Novel case of combination antibiotic therapy for treatment of a complicated polymicrobial urinary tract infection with one organism harboring a metallo-β-lactamase (MBL) in a pregnant patient

Carbapenem resistance due to metallo-beta-lactamases (MBLs) is a global phenomenon and an important challenge for antibiotic therapy (Boyd et al., 2020 [1]). While previous reports have demonstrated both in vitro and in vivo synergy using the combination of ceftazidime-avibactam and aztreonam against Stenotrophomonas maltophilia, an MBL-harboring organism, this treatment strategy has not been reported during pregnancy (Mojic et al., 2017 [2], [3], Mojica et al., 2016 [4], Alexander et al., 2020 [5]). We describe a 33-year-old pregnant female with polymicrobial, bilateral pyelonephritis caused by Stenotrophomonas maltophilia and other gram-negative bacteria. The organisms were eradicated with the combination of ceftazidime-avibactam and aztreonam followed by successful delivery with no observed adverse effects in either mother or child post-partum.

A New Statistical Method to Detect Disease Outbreaks from Hospital Emergency Department Data

Early detection and prediction of disease outbreaks are crucial for public health service delivery, containment response, saving patient lives, and reducing costs. We propose a new data-driven statistical methodology for outbreak detection and prediction based on routinely collected hospital Emergency Department data. The time between consecutive ED presentations matching a diagnosis of interest forms the basis of a novel index measure to signal that an outbreak has occurred. We validate the method using historical presentations of influenza-like illness made to a large sample of public hospital EDs in 2020 and compare outbreaks identified by the method with the start of the first wave of COVID-19. The method shows promise within the field of disease outbreak detection.

Predicting mid-pelvic interspinous distance in women using height and pubic arch angle

OBJECTIVE

To predict the interspinous distance (ISD) using the relationship between female height and pelvimetric measures on magnetic resonance (MR) images.

METHODS

We obtained measurements of the pubic arch angle (PAA), inlet-anteroposterior (AP) distance, mid-pelvis AP distance, outlet-AP distance, ISD, and ischial tuberosity distance using 710 pelvic MR images from nonpregnant reproductive-aged (21-50 years) women from January 2014 to June 2020. Patient height was also assessed from medical records. We determined the formula for predicting ISD using multiple regression analysis.

RESULTS

The mean ± standard deviation of the height, PAA, inlet-AP distance, mid-pelvis AP distance, outlet-AP distance, ISD, and ischial tuberosity distance were 160.0 ± 5.5 cm, 87.31 ± 6.6°, 129.7 ± 9.0 mm, 119.7 ± 8.5 mm, 111.71 ± 8.90 mm, 108.88 ± 8.0 mm, and 121.97 ± 11.8 mm, respectively. Two significant regression formulas for predicting ISD were identified as follows: ISD = 0.24973 × height - 0.06724 × inlet-AP distance + 0.12166 × outlet-AP distance + 0.29233 × ischial tuberosity distance + 0.32524 × PAA (P < 0.001, R2 = 0.9973 [adjusted R2 = 0.9973]) and ISD = 0.40935 × height + 0.49761 × PAA (P < 0.001, R2 = 0.9965 [adjusted R2 = 0.9965]).

CONCLUSION

ISD is the best predictor of obstructed labor. This study predicted ISD with 99% explanatory power using only the height and PAA. The PAA can be measured by transperineal ultrasound. This formula may successfully predict vaginal delivery or cephalopelvic disproportion.

Exosome from IFN-γ-Primed Induced Pluripotent Stem Cell-Derived Mesenchymal Stem Cells Improved Skin Inflammation and Barrier Function

The pathogenesis of atopic dermatitis (AD) is multifactorial, including immune dysregulation and epidermal barrier defects, and a novel therapeutic modality that can simultaneously target multiple pathways is needed. We investigated the therapeutic effects of exosomes (IFN-γ-iExo) secreted from IFN-γ-primed induced pluripotent stem cell-derived mesenchymal stem cells (iMSC) in mice with Aspergillus fumigatus-induced AD. IFN-γ-iExo was epicutaneously administered to mice with AD-like skin lesions. The effects of IFN-γ-iExo treatment were investigated through clinical scores, transepidermal water loss (TEWL) measurements, and histopathology. To elucidate the therapeutic mechanism, we used an in vitro model of human keratinocyte HaCaT cells stimulated with IL-4 and IL-13 and performed extensive bioinformatics analysis of skin mRNA from mice. The expression of indoleamine 2,3-dioxygenase was higher in IFN-γ primed iMSCs than in iMSCs. In human keratinocyte HaCaT cells, treatment with IFN-γ-iExo led to decreases in the mRNA expression of thymic stromal lymphopoietin, IL-25, and IL-33 and increases in keratin 1, keratin 10, desmoglein 1, and ceramide synthase 3. IFN-γ-iExo treatment significantly improved clinical and histological outcomes in AD mice, including clinical scores, TEWL, inflammatory cell infiltration, and epidermal thickness. Bioinformatics analysis of skin mRNA from AD mice showed that IFN-γ-iExo treatment is predominantly involved in skin barrier function and T cell immune response. Treatment with IFN-γ-iExo improved the clinical and histological outcomes of AD mice, which were likely mediated by restoring proper skin barrier function and suppressing T cell-mediated immune response.

