Is a randomised controlled trial of take home naloxone distributed in emergency settings likely to be feasible and acceptable? Findings from a UK qualitative study exploring perspectives of people who use opioids and emergency services staff

OBJECTIVE

Distribution of take-home naloxone (THN) by emergency services may increase access to THN and reduce deaths and morbidity from opioid overdose. As part of a feasibility study for a randomised controlled trial (RCT) of distribution of THN kits and education within ambulance services and Emergency Departments (EDs), we used qualitative methods to explore key stakeholders' perceptions of feasibility and acceptability of delivering the trial.

METHODS

We undertook semi-structured interviews and focus groups with 26 people who use opioids and with 20 paramedics and ED staff from two intervention sites between 2019 and 2021. Interviews and focus groups were recorded, transcribed verbatim and analysed using Framework Analysis.

RESULTS

People using opioids reported high awareness of overdose management, including personal experience of THN use. Staff perceived emergency service provision of THN as a low-cost, low-risk intervention with potential to reduce mortality, morbidity and health service use. Staff understood the trial aims and considered it compatible with their work. All participants supported widening access to THN but reported limited trial recruitment opportunities partly due to difficulties in consenting patients during overdose. Procedural problems, restrictive recruitment protocols, limited staff buy-in and patients already owning THN limited trial recruitment. Determining trial effectiveness was challenging due to high levels of alternative community provision of THN.

CONCLUSIONS

Distribution of THN in emergency settings was considered feasible and acceptable for stakeholders but an RCT to establish the effectiveness of THN delivery is unlikely to generate further useful evidence due to difficulties in recruiting patients and assessing benefits.

Innexin hemichannel activation by Microplitis bicoloratus ecSOD monopolymer reduces ROS

The extracellular superoxide dismutases (ecSODs) secreted by Microplitis bicoloratus reduce the reactive oxygen species (ROS) stimulated by the Microplitis bicoloratus bracovirus. Here, we demonstrate that the bacterial transferase hexapeptide (hexapep) motif and bacterial-immunoglobulin-like (BIg-like) domain of ecSODs bind to the cell membrane and transiently open hemichannels, facilitating ROS reductions. RNAi-mediated ecSOD silencing in vivo elevated ROS in host hemocytes, impairing parasitoid larva development. In vitro, the ecSOD-monopolymer needed to be membrane bound to open hemichannels. Furthermore, the hexapep motif in the beta-sandwich of ecSOD49 and ecSOD58, and BIg-like domain in the signal peptides of ecSOD67 were required for cell membrane binding. Hexapep motif and BIg-like domain deletions induced ecSODs loss of adhesion and ROS reduction failure. The hexapep motif and BIg-like domain mediated ecSOD binding via upregulating innexins and stabilizing the opened hemichannels. Our findings reveal a mechanism through which ecSOD reduces ROS, which may aid in developing anti-redox therapy.

Critical evaluation of artificial intelligence as a digital twin of pathologists for prostate cancer pathology

Prostate cancer pathology plays a crucial role in clinical management but is time-consuming. Artificial intelligence (AI) shows promise in detecting prostate cancer and grading patterns. We tested an AI-based digital twin of a pathologist, vPatho, on 2603 histological images of prostate tissue stained with hematoxylin and eosin. We analyzed various factors influencing tumor grade discordance between the vPatho system and six human pathologists. Our results demonstrated that vPatho achieved comparable performance in prostate cancer detection and tumor volume estimation, as reported in the literature. The concordance levels between vPatho and human pathologists were examined. Notably, moderate to substantial agreement was observed in identifying complementary histological features such as ductal, cribriform, nerve, blood vessel, and lymphocyte infiltration. However, concordance in tumor grading decreased when applied to prostatectomy specimens (κ = 0.44) compared to biopsy cores (κ = 0.70). Adjusting the decision threshold for the secondary Gleason pattern from 5 to 10% improved the concordance level between pathologists and vPatho for tumor grading on prostatectomy specimens (κ from 0.44 to 0.64). Potential causes of grade discordance included the vertical extent of tumors toward the prostate boundary and the proportions of slides with prostate cancer. Gleason pattern 4 was particularly associated with this population. Notably, the grade according to vPatho was not specific to any of the six pathologists involved in routine clinical grading. In conclusion, our study highlights the potential utility of AI in developing a digital twin for a pathologist. This approach can help uncover limitations in AI adoption and the practical application of the current grading system for prostate cancer pathology.

Intradialytic Hypotension and Mortality in Adolescents and Young Adults With Kidney Failure Receiving Maintenance Hemodialysis

Rationale & Objective

Intradialytic hypotension (IDH) is associated with mortality in adults with kidney failure requiring hemodialysis (HD); however, large-scale pediatric studies are lacking. Moreover, there is no evidence-based consensus definition of IDH in pediatric literature. We aimed to examine the association of commonly used definitions of IDH with mortality in adolescents and young adults.

Study Design

This was a retrospective observational cohort study.

Setting & Participants

In total, 1,199 adolescents and young adults (N = 320, aged 10-18 years and N = 879, aged 19-21 years) who initiated HD in a large dialysis organization were included.

Exposures

This study used different definitions of IDH.

Outcome

The study outcome was 2-year all-cause mortality.

Analytical Approach

Several definitions of IDH were selected a priori based on a literature review. Patients were classified as having IDH if it was present in at least 30% of HD treatments during the first 90 days after dialysis initiation. Cox proportional hazards regression was used to test whether IDH associated with 2-year all-cause mortality.

Results

Over a 2-year follow-up period, 54 (4.5%) patients died. Dependent on its definition, IDH was present in 2.9%-61.1% of patients. After the multivariable adjustment for sociodemographic and clinical characteristics, we found no association of IDH with mortality. Results were consistent across subgroups stratified by age (aged <18 and 19-21 years) and predialysis systolic blood pressure (<120, 120-150, and >150 mm Hg). We also examined IDH as occurring in <5%, 5%-29%, 30%-50%, and >50% of baseline treatments, and did not find a dose-response association with mortality (P > 0.05).

Limitations

Owing to low event rates, our current sample size may have been too small to detect a difference in mortality.

Conclusions

Our study found that IDH was not associated with mortality in adolescents and young adults.

Skeletal Muscle Area on CT: Determination of an Optimal Height Scaling Power and Testing for Mortality Risk Prediction

BACKGROUND. Sarcopenia is commonly assessed on CT by use of the skeletal muscle index (SMI), which is calculated as the skeletal muscle area (SMA) at L3 divided by patient height squared (i.e., a height scaling power of 2). OBJECTIVE. The purpose of this study was to determine the optimal height scaling power for SMA measurements on CT and to test the influence of the derived optimal scaling power on the utility of SMI in predicting all-cause mortality. METHODS. This retrospective study included 16,575 patients (6985 men, 9590 women; mean age, 56.4 years) who underwent abdominal CT from December 2012 through October 2018. The SMA at L3 was determined using automated software. The sample was stratified into two groups: 5459 patients without major medical conditions (based on ICD-9 and ICD-10 codes) who were included in the analysis for determining the optimal height scaling power and 11,116 patients with major medical conditions who were included for the purpose of testing this power. The optimal scaling power was determined by allometric analysis (whereby regression coefficients were fitted to log-linear sex-specific models relating height to SMA) and by analysis of statistical independence of SMI from height across scaling powers. Cox proportional hazards models were used to test the influence of the derived optimal scaling power on the utility of SMI in predicting all-cause mortality. RESULTS. In allometric analysis, the regression coefficient of log(height) in patients 40 years old and younger was 1.02 in men and 1.08 in women, and in patients older than 40 years old, it was 1.07 in men and 1.10 in women (all p < .05 vs regression coefficient of 2). In analyses for statistical independence of SMI from height, the optimal height scaling power (i.e., those yielding correlations closest to 0) was, in patients 40 years old and younger, 0.97 in men and 1.08 in women, whereas in patients older than 40 years old, it was 1.03 in men and 1.09 in women. In the Cox model used for testing, SMI predicted all-cause mortality with a higher concordance index using of a height scaling power of 1 rather than 2 in men (0.675 vs 0.663, p < .001) and in women (0.664 vs 0.653, p < .001). CONCLUSION. The findings support a height scaling power of 1, rather than a conventional power of 2, for SMI computation. CLINICAL IMPACT. A revised height scaling power for SMI could impact the utility of CT-based sarcopenia diagnoses in risk assessment.

