) had a shorter life expectancy at diagnosis (mean=15.0 vs 16.8 months, p=0.07; median=12.5 vs 13.9) and were more likely to have 8 or more inpatient days due to GBM (21% vs 8%, p=0.07) in the last 3 months prior to the survey. 62% of patients (n=541) had an MGMT-status recorded (tested: methylated or unmethylated), and 38% (n=334) were untested/ awaiting results (untested) at 1L. MGMT-tested patients had better life expectancy at diagnosis (mean=16.1 vs 12.9 months; median=15.0 vs 12.0) and longer TTP (mean=8.9 vs 7.8 months; median=7.8 vs 6.4) than untested patients. Among MGMT-tested patients, 58% were methylated and 42% were unmethylated. Methylated patients had similar life expectancy at diagnosis (mean=15.9 vs 16.3 months, p=0.85; median=15.0 vs 15.0) and TTP (mean=9.0 vs 8.8 months, p=0.42; median=8.0 vs 7.5) as unmethylated patients.

CONCLUSIONS

This analysis provides valuable insights into the 1L treatment outcomes of GBM patients in EU5 and Canada. Patients who did not undergo surgery had worse treatment outcomes. Steroid use appears to be associated with worse outcomes and higher healthcare resource utilization. Patient treatment outcomes varied depending on whether they are MGMT tested.

P14.36 Treatment patterns by O6-methylguanine DNA methyltransferase promoter (MGMT) status in newly-diagnosed glioblastoma multiforme (GBM): a multi-country chart review study

INTRODUCTION

This study explored the relationship between MGMT testing and treatment patterns of patients with newly-diagnosed GBM from France, Germany, Italy, Spain, the UK (EU5), and Canada.

MATERIALS AND METHODS

Medical oncologists and neuro-oncologists across EU5 and Canada completed a point in time, cross-sectional survey for the next eight GBM patients seen between May and July 2016 (GBM Disease-specific ProgrammeTM). Statistically significant differences (p<0.05) between groups are presented.

RESULTS

A total of 241 physicians reported on 1,747 GBM patients. 1L patients had mean age 59.7 years (SD=12.3) and 36% were female. Of 1,113 (64%) patients who had an MGMT test performed with results recorded (tested), 58% (n=651) were methylated and 42% (n=462) were unmethylated. The remaining 634 patients (36%) were MGMT untested or awaiting MGMT results at time of survey (untested). Overall, 63% of patients received surgery prior to their 1L drug therapy, 78% received radiotherapy (RT; mean 4.3 sessions) in conjunction with 1L drug therapy, 90% received corticosteroids during RT, and 89% received temozolomide (TMZ). Patients who received corticosteroids during RT received similar drug treatments to those that did not, but were less likely to receive surgery prior to 1L treatment (65% vs 83%). MGMT-tested patients were more likely to receive surgery (66% vs 57%) and RT (81% vs 71%) than untested patients. Tested patients were also more likely to receive TMZ (92% vs 83%), and less likely to receive procarbazine+/lomustine+/vincristine (PCV; 3% vs 7%) or other chemotherapies (5% vs 11%). For 1L patients that experienced side effects, the most common effects included fatigue (74%), nausea (60%), and appetite loss (59%). Untested patients were more likely to stop their 1L drug treatment due to progression/recurrence of GBM (44% vs 36%). Patients who received surgery prior to 1L treatment were more likely to receive TMZ than those who did not (93% vs 82%). Among MGMT tested patients at 1L, methylated patients were more likely to receive RT (84% vs 78%) and TMZ (95% vs 89%) than unmethylated patients, and less likely to receive PCV (2% vs 5%) or other chemotherapy (4% vs 7%). Methylated patients with reported treatment-related side effects were less likely to experience dehydration (0% vs 10%), loss of strength/unusual weakness (5% vs 25%), memory problems (16% vs 35%), and nausea (51% vs 75%).

CONCLUSIONS

More than one-third of GBM patients in EU5 and Canada are not tested for MGMT-methylation. Untested patients are less likely to receive standard treatments than tested patients. Generally, TMZ is used in most patients regardless of MGMT testing and status. MGMT-methylated patients are more likely to receive standard treatments and experience fewer side effects than MGMT-unmethylated patients.