Relation between sex and mortality after myocardial infarction in high-income and middle-income European countries

Background

The relationship between female sex and cardiovascular mortality in myocardial infarction (MI) is controversial. Most available data are from high-income countries (HIC) where baseline risk is lower and revascularization procedures are more likely, so the generalizability to other populations is unclear.

Purpose

The main goal of this study was to unravel the relation between patient-specific revascularization through percutaneous coronary intervention (PCI) and mortality among women and men.

Methods

Data were drawn from the ISACS-Archives (NCT04008173) which includes a large cohort of patients enrolled in 6 European HIC (Croatia, Italy, Lithuania, Hungary, Romania, and United Kingdom) and 7 middle-income countries (MIC; Bosnia & Herzegovina, Kosovo, Macedonia, Moldova, Montenegro, and Serbia). Participants were stratified by MI subtypes: STEMI and NSTEMI. The primary outcome was 30-day mortality. To yield unbiased sex estimates of the effects of MI on mortality we modeled covariates and outcomes by propensity score-based analytic methods. We calculated the women to men risk ratios (RRs) using weighting with estimates compared by test of interaction on the log scale.

Results

The cohort consisted of 22,087 patients with MI (30.2% women). Patient outcomes varied according to the subtype of MI. Females was associated with a greater excess risk of 30-day mortality in STEMI (RR: 1.94; 95% CI: 1.71–2.21) compared with NSTEMI (RR: 1.12; 95% CI: 0.95–1.50; P interaction &lt;0.001). Coronary revascularization reduced the incidence of death among women and men in the overall population. Despite this, the primary outcome of 30-day mortality remained higher in women than men with STEMI (RR: 2.38; 95% CI: 2.00–2.82) whereas it was comparable across sexes in patients with NSTEMI (RR: 1.21; 95% CI: 0.79–1.83; P interaction=0.002). Sex differences in mortality from STEMI were more significant in MIC compared with HIC (RRs: 2.30; 95% CI: 1.98–2.68 vs. 1.36; 95% CI: 1.05–1.75; P interaction &lt;0.001). The sex gap in mortality was mitigated by the use of revascularization therapy (RRs: 2.05; 95% CI: 1.68–2.50 in MIC vs. 2.17; 95% CI: 1.48–3.18 in HIC; P interaction=0.40)

Conclusion

Women presenting with STEMI have worse early mortality rates than their male counterparts in both HIC and MIC even in patients undergoing revascularization. By contrast, sex differences are attenuated or no longer apparent in NSTEMI. With no information on the type of MI on admission, sex differences in early outcomes are difficult to be fully understood.

Funding Acknowledgement

Type of funding sources: None.

Regulation of Hepatic Gluconeogenesis by Nuclear Receptor Coactivator 6

Nuclear receptor coactivator 6 (NCOA6) is a transcriptional coactivator of nuclear receptors and other transcription factors. A general Ncoa6 knockout mouse was previously shown to be embryonic lethal, but we here generated liver-specific Ncoa6 knockout (Ncoa6 LKO) mice to investigate the metabolic function of NCOA6 in the liver. These Ncoa6 LKO mice exhibited similar blood glucose and insulin levels to wild type but showed improvements in glucose tolerance, insulin sensitivity, and pyruvate tolerance. The decrease in glucose production from pyruvate in these LKO mice was consistent with the abrogation of the fasting-stimulated induction of gluconeogenic genes, phosphoenolpyruvate carboxykinase 1 (Pck1) and glucose-6-phosphatase (G6pc). The forskolin-stimulated inductions of Pck1 and G6pc were also dramatically reduced in primary hepatocytes isolated from Ncoa6 LKO mice, whereas the expression levels of other gluconeogenic gene regulators, including cAMP response element binding protein (Creb), forkhead box protein O1 and peroxisome proliferator-activated receptor γ coactivator 1α, were unaltered in the LKO mouse livers. CREB phosphorylation via fasting or forskolin stimulation was normal in the livers and primary hepatocytes of the LKO mice. Notably, it was observed that CREB interacts with NCOA6. The transcriptional activity of CREB was found to be enhanced by NCOA6 in the context of Pck1 and G6pc promoters. NCOA6-dependent augmentation was abolished in cAMP response element (CRE) mutant promoters of the Pck1 and G6pc genes. Our present results suggest that NCOA6 regulates hepatic gluconeogenesis by modulating glucagon/cAMP-dependent gluconeogenic gene transcription through an interaction with CREB.