Simulating immunosuppressive mechanism of Microplitis bicoloratus bracovirus coordinately fights Spodoptera frugiperda

Parasitoid wasps control pests via a precise attack leading to the death of the pest. However, parasitoid larvae exhibit self-protection strategies against bracovirus-induced reactive oxygen species impairment. This has a detrimental effect on pest control. Here, we report a strategy for simulating Microplitis bicoloratus bracovirus using Mix-T dsRNA targeting 14 genes associated with transcription, translation, cell-cell communication, and humoral signaling pathways in the host, and from wasp extracellular superoxide dismutases. We implemented either one-time feeding to the younger instar larvae or spraying once on the corn leaves, to effectively control the invading pest Spodoptera frugiperda. This highlights the conserved principle of "biological pest control," as elucidated by the triple interaction of parasitoid-bracovirus-host in a cooperation strategy of bracovirus against its pest host.

Organizational Factors in Clinical Data Sharing for Artificial Intelligence in Health Care

Importance

Limited sharing of data sets that accurately represent disease and patient diversity limits the generalizability of artificial intelligence (AI) algorithms in health care.

Objective

To explore the factors associated with organizational motivation to share health data for AI development.

Design, Setting, and Participants

This qualitative study investigated organizational readiness for sharing health data across the academic, governmental, nonprofit, and private sectors. Using a multiple case studies approach, 27 semistructured interviews were conducted with leaders in data-sharing roles from August 29, 2022, to January 9, 2023. The interviews were conducted in the English language using a video conferencing platform. Using a purposive and nonprobabilistic sampling strategy, 78 individuals across 52 unique organizations were identified. Of these, 35 participants were enrolled. Participant recruitment concluded after 27 interviews, as theoretical saturation was reached and no additional themes emerged.

Main Outcome and Measure

Concepts defining organizational readiness for data sharing and the association between data-sharing factors and organizational behavior were mapped through iterative qualitative analysis to establish a framework defining organizational readiness for sharing clinical data for AI development.

Results

Interviews included 27 leaders from 18 organizations (academia: 10, government: 7, nonprofit: 8, and private: 2). Organizational readiness for data sharing centered around 2 main constructs: motivation and capabilities. Motivation related to the alignment of an organization's values with data-sharing priorities and was associated with its engagement in data-sharing efforts. However, organizational motivation could be modulated by extrinsic incentives for financial or reputational gains. Organizational capabilities comprised infrastructure, people, expertise, and access to data. Cross-sector collaboration was a key strategy to mitigate barriers to access health data.

Conclusions and Relevance

This qualitative study identified sector-specific factors that may affect the data-sharing behaviors of health organizations. External incentives may bolster cross-sector collaborations by helping overcome barriers to accessing health data for AI development. The findings suggest that tailored incentives may boost organizational motivation and facilitate sustainable flow of health data for AI development.

Perceptions of Data Set Experts on Important Characteristics of Health Data Sets Ready for Machine Learning: A Qualitative Study

Importance

The lack of data quality frameworks to guide the development of artificial intelligence (AI)-ready data sets limits their usefulness for machine learning (ML) research in health care and hinders the diagnostic excellence of developed clinical AI applications for patient care.

Objective

To discern what constitutes high-quality and useful data sets for health and biomedical ML research purposes according to subject matter experts.

Design, Setting, and Participants

This qualitative study interviewed data set experts, particularly those who are creators and ML researchers. Semistructured interviews were conducted in English and remotely through a secure video conferencing platform between August 23, 2022, and January 5, 2023. A total of 93 experts were invited to participate. Twenty experts were enrolled and interviewed. Using purposive sampling, experts were affiliated with a diverse representation of 16 health data sets/databases across organizational sectors. Content analysis was used to evaluate survey information and thematic analysis was used to analyze interview data.

Main Outcomes and Measures

Data set experts' perceptions on what makes data sets AI ready.

Results

Participants included 20 data set experts (11 [55%] men; mean [SD] age, 42 [11] years), of whom all were health data set creators, and 18 of the 20 were also ML researchers. Themes (3 main and 11 subthemes) were identified and integrated into an AI-readiness framework to show their association within the health data ecosystem. Participants partially determined the AI readiness of data sets using priority appraisal elements of accuracy, completeness, consistency, and fitness. Ethical acquisition and societal impact emerged as appraisal considerations in that participant samples have not been described to date in prior data quality frameworks. Factors that drive creation of high-quality health data sets and mitigate risks associated with data reuse in ML research were also relevant to AI readiness. The state of data availability, data quality standards, documentation, team science, and incentivization were associated with elements of AI readiness and the overall perception of data set usefulness.

Conclusions and Relevance

In this qualitative study of data set experts, participants contributed to the development of a grounded framework for AI data set quality. Data set AI readiness required the concerted appraisal of many elements and the balancing of transparency and ethical reflection against pragmatic constraints. The movement toward more reliable, relevant, and ethical AI and ML applications for patient care will inevitably require strategic updates to data set creation practices.

Strength training is more effective than aerobic exercise for improving glycaemic control and body composition in people with normal-weight type 2 diabetes: a randomised controlled trial

AIMS/HYPOTHESIS

Type 2 diabetes in people in the healthy weight BMI category (<25 kg/m2), herein defined as 'normal-weight type 2 diabetes', is associated with sarcopenia (low muscle mass). Given this unique body composition, the optimal exercise regimen for this population is unknown.

METHODS

We conducted a parallel-group RCT in individuals with type 2 diabetes (age 18-80 years, HbA1c 47.5-118.56 mmol/mol [6.5-13.0%]) and BMI <25 kg/m2). Participants were recruited in outpatient clinics or through advertisements and randomly assigned to a 9 month exercise programme of strength training alone (ST), aerobic training alone (AER) or both interventions combined (COMB). We used stratified block randomisation with a randomly selected block size. Researchers and caregivers were blinded to participants' treatment group; however, participants themselves were not. Exercise interventions were conducted at community-based fitness centres. The primary outcome was absolute change in HbA1c level within and across the three groups at 3, 6 and 9 months. Secondary outcomes included changes in body composition at 9 months. Per adherence to recommended exercise protocol (PP) analysis included participants who completed at least 50% of the sessions.

RESULTS

Among 186 individuals (ST, n=63; AER, n=58; COMB, n=65) analysed, the median (IQR) age was 59 (53-66) years, 60% were men and 83% were Asian. The mean (SD) HbA1c level at baseline was 59.6 (13.1) mmol/mol (7.6% [1.2%]). In intention-to-treat analysis, the ST group showed a significant decrease in HbA1c levels (mean [95% CI] -0.44 percentage points [-0.78, -0.12], p=0.002), while no significant change was observed in either the COMB group (-0.35 percentage points, p=0.13) or the AER group (-0.24 percentage points, p=0.10). The ST group had a greater improvement in HbA1c levels than the AER group (p=0.01). Appendicular lean mass relative to fat mass increased only in the ST group (p=0.0008), which was an independent predictor of HbA1c change (beta coefficient -7.16, p=0.01). Similar results were observed in PP analysis. Only one adverse event, in the COMB group, was considered to be possibly associated with the exercise intervention.

CONCLUSIONS/INTERPRETATION

In normal-weight type 2 diabetes, strength training was superior to aerobic training alone, while no significant difference was observed between strength training and combination training for HbA1c reduction. Increased lean mass relative to decreased fat mass was an independent predictor of reduction in HbA1c level.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02448498.

FUNDING

This study was funded by the National Institutes of Health (NIH; R01DK081371).

Liquid biopsy analysis of lipometabolic exosomes in pancreatic cancer

Pancreatic cancer is characterized by its high malignancy, insidious onset and poor prognosis. Most patients with pancreatic cancer are usually diagnosed at advanced stage or with the distant metastasis due to the lack of an effective early screening method. Liquid biopsy technology is promising in studying the occurrence, progression, and early metastasis of pancreatic cancer. In particular, exosomes are pivotal biomarkers in lipid metabolism and liquid biopsy of blood exosomes is valuable for the evaluation of pancreatic cancer. Lipid metabolism is crucial for the formation and activity of exosomes in the extracellular environment. Exosomes and lipids have a complex relationship of mutual influence. Furthermore, spatial metabolomics can quantify the levels and spatial locations of individual metabolites in cancer tissue, cancer stroma, and para-cancerous tissue in pancreatic cancer. However, the relationship among exosomes, lipid metabolism, and pancreatic cancer is also worth considering. This study mainly updates the research progress of metabolomics in pancreatic cancer, their relationship with exosomes, an important part of liquid biopsy, and their lipometabolic roles in pancreatic cancer. We also discuss the mechanisms by which possible metabolites, especially lipid metabolites through exosome transport and other processes, contribute to the recurrence and metastasis of pancreatic cancer.