Constraints on Ultrahigh-Energy Cosmic-Ray Sources from a Search for Neutrinos above 10 PeV with IceCube

We report constraints on the sources of ultrahigh-energy cosmic rays (UHECRs) above 10^{9}  GeV, based on an analysis of seven years of IceCube data. This analysis efficiently selects very high- energy neutrino-induced events which have deposited energies from 5×10^{5}  GeV to above 10^{11}  GeV. Two neutrino-induced events with an estimated deposited energy of (2.6±0.3)×10^{6}  GeV, the highest neutrino energy observed so far, and (7.7±2.0)×10^{5}  GeV were detected. The atmospheric background-only hypothesis of detecting these events is rejected at 3.6σ. The hypothesis that the observed events are of cosmogenic origin is also rejected at >99% CL because of the limited deposited energy and the nonobservation of events at higher energy, while their observation is consistent with an astrophysical origin. Our limits on cosmogenic neutrino fluxes disfavor the UHECR sources having a cosmological evolution stronger than the star formation rate, e.g., active galactic nuclei and γ-ray bursts, assuming proton-dominated UHECRs. Constraints on UHECR sources including mixed and heavy UHECR compositions are obtained for models of neutrino production within UHECR sources. Our limit disfavors a significant part of parameter space for active galactic nuclei and new-born pulsar models. These limits on the ultrahigh-energy neutrino flux models are the most stringent to date.

The Challenge of Infectious Disease: Time to Take Gender into Account

Efforts to address infectious diseases have long been hindered by the failure to take into account the social aspects of these diseases. Gender is a fundamental dimension of these social aspects. There is currently a focus in international health on the import ance of addressing diseases of poverty. Attention to gender is a crucial part of a poverty-focused response to the challenges posed by infectious disease. In this article we provide a framework for analysing gender inequities in infectious disease in developing countries, and briefly draw implications for policy and practice.

Gender identities, status, roles and responsibilities influence vulnerability to dis ease, access to health care, and the impact of disease for women, men, girls and boys. Women's and men's roles affect their risk of infection with specific diseases, whilst gender relations influence their ability to protect their own health. Gender differences in access to and control over resources, in decision-making power in the household and in roles and activities can limit women's ability to access health care for them selves and their children. Gendered norms and identities influence both women's and men's willingness and ability to seek care. The social consequences of infectious disease are often more severe for women than for men, and illness imposes a parti cularly heavy labour burden upon women.

Health services need to adjust their practices to improve the appropriateness of preventive and curative services for infectious disease control for both women and men amongst the poor and disadvantaged. However, measures to reduce gender inequities in health cannot be limited to the health sector alone.

Early changes in Achilles tendon behaviour in vivo following downhill backwards walking

Downhill backwards walking causes repeated, cyclical loading of the muscle-tendon unit. The effect this type of repeated loading has on the mechanical behaviour of the Achilles tendon is presently unknown. This study aimed to investigate the biomechanical response of the Achilles tendon aponeurosis complex following a downhill backwards walking protocol. Twenty active males (age: 22.3 ± 3.0 years; mass: 74.7 ± 5.6 kg; height: 1.8 ± 0.7 m) performed 60 min of downhill (8.5°), backwards walking on a treadmill at -0.67 m · s(-1). Data were collected before, immediately post, and 24-, 48- and 168-h post-downhill backwards walking. Achilles tendon aponeurosis elongation, strain and stiffness were measured using ultrasonography. Muscle force decreased immediately post-downhill backward walking (P = 0.019). There were increases in Achilles tendon aponeurosis stiffness at 24-h post-downhill backward walking (307 ± 179.6 N · mm(-1), P = 0.004), and decreases in Achilles tendon aponeurosis strain during maximum voluntary contraction at 24 (3.8 ± 1.7%, P = 0.008) and 48 h (3.9 ± 1.8%, P = 0.002) post. Repeated cyclical loading of downhill backwards walking affects the behaviour of the muscle-tendon unit, most likely by altering muscle compliance, and these changes result in tendon stiffness increases.