Comorbid alcohol use and post-traumatic stress disorders: Pharmacotherapy with aldehyde dehydrogenase 2 inhibitors versus current agents

The increased risk of alcohol use disorder (AUD) in individuals with post-traumatic stress disorder (PTSD) is well-documented. Compared to individuals with PTSD or AUD alone, those with co-existing PTSD and AUD exhibit greater symptom severity, poorer quality of life, and poorer treatment outcomes. Although the treatment of comorbid AUD is vital for the effective management of PTSD, there is a lack of evidence on how to best treat comorbid PTSD and AUD, and currently, there are no FDA-approved treatments for the PTSD-AUD comorbidity. The objective of this manuscript is to review the evidence of a promising target for treating the AUD-PTSD comorbidity. First, we summarize the epidemiological evidence and review the completed clinical studies that have tested pharmacotherapeutic approaches for co-existing AUD and PTSD. Next, we summarize the shared pathological factors between AUD and PTSD. We conclude by providing a rationale for selectively inhibiting aldehyde dehydrogenase-2 as a potential target to treat comorbid AUD in persons with PTSD.

Resistance to inflammation underlies enhanced fitness in clonal hematopoiesis

[Figure: see text].

Innate Type 2 Response to Aspergillus fumigatus in a Murine Model of Atopic Dermatitis-like Skin Inflammation

BACKGROUND

Atopic dermatitis (AD) is a chronic and relapsing inflammatory skin disease mediated by T helper type 2 (Th2) cells in acute phase. Group 2 innate lymphoid cells (ILCs) play a role in the initiation of the Th2 response. Although mold exposure is associated with the development of AD, studies on the underlying mechanisms are lacking. This study investigated whether group 2 ILCs are involved in inflammation in AD-like skin induced by Aspergillus fumigatus (Af).

METHODS

We investigated changes of group 2 ILCs population in Af-induced AD-like skin lesions. To induce AD-like skin lesions, Af extracts were applied to the dorsal skin of BALB/c and Rag1^-/- mice five times per week, with repeat exposures at 2-week intervals.

RESULTS

The clinical parameters were higher in the Af-treated group than in the control group. Histologic findings revealed epiderrmal and dermal thickening as well as eosinophil and mast cell infiltration into the skin of Af-treated mice. Populations of group 2 ILCs in the skin were also significantly higher in the Af-treated group. In addition, interleukin-33 mRNA expression was significantly higher in the skin lesions of the Af-treated mice. In the Rag1^-/- mice lacking mature lymphocytes, AD-like skin lesions were still induced by Af and ILCs depletion using an anti-CD90.2 mAb lowered the Af-induced inflammatory response.

CONCLUSIONS

Group 2 ILCs may play a role in a murine model of Af-induced AD-like skin lesions.

Acute heart failure: a mechanism underscoring sex differences in outcomes following acute coronary syndromes

Background

It remains uncertain whether female sex is itself a strong risk factor for worse outcomes in acute coronary syndromes (ACS).

Purpose

We hypothesized that sex differences in vulnerability to heart failure after ACS may modify the association between sex and outcomes.

Methods

Data were drawn from the ISACS-Archives network of registries. The study population consisted of 87,812 patients with known time from symptom onset to hospital presentation. Participants were stratified by ACS subtypes: STEMI and NSTE-ACS Data on presenting heart failure symptoms were collected from medical record abstraction. Heart failure was categorized as Killip class &gt;2. Time from symptom onset to hospital presentation was categorized as early (≤120 minutes) or late (&gt;120 minutes). Primary outcome measure was 30-day mortality. Estimates were performed using a parametric balancing strategy by weighting and compared by test of interaction on the log scale.