PRESS survey: PREvention of surgical site infection-a global pan-specialty survey of practice protocol

Background

Surgical site infections (SSI) complicate up to 40% of surgical procedures, leading to increased patient morbidity and mortality. Previous research identified disparities in SSI prevention guidelines and clinical practices across different institutions. The study aims to identify variations in SSI prevention practices within and between specialties and financial systems and provide a representation of existing SSI preventative measures to help improve the standardization of SSI prevention practices.

Methods

This collaborative cross-sectional survey will be aimed at pan-surgical specialties internationally. The study has been designed and will be reported in line with the CROSS and CHERRIES standards. An international study steering committee will design and internally validate the survey in multiple consensus-based rounds. This will be based on SSI prevention measures outlined in the CDC (2017), WHO (2018), NICE (2019), Wounds UK (2020) and the International Surgical Wound Complications Advisory Panel (ISWCAP) guidelines. The questionnaire will include demographics, SSI surveillance, preoperative, peri-operative and postoperative SSI prevention. Data will be collected on participants' surgical specialty, operative grade, of practice and financial healthcare system of practice. The online survey will be designed and disseminated using QualtricsXM Platform™ through national and international surgical colleges and societies, in addition to social media and snowballing. Data collection will be open for 3 months with reminders, and raking will be used to ascertain the sample. Responses will be analyzed, and the chi-square test used to evaluate the impact of SSI prevention variables on responses.

Discussion

Current SSI prevention practice in UK Vascular surgery varies considerably, with little consensus on many measures. Given the inconsistency in guidelines on how to prevent SSIs, there is a need for standardization. This survey will investigate the disparity in SSI preventative measures between different surgical fields and countries.

Efficient Augmented Intelligence Framework for Bladder Lesion Detection

PURPOSE

Development of intelligence systems for bladder lesion detection is cost intensive. An efficient strategy to develop such intelligence solutions is needed.

MATERIALS AND METHODS

We used four deep learning models (ConvNeXt, PlexusNet, MobileNet, and SwinTransformer) covering a variety of model complexity and efficacy. We trained these models on a previously published educational cystoscopy atlas (n = 312 images) to estimate the ratio between normal and cancer scores and externally validated on cystoscopy videos from 68 cases, with region of interest (ROI) pathologically confirmed to be benign and cancerous bladder lesions (ie, ROI). The performance measurement included specificity and sensitivity at frame level, frame sequence (block) level, and ROI level for each case.

RESULTS

Specificity was comparable between four models at frame (range, 30.0%-44.8%) and block levels (56%-67%). Although sensitivity at the frame level (range, 81.4%-88.1%) differed between the models, sensitivity at the block level (100%) and ROI level (100%) was comparable between these models. MobileNet and PlexusNet were computationally more efficient for real-time ROI detection than ConvNeXt and SwinTransformer.

CONCLUSION

Educational cystoscopy atlas and efficient models facilitate the development of real-time intelligence system for bladder lesion detection.

First Dark Matter Search with Nuclear Recoils from the XENONnT Experiment

We report on the first search for nuclear recoils from dark matter in the form of weakly interacting massive particles (WIMPs) with the XENONnT experiment, which is based on a two-phase time projection chamber with a sensitive liquid xenon mass of 5.9 ton. During the (1.09±0.03)  ton yr exposure used for this search, the intrinsic ^{85}Kr and ^{222}Rn concentrations in the liquid target are reduced to unprecedentedly low levels, giving an electronic recoil background rate of (15.8±1.3)  events/ton yr keV in the region of interest. A blind analysis of nuclear recoil events with energies between 3.3 and 60.5 keV finds no significant excess. This leads to a minimum upper limit on the spin-independent WIMP-nucleon cross section of 2.58×10^{-47}  cm^{2} for a WIMP mass of 28  GeV/c^{2} at 90% confidence level. Limits for spin-dependent interactions are also provided. Both the limit and the sensitivity for the full range of WIMP masses analyzed here improve on previous results obtained with the XENON1T experiment for the same exposure.

Toward precision sleep medicine: variations in sleep outcomes among disaggregated Asian Americans in the National Health Interview Survey (2006-2018)

STUDY OBJECTIVES

Asian Americans report higher rates of insufficient sleep than non-Hispanic Whites (NHWs). It is unclear how sleep outcomes differ among disaggregated Asian subgroups.

METHODS

The National Health Interview Survey (2006-2018) was used to analyze self-reported sleep duration and quality measures for Asian American subgroups (Chinese [n = 11,056], Asian Indian [n = 11,249], Filipino [n = 13,211], and other Asians [n = 21,767]). Outcomes included hours of sleep per day, the number of days reporting trouble falling asleep, staying asleep, waking up rested, and taking sleep medication in the past week. Subsetted multivariate logistic regression was used to assess factors impacting sleep outcomes by ethnicity.

RESULTS

29.2% of NHWs, 26.4% of Chinese, 24.5% of Asian Indians, and 38.4% of Filipinos reported insufficient sleep duration. Filipinos were less likely to report sufficient sleep duration (odds ratio 0.55, [confidence interval 95% 0.50-0.59]) and more likely to report trouble falling asleep (1.16 [1.01-1.33]) than NHWs. Chinese and Asian Indians had less trouble staying asleep (0.67 [0.58-0.77], 0.51 [0.44-0.59]) and falling asleep (0.77 [0.66-0.89], 0.72, [0.62-0.82]) than NHWs, and Asian Indians were more likely to wake feeling well rested (1.66 [1.48-1.87]). All Asian subgroups were less likely to report using sleep medications than NHWs. Foreign-born status had a negative association with sufficient sleep duration in Filipinos but a positive association in Asian Indians and Chinese.

CONCLUSIONS

Filipinos report the highest burden of poor sleep outcomes, and Asian Indians report significantly better sleep outcomes. These findings highlight the importance of disaggregating Asian ethnic subgroups to address their health needs.

CITATION

Wang RZ, Jamal A, Wang Z, et al. Toward precision sleep medicine: variations in sleep outcomes among disaggregated Asian Americans in the National Health Interview Survey (2006-2018). J Clin Sleep Med. 2023;19(7):1259-1270.

Searching for Heavy Dark Matter near the Planck Mass with XENON1T

Multiple viable theoretical models predict heavy dark matter particles with a mass close to the Planck mass, a range relatively unexplored by current experimental measurements. We use 219.4 days of data collected with the XENON1T experiment to conduct a blind search for signals from multiply interacting massive particles (MIMPs). Their unique track signature allows a targeted analysis with only 0.05 expected background events from muons. Following unblinding, we observe no signal candidate events. This Letter places strong constraints on spin-independent interactions of dark matter particles with a mass between 1×10^{12} and 2×10^{17}  GeV/c^{2}. In addition, we present the first exclusion limits on spin-dependent MIMP-neutron and MIMP-proton cross sections for dark matter particles with masses close to the Planck scale.

Conceptual framework and documentation standards of cystoscopic media content for artificial intelligence

BACKGROUND

The clinical documentation of cystoscopy includes visual and textual materials. However, the secondary use of visual cystoscopic data for educational and research purposes remains limited due to inefficient data management in routine clinical practice.

METHODS

A conceptual framework was designed to document cystoscopy in a standardized manner with three major sections: data management, annotation management, and utilization management. A Swiss-cheese model was proposed for quality control and root cause analyses. We defined the infrastructure required to implement the framework with respect to FAIR (findable, accessible, interoperable, reusable) principles. We applied two scenarios exemplifying data sharing for research and educational projects to ensure compliance with FAIR principles.

RESULTS

The framework was successfully implemented while following FAIR principles. The cystoscopy atlas produced from the framework could be presented in an educational web portal; a total of 68 full-length qualitative videos and corresponding annotation data were sharable for artificial intelligence projects covering frame classification and segmentation problems at case, lesion, and frame levels.

CONCLUSION

Our study shows that the proposed framework facilitates the storage of visual documentation in a standardized manner and enables FAIR data for education and artificial intelligence research.