Evidence for Astrophysical Muon Neutrinos from the Northern Sky with IceCube

Results from the IceCube Neutrino Observatory have recently provided compelling evidence for the existence of a high energy astrophysical neutrino flux utilizing a dominantly Southern Hemisphere data set consisting primarily of ν(e) and ν(τ) charged-current and neutral-current (cascade) neutrino interactions. In the analysis presented here, a data sample of approximately 35,000 muon neutrinos from the Northern sky is extracted from data taken during 659.5 days of live time recorded between May 2010 and May 2012. While this sample is composed primarily of neutrinos produced by cosmic ray interactions in Earth's atmosphere, the highest energy events are inconsistent with a hypothesis of solely terrestrial origin at 3.7σ significance. These neutrinos can, however, be explained by an astrophysical flux per neutrino flavor at a level of Φ(E(ν))=9.9(-3.4)(+3.9)×10(-19)  GeV(-1) cm(-2) sr(-1) s(-1)(E(ν)/100  TeV(-2), consistent with IceCube's Southern-Hemisphere-dominated result. Additionally, a fit for an astrophysical flux with an arbitrary spectral index is performed. We find a spectral index of 2.2(-0.2)(+0.2), which is also in good agreement with the Southern Hemisphere result.

OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for primary prevention of osteoarthritis by joint injury prevention in sport and recreation

The risk of post-traumatic osteoarthritis (PTOA) substantially increases following joint injury. Research efforts should focus on investigating the efficacy of preventative strategies in high quality randomized controlled trials (RCT). The objective of these OARSI RCT recommendations is to inform the design, conduct and analytical approaches to RCTs evaluating the preventative effect of joint injury prevention strategies. Recommendations regarding the design, conduct, and reporting of RCTs evaluating injury prevention interventions were established based on the consensus of nine researchers internationally with expertise in epidemiology, injury prevention and/or osteoarthritis (OA). Input and resultant consensus was established through teleconference, face to face and email correspondence over a 1 year period. Recommendations for injury prevention RCTs include context specific considerations regarding the research question, research design, study participants, randomization, baseline characteristics, intervention, outcome measurement, analysis, implementation, cost evaluation, reporting and future considerations including the impact on development of PTOA. Methodological recommendations for injury prevention RCTs are critical to informing evidence-based practice and policy decisions in health care, public health and the community. Recommendations regarding the interpretation and conduct of injury prevention RCTs will inform the highest level of evidence in the field. These recommendations will facilitate between study comparisons to inform best practice in injury prevention that will have the greatest public health impact.

Patient-Reported Outcome (PRO) questionnaires for young to middle-aged adults with hip and groin disability: a systematic review of the clinimetric evidence

BACKGROUND/AIM

To recommend Patient-Reported Outcome (PRO) questionnaires to measure hip and groin disability in young-aged to middle-aged adults.

METHODS

A systematic review was performed in June 2014. The methodological quality of the studies included was determined using the COnsensus-based Standards for the selection of health Measurement INstruments list (COSMIN) together with standardised evaluations of measurement properties of each PRO.

RESULTS

Twenty studies were included. Nine different questionnaires for patients with hip disability, and one for hip and groin disability, were identified. Hip And Groin Outcome Score (HAGOS), Hip Outcome Score (HOS), International Hip Outcome Tool-12 (IHOT-12) and IHOT-33 were the most thoroughly investigated PROs and studies including these PROs reported key aspects of the COSMIN checklist. HAGOS and IHOT-12 were based on studies with the least ratings of poor study methodology (23% and 31%, respectively), whereas IHOT-33 and HOS had a somewhat larger distribution (46%). These PROs all contain adequate measurement qualities for content validity (except HOS), test-retest reliability, construct validity, responsiveness and interpretability. No information or poor quality rating on methodological aspects made it impossible to fully evaluate the remaining PROs at present.

CONCLUSIONS

HAGOS, HOS, IHOT-12 and IHOT-33 can be recommended for assessment of young-aged to middle-aged adults with pain related to the hip joint, undergoing non-surgical treatment or hip arthroscopy. At present, HAGOS is the only PRO also aimed for young-aged to middle-aged adults presenting with groin pain and is recommended for use in this population.

TRIAL REGISTRATION NUMBER

CRD42014009995.