Results

Among the study sample, 30922 (35.2%) patients were women. Patient outcomes varied according to subtype of ACS. The mortality rates at 30-days were significantly higher among women vs men in STEMI (RR:1.65; 95% CI: 1.56–1.73) compared with NSTE-ACS (RR:1.18; 95% CI: 1.09–1.28; P interaction &lt;0.0001). Similarly, the women vs men RR of heart failure was higher in STEMI (RR: 1.24; 95% CI: 1.20–1.29) compared with NSTE-ACS (RR:1.02; 95% CI: 0.97–1.08; P interaction &lt;0.0001). Sex difference in heart failure rates with STEMI presentation were independent (P&lt;0.0001) of early (34.3% in women vs 24.2% in men) or late (35.5% in women vs 30.7% in men) hospital presentation. The same finding was not seen in NSTE-ACS patients. Overall, women presenting with heart failure was had higher 30-day mortality than did their male counterparts with heart failure (29.8% vs 25.5%; RR: 1.24; 95% CI: 1.17–1.31).

Conclusions

Women exhibit substantially more vulnerability to heart failure in STEMI than men: a greater percentage of women have heart failure, and women with heart failure have higher 30-day mortality than men with heart failure. This finding was not seen in NSTE-ACS. heart failure on initial assessment is a key feature to explain the sex gap in mortality after ACS.

Funding Acknowledgement

Type of funding sources: None.

Statins for primary prevention among elderly men and women

Background

The debate about statins in primary prevention of cardiovascular (CV) disease is still alive, especially in old and very old adults.

Purpose

We undertook a propensity match-weighted cohort study to investigate whether statin treatment recommendations translate into improved cardiovascular (CV) outcomes in the current routine clinical care of the elderly.

Methods

We included in our analysis 5,619 people aged 65 years or older from the ISACS (International Survey of Acute Coronary Syndrome) Archives (NCT04008173) who presented to hospital with a first manifestation of CV disease. Participants were stratified as statin users versus nonusers and as old (65 to 75 years) versus very old (76 years or over) adults. We estimated the effects of statins on the most severe clinical manifestation of CV disease, namely ST segment elevation myocardial infarction (STEMI), using inverse probability of treatment weighting models. Estimates were compared by test of interaction on the log scale.

Results

The risk of STEMI was much lower in statin users than in nonusers in both patients aged 65 to 75 years (14.7% absolute risk reduction; relative risk [RR] ratio: 0.55, 95% CI 0.45 to 0.66) and those aged 76 years and older (13.3% absolute risk reduction; RR ratio: 0.58, 95% CI 0.46 to 0.72). Estimates were similar in patients with and without history of hypercholesterolemia (interaction test; p value= 0.2408). Proportional reductions in STEMI diminished with female sex in the old (p for interaction=0.002), but not in the very old age (p for interaction=0.26). We also observed a remarkable reduction in the risk of 30- day mortality from STEMI with statin therapy in both age groups (10.2% absolute risk reduction; RR ratio: 0.39; 95% CI 0.23 – 0.68 for patients aged 76 or over and 3.8% absolute risk reduction; RR ratio 0.37; 95% CI 0.17 – 0.82 for patients aged 65 to 75 years old; interaction test, p value=0.4570).

Conclusion

Preventive statin therapy in the elderly reduces the risk of STEMI with benefits in mortality from STEMI, irrespective of the presence of a history of hypercholesterolemia. This effect persists after the age of 76 years. Benefits are less pronounced in women.

Funding Acknowledgement

Type of funding sources: None.

Retrospective evaluation of the relationship between admission variables and brain herniation in dogs (2010-2019): 54 cases

OBJECTIVE

To document the admission systolic blood pressure (SBP), heart rate (HR), and modified Glasgow coma scale (MGCS) score in dogs with and without brain herniation and to determine their relationship with brain herniation.

DESIGN

Retrospective study between 2010 and 2019.

SETTING

University veterinary teaching hospital.

ANIMALS

Fifty-four client-owned dogs with brain herniation and 40 client-owned dogs as a control group, as determined on magnetic resonance imaging.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

SBP, HR, MGCS score, and outcome were extracted from medical records. MGCS score was retrospectively calculated based on initial neurological examination in dogs with adequate available information. Dogs with brain herniation had a significantly higher SBP (P = 0.0078), greater SBP-HR difference (P = 0.0006), and lower MGCS score (P < 0.0001) compared to control dogs. A cutoff value of an SBP ≥ 178 mm Hg, SBP-HR ≥ 60, and MGCS score ≤ 14 each provides a specificity of 90%-98%. A combination of an SBP > 140 mm Hg and HR < 80/min provided 24% sensitivity and 100% specificity to diagnose dogs with brain herniation (P < 0.0001).

CONCLUSIONS

A high SBP, a greater difference between SBP and HR, a combination of higher SBP and lower HR, and a low MGCS score were associated with brain herniation in dogs presenting with neurological signs upon admission. Early recognition of these abnormalities may help veterinarians to suspect brain herniation and determine timely treatment.