Design and rationale of re-energize fontan: Randomized exercise intervention designed to maximize fitness in fontan patients

In this manuscript, we describe the design and rationale of a randomized controlled trial in pediatric Fontan patients to test the hypothesis that a live-video-supervised exercise (aerobic+resistance) intervention will improve cardiac and physical capacity; muscle mass, strength, and function; and endothelial function. Survival of children with single ventricles beyond the neonatal period has increased dramatically with the staged Fontan palliation. Yet, long-term morbidity remains high. By age 40, 50% of Fontan patients will have died or undergone heart transplantation. Factors that contribute to onset and progression of heart failure in Fontan patients remain incompletely understood. However, it is established that Fontan patients have poor exercise capacity which is associated with a greater risk of morbidity and mortality. Furthermore, decreased muscle mass, abnormal muscle function, and endothelial dysfunction in this patient population is known to contribute to disease progression. In adult patients with 2 ventricles and heart failure, reduced exercise capacity, muscle mass, and muscle strength are powerful predictors of poor outcomes, and exercise interventions can not only improve exercise capacity and muscle mass, but also reverse endothelial dysfunction. Despite these known benefits of exercise, pediatric Fontan patients do not exercise routinely due to their chronic condition, perceived restrictions to exercise, and parental overprotection. Limited exercise interventions in children with congenital heart disease have demonstrated that exercise is safe and effective; however, these studies have been conducted in small, heterogeneous groups, and most had few Fontan patients. Critically, adherence is a major limitation in pediatric exercise interventions delivered on-site, with adherence rates as low as 10%, due to distance from site, transportation difficulties, and missed school or workdays. To overcome these challenges, we utilize live-video conferencing to deliver the supervised exercise sessions. Our multidisciplinary team of experts will assess the effectiveness of a live-video-supervised exercise intervention, rigorously designed to maximize adherence, and improve key and novel measures of health in pediatric Fontan patients associated with poor long-term outcomes. Our ultimate goal is the translation of this model to clinical application as an "exercise prescription" to intervene early in pediatric Fontan patients and decrease long-term morbidity and mortality.

CO2-Activation Nanofiber Carbon Paper as a High-Performance Interlayer for Trapping Polysulfides in Li-S Batteries

Lithium-sulfur (Li-S) batteries have high theoretical energy density but low sulfur utilization due to the inherent insulating nature of sulfur and the shuttle effect of polysulfides. Herein, the CO₂-activation carbon paper was prepared by poly(p-phenylenebenzobisoxazole) (PBO) nanofiber and was first applied as an interlayer for efficiently alleviating the shuttle effect of polysulfides in Li-S batteries. This interlayer exhibits good flexibility and strength with rich -C═O and -COOH functional groups on the three-dimensional porous structure, which improves chemical adsorption on Li₂S_x species and ion rapid diffusion via interconnected diffusion channels and thus enhances the electrochemical kinetics. The initial specific capacity is 1367.4 mAh g^-1 and remains 999.8 mAh g^-1 after 200 cycles at 0.2C and 780.1 mAh g^-1 at 5C, and the Coulombic efficiency is high, up to 99.8%, which is much better than that for the carbon paper without CO₂ activation. The highly conductive flexible PBO carbon paper may bring breakthroughs in performance and thus lead to more practical applications of Li-S batteries.

Serial Lung Perfusion Scintigraphy After Unifocalization and Repair of Tetralogy of Fallot With Major Aortopulmonary Collaterals

Background

In patients with tetralogy of Fallot and major aortopulmonary collaterals (MAPCAs), pulmonary blood supply is highly variable. Our approach to this condition emphasizes complete unifocalization of the pulmonary circulation, incorporating all lung segments and addressing stenoses out to the segmental level. Post-repair, we recommend serial lung perfusion scintigraphy (LPS) to assess short-term changes in pulmonary blood flow distribution.

Methods

We reviewed post-discharge and follow-up LPS performed through three years post-repair and analyzed serial changes in perfusion, risk factors for change, and the relationship between LPS parameters and pulmonary artery reintervention.

Results

Of 543 patients who had postoperative LPS results in our system, 317 (58%) had only a predischarge LPS available for review, while 226 had 1 (20%) or more (22%) follow-up scans within three years. Overall, pulmonary flow distribution prior to discharge was balanced, and there was minimal change over time; however, there was considerable patient-to-patient variation in both metrics. On multivariable mixed modeling, time after repair ( P = .025), initial anatomy consisting of a ductus arteriosus to one lung ( P < .001), and age at repair ( P = .014) were associated with changes on serial LPS. Patients who had follow-up LPS were more likely to undergo pulmonary artery reintervention, but within that cohort, LPS parameters were not associated with reintervention risk.

Conclusion

Serial LPS during the first year after MAPCAs repair is a noninvasive method of screening for significant post-repair pulmonary artery stenosis that occurs in a small but important minority of patients. In patients who received follow-up LPS beyond the perioperative period, there was minimal change over time in the population overall, but large changes in some patients and considerable variability. There was no statistical association between LPS findings and pulmonary artery reintervention.

Disparities and Trends in Routine Adult Vaccination Rates Among Disaggregated Asian American Subgroups, National Health Interview Survey 2006-2018

Introduction

Vaccination rates may be improved through culturally tailored messages, but little is known about them among disaggregated Asian American subgroups. We assessed the vaccination rates for key vaccines among these subgroups.

Methods

Using the National Health Interview Survey, we analyzed recent vaccination rates (2015-2018, n=188,250) and trends (2006-2018) among Asians (Chinese [n=3,165], Asian Indian [n=3,525], Filipino [n=3,656], other Asian [n=5,819]) and non-Hispanic White adults (n=172,085) for 6 vaccines (the human papillomavirus, hepatitis B, pneumococcal, influenza, tetanus-diphtheria [tetanus], and shingles vaccines). We controlled demographic, socioeconomic, and health-related variables in multivariable logistic regression and predicted marginal modeling analyses. We also computed vaccination rates among Asian American subgroups on the 2015-2018 National Health Interview Survey data stratified by foreign-born and U.S.-born status. We used Joinpoint regression to analyze trends in vaccination rates. All analyses were conducted in 2021 and 2022.

Results

Among Asians, shingles (29.2%; 95% CI=26.6, 32.0), tetanus (53.7%; 95% CI=51.8, 55.6), and pneumococcal (53.8%; 95% CI=50.1, 57.4) vaccination rates were lower than among non-Hispanic Whites. Influenza (47.9%; 95% CI=46.2, 49.6) and hepatitis B (40.5%; 95% CI=39.0, 42.7) vaccination rates were similar or higher than among non-Hispanic Whites (48.4%; 95% CI=47.9, 48.9 and 30.7%; 95% CI=30.1, 31.3, respectively). Among Asians, we found substantial variations in vaccination rates and trends. For example, Asian Indian women had lower human papillomavirus vaccination rates (12.9%; 95% CI=9.1, 18.0) than all other Asian subgroups (Chinese: 37.9%; 95% CI=31.1, 45.2; Filipinos: 38.7%; 95% CI=29.9, 48.3; other Asians: 30.4%; 95% CI=24.8, 36.7) and non-Hispanic Whites (36.1%; 95% CI=34.8, 37.5). Being male, having lower educational attainment and income, having no health insurance or covered by public health insurance only, and lower frequency of doctor visits were generally associated with lower vaccine uptakes. Foreign-born Asian aggregate had lower vaccination rates than U.S.-born Asian aggregate for all vaccines except for influenza. We also found subgroup-level differences in vaccination rates between foreign-born and U.S.-born Asians. We found that (1) foreign-born Chinese, Asian Indians, and other Asians had lower human papillomavirus and hepatitis B vaccination rates; (2) foreign-born Chinese and Filipinos had lower pneumococcal vaccination rates; (3) foreign-born Chinese and Asian Indians had lower influenza vaccination rates; and (4) all foreign-born Asian subgroups had lower tetanus vaccination rates.

Conclusions

Vaccination rates and trends differed among Asian American subgroups. Culturally tailored messaging and interventions may improve vaccine uptakes.

Adipocytokines and Associations With Abnormal Body Composition in Rheumatoid Arthritis

OBJECTIVE

We determined associations between adipokines and abnormal body composition in patients with rheumatoid arthritis (RA).

METHODS

Combining data from three RA cohorts, whole-body dual-energy absorptiometry measures of appendicular lean mass and fat mass indices were converted to age-, sex-, and race- and ethnicity-specific Z scores. Lean mass relative to fat mass was determined based on prior methods. Independent associations between body composition profiles and circulating levels of adiponectin, leptin, and fibroblast growth factor (FGF)-21 were assessed using linear and logistic regression models adjusting for demographic characteristics and study cohort. We also determined the improvement in the area under the curve (AUC) for prediction of low lean mass when adipokines were added to predictive models that included clinical factors such as demographic characteristics, study, and body mass index (BMI).

RESULTS

Among 419 participants, older age was associated with higher levels of all adipokines, whereas higher C-reactive protein level was associated with lower adiponectin levels and higher FGF-21 levels. Greater fat mass was strongly associated with lower adiponectin levels and higher leptin and FGF-21 levels. Higher levels of adiponectin, leptin, and FGF-21 were independently associated with low lean mass. The addition of adiponectin and leptin levels to regression models improved prediction of low lean mass when combined with demographic characteristics, study, and BMI (AUC 0.75 vs. 0.66).

CONCLUSION

Adipokines are associated with both excess adiposity and low lean mass in patients with RA. Improvements in the prediction of body composition abnormalities suggest that laboratory screening could help identify patients with altered body composition who may be at greater risk of adverse outcomes.

Cystatin C and Creatinine Concentrations are Uninformative Biomarkers of Sarcopenia: A Cross-Sectional NHANES Study

OBJECTIVES

Differences in creatinine and cystatin C-based estimates of glomerular filtration rate (eGFR_Diff = eGFR_Cr - eGFR_CysC) may reflect differences in muscle mass. We sought to determine if eGFR_Diff (1) reflects lean mass, (2) identifies sarcopenic individuals beyond estimates based on age, BMI, and sex; and (3) demonstrates associations differently in those with and without chronic kidney disease (CKD).

DESIGN AND METHODS

This cross-sectional study included 3,754 participants, ages 20-85 years, with creatinine and cystatin C concentration levels, and DXA scans from NHANES data (1999 to 2006). DXA appendicular lean mass index (ALMI) estimated muscle mass. Non-race-based CKD EPI equations estimated GFR using creatinine (eGFR_Cr), cystatin C (eGFR_CysC), and both biomarkers (eGFR_CysC&Cr). CKD was defined as eGFR_CysC&Cr < 60 mL/min/1.73m². ALMI sex-specific T-scores (compared with young adult) < -2.0 defined sarcopenia. In estimating ALMI, we compared the coefficient of determination (R²) values from: 1) eGFR_Diff, 2) clinical characteristics (age, BMI, and sex), and 3) clinical characteristics plus eGFR_Diff. Using logistic regression, we evaluated each model's C-statistic to diagnose sarcopenia.

RESULTS

eGFR_DIFF was negatively and weakly associated with ALMI (No CKD: R² = 0.006, p-value 0.002; CKD: R² = 0.001, p-value 0.9). Clinical characteristics explained most of the variation in ALMI (No CKD: R² = 0.851, CKD: R² = 0.828), and provided strong discrimination of sarcopenia (No CKD C-statistic: 0.950; CKD C-statistic: 0.943). Adding eGFR_Diff improved the R² by 0.025, and the C-statistic by 0.003. Tests for interaction between eGFR_Diff and CKD were not significant (all p-values > 0.05).

CONCLUSIONS

Although eGFR_Diff has statistically significant associations with ALMI and sarcopenia in univariate analyses, multivariate analyses demonstrate that eGFR_Diff does not capture more information beyond routine clinical characteristics (age, BMI, and sex).

Trabecular Bone Score (TBS) Varies with Correction for Tissue Thickness Versus Body Mass Index: Implications When Using Pediatric Reference Norms

Trabecular bone score (TBS) derived from secondary analysis of lumbar spine dual-energy X-ray absorptiometry (DXA) scans improves fracture prediction independent of bone mineral density (BMD) in adults. The utility of TBS to assess fracture risk in younger patients has not been established because pediatric norms have been lacking. Robust TBS reference data from the Bone Mineral Density in Childhood Study (BMDCS) have been published. TBS values for the BMDCS study were derived using an algorithm that accounts for tissue thickness (TBS_TH ) rather than the commercially available algorithm that adjusts for body mass index (BMI; TBS_BMI ). We examined the magnitude of differences in TBS_TH and TBS_BMI in a cohort of 189 healthy youth. TBS values using both algorithms increased with age and pubertal development in a similar pattern. However, TBS_BMI values were systematically and significantly higher than TBS_TH (mean = 0.06, p < 0.0001). The difference between calculated TBS_BMI and TBS_TH was not uniform. Differences were greater at lower TBS values, in males, in older individuals, in those at later Tanner stages, and in those with a greater BMI Z-score. These systematic differences preclude the development of a simple formula to allow conversion of TBS_BMI to TBS_TH "equivalents." Because of these systematic differences in these two algorithms, using an individual's TBS_BMI to calculate a Z-score using the BMDCS TBS_TH reference values results in a falsely higher TBS Z-score (differences mean = 0.73, interquartile range [IQR] = 0.3 to 1.6). Until TBS_TH software for Hologic DXA equipment becomes commercially available, BMDCS TBS reference norms should not be used. © 2023 American Society for Bone and Mineral Research (ASBMR).

Conceptual Framework and Documentation Standards of Cystoscopic Media Content for Artificial Intelligence

BACKGROUND

The clinical documentation of cystoscopy includes visual and textual materials. However, the secondary use of visual cystoscopic data for educational and research purposes remains limited due to inefficient data management in routine clinical practice.

METHODS

A conceptual framework was designed to document cystoscopy in a standardized manner with three major sections: data management, annotation management, and utilization management. A Swiss-cheese model was proposed for quality control and root cause analyses. We defined the infrastructure required to implement the framework with respect to FAIR (findable, accessible, interoperable, re-usable) principles. We applied two scenarios exemplifying data sharing for research and educational projects to ensure the compliance with FAIR principles.

RESULTS

The framework was successfully implemented while following FAIR principles. The cystoscopy atlas produced from the framework could be presented in an educational web portal; a total of 68 full-length qualitative videos and corresponding annotation data were sharable for artificial intelligence projects covering frame classification and segmentation problems at case, lesion and frame levels.

CONCLUSION

Our study shows that the proposed framework facilitates the storage of the visual documentation in a standardized manner and enables FAIR data for education and artificial intelligence research.

Global research hot spot and trends in tinnitus treatment between 2000 and 2021: A bibliometric and visualized study

Background

In the 21^st century, the prevalence of tinnitus is increasing, impacting approximately one in five people. It is a very complicated condition that significantly affects quality of life. Despite the availability of hundreds of tinnitus treatment options, none are very successful. In light of this, there has been a steady increase in studies on tinnitus treatments in the recent past. To comprehend them better, this study used bibliometric approaches to analyze and summarize 21^st century scientific research accomplishments in tinnitus treatment.

Methods

The Web of Science Core Collection (WoSCC) was searched for papers that had been published and related to the treatment of tinnitus. VOSviewer, CiteSpace, R, and Tableau software programs were used to conduct bibliometric studies. To evaluate and visualize the results.

Results

2,933 publications on tinnitus treatment were found in 74 countries. Between 2000 and 2021, publications increased steadily. Otolaryngology-Head & Neck Surgery had the highest impact factor, whereas Otology & Neurotology had the most magazines and the highest h, g, and m index. Langguth B was the most prolific author in terms of productivity during the past 21 years. Numerous eminent authors and organizations from multiple nations collaborated. With 626 papers, the United States of America (USA) contributed the most to this field, making them the leading contributor. Neuroplasticity, sound therapy, and cognitive behavioral therapy (CBT) have attracted the attention of researchers, leading to the development of innovative diagnostic and treatment strategies for tinnitus.

Conclusion

This bibliometric study provides a comprehensive analysis of worldwide publications, cooperation, and research hotspots in tinnitus therapy, revealing the present status of research on this issue and guiding tinnitus treatment research in the coming years.

[Methylophiopogonanone a Inhibits LPS/ATP-Induced Macrophage Pyroptosis via ROS/NLRP3 Pathway]

As a byproduct of mitochondrial respiration or metabolism, reactive oxygen species (ROS) can act as a signaling molecule to activate NLR family pyrin domain containing 3 (NLRP3) inflammasome, thereby triggering immune response. NLRP3 inflammasome acts as a sensor of various danger signals and is central to the control of pyroptosis occurrence. Macrophage pyroptosis is closely related to atherosclerosis, arthritis, pulmonary fibrosis and other inflammatory diseases. Methylophiopogonanone A (MO-A) is a main homoisoflavonoid in Chinese herb Ophiopogonis Radix, which has antioxidant effect. However, it is not clear whether MO-A can alleviate macrophage pyroptosis by inhibiting oxidative stress. Here we have shown that MO-A increases the activities of superoxide dismutase (SOD) and catalase (CAT), inhibits the production of ROS, reduces the activation of NLRP3 inflammasome and the release of lactate dehydrogenase (LDH), and inhibits pyroptosis in macrophages induced by lipopolysaccharides (LPS) and adenosine triphosphate (ATP). These effects can be reversed by the ROS promoter H2O2. Therefore, MO-A can inhibit macrophage pyroptosis through the ROS/NLRP3 pathway and may be considered as a candidate drug for the treatment of inflammatory diseases.

Associations Between Low Serum Urate, Body Composition, and Mortality

OBJECTIVE

Controversy remains as to whether low serum urate or uric acid (UA) levels contribute to adverse outcomes. We evaluated the relation between low serum UA levels and sarcopenia and assessed whether sarcopenia confounds associations between these low levels and mortality.

METHODS

We utilized data from the National Health and Nutrition Examination Survey (1999-2006). Participants with available whole-body dual x-ray absorptiometry body composition measurements and serum UA concentrations were included. Body composition assessments included body mass index (BMI), waist circumference, maximum lifetime BMI, and age-, sex-, and race-specific appendicular lean mass index (ALMI) and fat mass index (FMI) Z scores. We also calculated Z scores for ALMI relative to FMI (ALMIFMI ). We evaluated associations between serum UA levels and body composition using logistic regression and assessed associations between serum UA levels and mortality before and after adjusting for differences in body composition using Cox proportional hazards regression.

RESULTS

Among the 13,979 participants, low serum UA concentrations (<2.5 mg/dl in women, <3.5 mg/dl in men) were associated with low lean mass (ALMI and ALMIFMI Z scores), underweight BMI (<18.5 kg/m2 ), and higher rates of weight loss. The proportion of patients with low ALMI Z scores was 29% in the low serum UA group and 16% in the normal serum UA group (P = 0.001). Low serum UA levels were associated with increased mortality before we adjusted for body composition (hazard ratio 1.61 [95% confidence interval 1.14-2.28]; P = 0.008) but was attenuated and not significant after adjustment for body composition and weight loss (hazard ratio 1.30 [95% confidence interval 0.92-1.85], P = 0.13).

CONCLUSION

Sarcopenia and weight loss are more common among patients with low serum UA concentrations. Differences in body composition may help to explain associations between low levels of serum UA and higher mortality.

Bone Mineral Density and Vascular Calcification in Children and Young Adults With CKD 4 to 5 or on Dialysis

Introduction

Older adults with chronic kidney disease (CKD) can have low bone mineral density (BMD) with concurrent vascular calcification. Mineral accrual by the growing skeleton may protect young people with CKD from extraosseous calcification. Our hypothesis was that children and young adults with increasing BMD do not develop vascular calcification.

Methods

This was a multicenter longitudinal study in children and young people (5-30 years) with CKD stages 4 to 5 or on dialysis. BMD was assessed by tibial peripheral quantitative computed tomography (pQCT) and lumbar spine dual-energy X-ray absorptiometry (DXA). The following cardiovascular imaging tests were undertaken: cardiac computed tomography for coronary artery calcification (CAC), ultrasound for carotid intima media thickness z-score (cIMTz), pulse wave velocity z-score (PWVz), and carotid distensibility for arterial stiffness. All measures are presented as age-adjusted and sex-adjusted z-scores.

Results

One hundred participants (median age 13.82 years) were assessed at baseline and 57 followed up after a median of 1.45 years. Trabecular BMD z-score (TrabBMDz) decreased (P = 0.01), and there was a nonsignificant decrease in cortical BMD z-score (CortBMDz) (P = 0.09). Median cIMTz and PWVz showed nonsignificant increase (P = 0.23 and P = 0.19, respectively). The annualized increase in TrabBMDz (ΔTrabBMDz) was an independent predictor of cIMTz increase (R ² = 0.48, β = 0.40, P = 0.03). Young people who demonstrated statural growth (n = 33) had lower ΔTrabBMDz and also attenuated vascular changes compared with those with static growth (n = 24).

Conclusion

This hypothesis-generating study suggests that children and young adults with CKD or on dialysis may develop vascular calcification even as their BMD increases. A presumed buffering capacity of the growing skeleton may offer some protection against extraosseous calcification.

Search for New Physics in Electronic Recoil Data from XENONnT

We report on a blinded analysis of low-energy electronic recoil data from the first science run of the XENONnT dark matter experiment. Novel subsystems and the increased 5.9 ton liquid xenon target reduced the background in the (1, 30) keV search region to (15.8±1.3)  events/(ton×year×keV), the lowest ever achieved in a dark matter detector and ∼5 times lower than in XENON1T. With an exposure of 1.16 ton-years, we observe no excess above background and set stringent new limits on solar axions, an enhanced neutrino magnetic moment, and bosonic dark matter.

The role of estrogen in circular RNA and metabonomics in a Neisseria gonorrhoeae infection model

Background

Previous study shows that estrogen exerts both immunosuppressive and immunostimulative effects.

Methods

In this study, estrogen was added to a Neisseria gonorrhoeae infection model, and transcriptome sequencing and metabolomics studies were performed to clarify the changes in circular RNA (circRNA) and metabolic pathways regulated by the addition of estrogen.

Results

The results showed that following the addition of estrogen to the gonococcal infection model, the expression of circRNAs was up-regulated and the expression of circRNAs was down-regulated. In the metabolic group, it was found that after the addition of estrogen, the expression of nine metabolites was down-regulated and 61 metabolites were up-regulated. Furthermore, through network interaction analysis of differentially-expressed circRNAs and differentially-expressed metabolites, we found that the top 10 significantly related metabolites and circRNA were 2-Epoxybutane/novel_circ_0024520; 1,2-Epoxybutane/novel_circ_0061793; 2-Imino-4-methylpiperidine/novel_circ_0012178; 2-Imino-4-methylpiperidine/novel_circ_0056959; Acetone oxime/novel_circ_0012178; Adifoline/novel_circ_0012178; CARBETAPENTANE/novel_circ_0054387; CARBETAPENTANE/novel_circ_0056959; deoxy-PF1140/mmu_circ_0000397; and Methyl (2E,6Z)-dodecadienoate/novel_circ_0012178. Among these, CARBETAPENTANE/novel_circ_0054387 and CARBETAPENTANE/novel_circ_0056959 were positively correlated, while the remaining metabolites were negatively correlated.

Conclusions

In this study, high-throughput sequencing and metabolomics mass spectrum were applied to screen the differentially-expressed circRNAs and metabolites regulated by estrogen, which will help to provide new research ideas and indicators for asymptomatic infections in women, and can be meaningful for the relevant study in the future.

The effect of different poly fibers separator-modified materials on blocking polysulfides for high performance Li-S batteries

Herein, we reported that KOH impregnation can generate a large number of porous structures with fruitful nitrogen self-doped groups during the carbonized process for poly (p-phenylene terephthalamide) fiber and poly (p-phenylene benzobisoxazole) fiber (denoted as PPTA and PBO, respectively). The intrinsical insulation, volume change, and shuttle effect of polysulfides then can be more significantly improved for the PBO-coated separator than the PPTA case. The discharge capacity primary achieves 1,322 mA h/g, which retains 827 mA h/g even after 200 cycles at 0.2 C for the cell with PBO-coated separator. The reversible specific discharge capacity maintains 841 mA h/g with a Coulomb efficiency of 99.7% at 5 C. The nitrogen self-doped nanocarbon particles are etched by KOH with the simple one-step preparation, which has promising application as Li-S battery cathode.

Self-assembled NIR-responsive MoS2@quaternized chitosan/nanocellulose composite paper for recyclable antibacteria

Paper products are widely used in daily life, while the lack of antibacterial activity has made them become some disease transmission media. Herein, we introduced NIR-responsive molybdenum disulfide nanosheets (MoS₂) to endow nanocellulose paper antibacterial activity by electrostatic self-assembly with quaternized chitosan (QCS). Firstly, the MoS₂ nanosheets were exfoliated and stabilized with QCS under ultrasonication. The strong coordination between QCS and MoS₂ as well as the electrostatic attraction between QCS and cellulose nanofiber (CNF) helped to fabricate the MoS₂@QCS/CNF composite paper. The MoS₂@QCS/CNF composite paper exhibited excellent photothermal and photodynamic activity, achieving over 99.9% antibacterial efficacy against both E. coli and S. aureus, respectively. The hyperthermia induced by MoS₂ accelerated the glutathione (GSH) consumption and the reactive oxygen species (ROS)-independent oxidative stress destroyed the bacteria membranes integrity, synergistically leading to the malondialdehyde (MDA) oxidation and protein leakage to inhibit the bacteria growth. Importantly, the self-assembled fibrous network incorporating with the photo-stable antibacterial MoS₂ enabled the flexible composite paper with excellent mechanical strength and recyclability for long-term antimicrobial, possessing over 99.9% inhibition even after five cycles. No cell cytotoxicity was observed for the MoS₂@QCS/CNF composite paper, suggesting the potential of composite paper for bacterial infection control.

Material radiopurity control in the XENONnT experiment

The selection of low-radioactive construction materials is of the utmost importance for rare-event searches and thus critical to the XENONnT experiment. Results of an extensive radioassay program are reported, in which material samples have been screened with gamma-ray spectroscopy, mass spectrometry, and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$^{222}$$\end{document}222Rn emanation measurements. Furthermore, the cleanliness procedures applied to remove or mitigate surface contamination of detector materials are described. Screening results, used as inputs for a XENONnT Monte Carlo simulation, predict a reduction of materials background (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\sim $$\end{document}∼17%) with respect to its predecessor XENON1T. Through radon emanation measurements, the expected \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$^{222}$$\end{document}222Rn activity concentration in XENONnT is determined to be 4.2 (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$^{+0.5}_{-0.7}$$\end{document}-0.7+0.5) \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\upmu $$\end{document}μBq/kg, a factor three lower with respect to XENON1T. This radon concentration will be further suppressed by means of the novel radon distillation system.

ASSOCIATION BETWEEN THE CTLA-4 EXON 1+49A/G POLYMORPHISM AND THE RELAPSE OF GRAVE'S DISEASE AFTER ATD WITHDRAWAL: A META-ANALYSIS

Background

The cytotoxic T lymphocyte-associated molecules-4 (CTLA-4) is related to the relapse of Graves' disease (GD) after anti-thyroid drugs (ATDs) withdrawal. We performed a meta-analysis to generate large-scale evidence on whether the CTLA-4 exon 1+49A/G polymorphism can predict the relapse of GD after ATDs withdrawal.

Methods and Results

The PubMed, EMBASE,the Cochrane Library and reference lists of relevant studies were searched to identify eligible studies from inception to Jan, 2021. Ten eligible studies consisting of 1450 GD patients with a total of 848 relapsed patients were included in the meta-analysis.In Caucasians patients, the CTLA-4 exon 1+49A/G polymorphism significantly elevated the relapse risk of GD in additive (OR = 2.07, 95% CI: 1.18-3.62, P=0.011), dominant (OR = 2.52, 95% CI: 1.17-5.41, P=0.02), homozygote model(OR = 3.264, 95% CI: 1.25-8.52, P=0.016), except recessive (OR = 2.18, 95% CI = 0.98-4.86, P = 0.062) and heterozygote model (OR = 2.141, 95% CI = 0.958-4.786, P = 0.064). In Asian subgroup, none of these genotypes show any associations with the relapse of GD after ATDs withdrawal.

Conclusion

This meta-analysis suggests that the CTLA-4 exon1 +49A/G polymorphism is associated with the relapse risk of GD after ATDs withdrawal in Caucasians, not Asians. Compared with the AA genotype, Caucasian patients with GG genotype have 3.264 times risk of relapse. A more aggressive treatment such as radioactive iodine or thyroidectomy, or longer periods treatment of ATDs should be recommended in Caucasian patients with the GG genotype.

Bracovirus Sneaks Into Apoptotic Bodies Transmitting Immunosuppressive Signaling Driven by Integration-Mediated eIF5A Hypusination

A typical characteristics of polydnavirus (PDV) infection is a persistent immunosuppression, governed by the viral integration and expression of virulence genes. Recently, activation of caspase-3 by Microplitis bicoloratus bracovirus (MbBV) to cleave Innexins, gap junction proteins, has been highlighted, further promoting apoptotic cell disassembly and apoptotic body (AB) formation. However, whether ABs play a role in immune suppression remains to be determined. Herein, we show that ABs transmitted immunosuppressive signaling, causing recipient cells to undergo apoptosis and dismigration. Furthermore, the insertion of viral–host integrated motif sites damaged the host genome, stimulating eIF5A nucleocytoplasmic transport and activating the eIF5A-hypusination translation pathway. This pathway specifically translates apoptosis-related host proteins, such as P53, CypA, CypD, and CypJ, to drive cellular apoptosis owing to broken dsDNA. Furthermore, translated viral proteins, such Vank86, 92, and 101, known to complex with transcription factor Dip3, positively regulated DHYS and DOHH transcription maintaining the activation of the eIF5A-hypusination. Mechanistically, MbBV-mediated extracellular vesicles contained inserted viral fragments that re-integrated into recipients, potentially via the homologous recombinant repair system. Meanwhile, this stimulation regulated activated caspase-3 levels via PI3K/AKT 308 and 473 dephosphorylation to promote apoptosis of granulocyte-like recipients Sf9 cell; maintaining PI3K/AKT 473 phosphorylation and 308 dephosphorylation inhibited caspase-3 activation leading to dismigration of plasmatocyte-like recipient High Five cells. Together, our results suggest that integration-mediated eIF5A hypusination drives extracellular vesicles for continuous immunosuppression.

CheXED: Comparison of a Deep Learning Model to a Clinical Decision Support System for Pneumonia in the Emergency Department

PURPOSE

Patients with pneumonia often present to the emergency department (ED) and require prompt diagnosis and treatment. Clinical decision support systems for the diagnosis and management of pneumonia are commonly utilized in EDs to improve patient care. The purpose of this study is to investigate whether a deep learning model for detecting radiographic pneumonia and pleural effusions can improve functionality of a clinical decision support system (CDSS) for pneumonia management (ePNa) operating in 20 EDs.

MATERIALS AND METHODS

In this retrospective cohort study, a dataset of 7434 prior chest radiographic studies from 6551 ED patients was used to develop and validate a deep learning model to identify radiographic pneumonia, pleural effusions, and evidence of multilobar pneumonia. Model performance was evaluated against 3 radiologists' adjudicated interpretation and compared with performance of the natural language processing of radiology reports used by ePNa.

RESULTS

The deep learning model achieved an area under the receiver operating characteristic curve of 0.833 (95% confidence interval [CI]: 0.795, 0.868) for detecting radiographic pneumonia, 0.939 (95% CI: 0.911, 0.962) for detecting pleural effusions and 0.847 (95% CI: 0.800, 0.890) for identifying multilobar pneumonia. On all 3 tasks, the model achieved higher agreement with the adjudicated radiologist interpretation compared with ePNa.

CONCLUSIONS

A deep learning model demonstrated higher agreement with radiologists than the ePNa CDSS in detecting radiographic pneumonia and related findings. Incorporating deep learning models into pneumonia CDSS could enhance diagnostic performance and improve pneumonia management.

Fertility preservation in transgender and non-binary adolescents and young adults

Although 37.5–51% of transgender adults state they would’ve considered freezing gametes before gender-affirming therapy if offered and 24–25.8% of transgender adolescents express interest in having biological children, less than 5% of transgender adolescents have opted for fertility preservation. We sought to assess fertility preservation utilization in our multidisciplinary adolescent gender clinic. We also aimed to identify fertility preservation utilization and interest among non-binary adolescents and young adults. A retrospective review was conducted of patients seen in the Stanford Pediatric & Adolescent Gender Clinic from October 2015 through March 2019 who were >10 years of age at initial visit. All individuals with documented discussion of fertility preservation were offered referral for formal fertility preservation consultation but only 24% of patients accepted. Only 6.8% of individuals subsequently underwent fertility preservation (n = 9). Transfeminine adolescents are more likely to pursue fertility preservation than transmasculine adolescents (p = 0.01). The rate of fertility preservation in non-binary adolescents did not significantly differ from those in transfeminine adolescents (p = 1.00) or transmasculine adolescents (p = 0.31). Although only one non-binary individual underwent fertility preservation, several more expressed interest with 36% accepting referral (n = 4) and 27% being seen in consultation (n = 3). Despite offering fertility preservation with designated members of a gender clinic team, utilization remains low in transgender adolescents. Additionally, non-binary adolescents and their families are interested in fertility preservation and referrals should be offered to these individuals. Further studies and advocacy are required to continue to address fertility needs of transgender adolescents.

335 Early Initiation of Biochemical Venous Thromboembolism Prophylaxis Following Traumatic Spleen Injury Is Safe and Effectively Reduce VTE Events

Aim

This study examines the safety and timing initiating VTE prophylaxis post traumatic splenic injuries (TSI).

Method

Patients with TSI were identified from prospectively maintained Trauma Audit and Research Network (TARN) database from 2015–2020 in a single tertiary trauma centre. Clinical and radio-logical information were collected retrospectively. TSI were graded using American Association for the Surgery of Trauma (AAST) splenic injury scale. Chemical venous thromboprophylaxis initiation were categorised as not given, &lt;48h and &gt;48h following the injury.

Results

In total 102 patient were included out of 136 patients identified with TSI. 34 patients were excluded for lack of electronic data, palliative decision, or fatal condition on arrival. 12 patients out of 102 required operative management (OM) and 90 patients NOM. VTE prophylaxis was not given for 31 (30.4%). Medical reasons for this include severe brain injury and early discharge before 48 hours. VTE prophylaxis was initiated for 37 (36.3%) patients within 48 hours, and for 34 patients (33.3%) after 48 hours of admission. Seven patients developed thromboembolic events, majority of which (6/7) received VTE prophylaxis after 48 hours. Importantly, none of the patients who received VTE prophylaxis had rebleeding.

Conclusions

This study showed that early initiation of chemical VTE prophylaxis (&lt;48h) is safe, resulted in lower incidence of DVTs/PEs without increasing the risk of bleeding. Results from this study supports recommendation from other studies 1 to initiate chemical VTE prophylaxis after TSI as early as 24h post injury with no other contra-indications.

Transabdominal Laparoscopic Ureteroureterostomy With the Intraoperative Retrograde Ureteroscopy-Assisted Technique for Multiple Ureteral Polyps: A Single-Center 10 Years Experiences

Background

The purpose of this study was to report our experience in treating multiple ureteral polyps with transabdominal laparoscopic ureteroureterostomy (LAP-UU) with intraoperative retrograde ureteroscopy (RU)-assisted technique.

Methods

The data of 32 patients who underwent transabdominal LAP-UU with the intraoperative RU-assisted technique due to multiple ureteral polyps between January 2011 and March 2021 were reviewed at our institute. After administration of anesthesia, patients were placed in a passive position and underwent a three-port transabdominal laparoscopy with RU. Detailed data were reviewed, such as demographic characteristics, intraoperative outcomes, postoperative data, complications, and pathology reports.

Results

Thirty-two patients were diagnosed with multiple ureteral polyps underwent this surgery method at our institution. The mean duration of symptoms at the time of diagnosis was approximately 7.1 months. The mean age of patients was 42.4 years, with men accounting for 68.8% (22/32), lesion of left for 56.3% (18/32), and the upper ureter for 62.5% (20/32). Furthermore, the median length of the polyps was 3.6 cm, the mean operative time was 174.6 min, and the estimated blood loss (EBL) was about 86.8 ml. The mean time to begin a liquid diet and to be out of bed were 1.7 and 2.3 days, respectively. The average length of hospital stay was 6.3 days. The ureteral stent was removed by cystoscope 2–3 months after surgery. Follow-up duration ranged from 3 to 112 months and none of the patients required another surgery for recurrence.

Conclusion

Transabdominal LAP-UU combined with the intraoperative RU-assisted technique is an effective, safe, and reliable surgical option for patients with multiple ureteral polyps. Further long-term follow-up is recommended.

Advance Care Planning Preferences for Adolescents With Cardiac Disease

BACKGROUND AND OBJECTIVES

Adolescents with cardiac disease are at risk for life-changing complications and premature death. The importance of advance care planning (ACP) in adults with congenital heart disease and in pediatric patients with HIV and cancer has been demonstrated. ACP preferences of adolescents with heart disease have not been evaluated. We describe ACP preferences of adolescents with heart disease and compare with those of their caregivers.

METHODS

Outpatient adolescents aged 12 to 18 years with heart failure, cardiomyopathy, heart transplantation, or who were at risk for cardiomyopathy, as well as their caregivers, completed self-administered questionnaires which evaluated participants' opinions regarding content and timing of ACP discussions, preferences for end-of-life communication, and emotional responses to ACP.

RESULTS

Seventy-eight adolescents and 69 caregivers participated, forming 62 adolescent-caregiver dyads. Adolescents and caregivers reported that adolescent ACP discussions should occur early in the disease course (75% and 61%, respectively). Adolescents (92%) wanted to be told about terminal prognosis, whereas only 43% of caregivers wanted the doctor to tell their child this information. Most adolescents (72%) and caregivers (67%) anticipated that discussing ACP would make the adolescent feel relieved the medical team knew their wishes. Most caregivers (61%) believed that adolescents would feel stress associated with ACP discussions, whereas only 31% of adolescents anticipated this.

CONCLUSIONS

Adolescents and their caregivers agree that ACP should occur early in disease course. There are discrepancies regarding communication of prognosis and perceived adolescent stress related to ACP discussions. Facilitated conversations between patient, caregiver, and providers may align goals of care and communication preferences.

Quality of life from cytoreductive surgery in advanced Ovarian cancer: investigating association with disease burden and surgical complexity in the international, prospective, SOCQER2 cohort study

OBJECTIVE

To investigate quality of life (QoL) and association with surgical complexity and disease burden after surgical resection for advanced ovarian cancer in centres with variation in surgical approach DESIGN: Prospective multicentre observational study SETTING: United Kingdom, Kolkata, India, and Melbourne, Australia gynaecological cancer surgery centres.

PARTICIPANTS

Patients undergoing surgical resection for late stage ovarian cancer. Exposure Low, intermediate or high Surgical Complexity Score (SCS) surgery MAIN OUTCOMES AND MEASURES: Primary: EORTC-QLQ-C30 Global score change. Secondary: EORTC OV28, progression free survival.

RESULTS

Patients' pre-operative disease burden and SCS varied between centres, confirming differences in surgical ethos. QoL response rates were 90% up to 18 months. Mean change from the pre-surgical baseline in the EORTC QLQ-C30 was 3.4 (SD 1.8, n=88) in the low, 4.0 (SD 2.1, n=55) in the intermediate and 4.3 (SD 2.1, n=52) in the high SCS group after 6 weeks (p=0.048) and 4.3 (SD 2.1, n=51), 5.1 (SD 2.2, n=41) and 5.1 (SD 2.2, n=35) respectively after 12 months (p=0.133). In a repeated measures model, there were no clinically or statistically meaningful differences in EORTC QLQ-C30 global scores between the three SCS groups, p= 0.840 but there was a small statistically significant improvement in all groups over time (p<0.001). The high SCS group experienced small to moderate decreases in physical (p=0.004), role (p=0.016) and emotional (p=0.001) function at 6 weeks post-surgery which resolved by 6-12 months.

CONCLUSIONS AND RELEVANCE

Global QoL of patients undergoing low, intermediate, and high SCS surgery improved at 12 months post operation and was no worse in patients undergoing extensive surgery.

Learning Domain-Agnostic Visual Representation for Computational Pathology Using Medically-Irrelevant Style Transfer Augmentation

Suboptimal generalization of machine learning models on unseen data is a key challenge which hampers the clinical applicability of such models to medical imaging. Although various methods such as domain adaptation and domain generalization have evolved to combat this challenge, learning robust and generalizable representations is core to medical image understanding, and continues to be a problem. Here, we propose STRAP (Style TRansfer Augmentation for histoPathology), a form of data augmentation based on random style transfer from non-medical style sources such as artistic paintings, for learning domain-agnostic visual representations in computational pathology. Style transfer replaces the low-level texture content of an image with the uninformative style of randomly selected style source image, while preserving the original high-level semantic content. This improves robustness to domain shift and can be used as a simple yet powerful tool for learning domain-agnostic representations. We demonstrate that STRAP leads to state-of-the-art performance, particularly in the presence of domain shifts, on two particular classification tasks in computational pathology. Our code is available at https://github.com/rikiyay/style-transfer-for-digital-pathology.