Intraindividual Comparison between the Contrast-Enhanced Golden-Angle Radial Sparse Parallel Sequence and the Conventional Fat-Suppressed Contrast-Enhanced T1-Weighted Spin-Echo Sequence for Head and Neck MRI

BACKGROUND AND PURPOSE

The golden-angle radial sparse parallel-volumetric interpolated breath-hold (GRASP-VIBE) sequence is a recently introduced imaging technique with high resolution. This study compared the image quality between conventional fat-suppressed T1-weighted TSE and GRASP-VIBE after gadolinium enhancement in the head and neck region.

MATERIALS AND METHODS

Data from 65 patients with clinical indications for head and neck MR imaging between September 2020 and January 2021 were retrospectively reviewed. Two radiologists assessed the overall image quality, overall artifacts, and image conspicuities in the oropharynx, hypopharynx, and cervical lymph nodes according to 5-point scores (best score: 5). Interobserver agreement was assessed using weighted κ statistics. The SNR and contrast-to-noise ratio were calculated and compared between the 2 sequences using a paired Wilcoxon signed rank test.

RESULTS

The analysis included 52 patients (mean age, 60 [SD, 14 ] years; male, 71.2% [37/52]) who were mostly diagnosed with head and neck malignancies (94.3% [50/52]). κ statistics ranged from slight agreement in cervical lymph node conspicuity (κ = 0.18) to substantial agreement in oropharyngeal mucosal conspicuity (κ = 0.80) (κ range, 0.18-0.80). Moreover, GRASP-VIBE demonstrated significantly higher mean scores in overall image quality (4.68 [SD, 0.41] versus 3.66 [SD, 0.73]), artifacts (4.47 [SD, 0.48] versus 3.58 [SD, 0.71]), oropharyngeal mucosal conspicuity (4.85 [SD, 0.41] versus 4.11 [SD, 0.79]), hypopharyngeal mucosal conspicuity (4.84 [SD, 0.34] versus 3.58 [SD, 0.81]), and cervical lymph node conspicuity (4.79 [SD, 0.32] versus 4.08 [SD, 0.64]) than fat-suppressed T1-weighted TSE (all, P < .001). Furthermore, GRASP-VIBE demonstrated a higher SNR (22.8 [SD, 11.5] versus 11.3 [SD, 5.6], P < .001) and contrast-to-noise ratio (4.7 [SD, 5.4] versus 2.3 [SD, 2.7], P = .059) than fat-suppressed T1-weighted TSE.

CONCLUSIONS

GRASP-VIBE provided better image quality with fewer artifacts than conventional fat-suppressed T1-weighted TSE for the head and neck regions.

Type B valvular and supravalvular pulmonic stenosis with aberrant pre-pulmonic right coronary artery diagnosed by non-electrocardiography-gated, multislice computed tomography in a Boston terrier

Pulmonic stenosis (PS) is a common congenital heart disease in dogs. It may be associated with an aberrant coronary artery (CA) in brachycephalic breeds. If present, a CA anomaly must be identified before pulmonic valvuloplasty. A 1.7-year-old Boston terrier was referred for a grade V/VI systolic heart murmur and exercise intolerance. Echocardiography revealed combined type B valvular and supravalvular PS; an aberrant CA was also suspected. Non-electrocardiography (ECG)-gated, 160-multislice computed tomographic angiography (CTA) confirmed severe right ventricular wall hypertrophy, a hypoplastic pulmonic valve annulus, and severe supravalvular PS with a marked main pulmonary artery bulge; a single left coronary ostium with an anomalous pre-pulmonic right CA was also identified. Surgical correction with pulmonic valvuloplasty and pulmonary artery patch angioplasty under cardiopulmonary bypass was planned. The patient died intraoperatively due to profound hypotension after weaning from extracorporeal circulation. However, this is the first case report in which type B valvular and supravalvular PS with an aberrant pre-pulmonic right CA was diagnosed by non-ECG-gated, 160-multislice CTA in a Boston terrier, showing a similar level of image quality to ECG-gated CTA. Thus, in PS cases, high-slice CTA may be helpful to determine if CA anomalies are present and to establish a therapeutic plan.

Edwardsiella tarda, a rare human pathogen isolated from a perihepatic abscess: Implications of transient versus long term colonization of the gastrointestinal tract

Although gastroenteritis is the most commonly described manifestation of Edwardsiella tarda infection, the pathogenesis and transient or long-term colonization of the gastrointestinal tract of this organism in human disease is not clear. We describe a rare manifestation of E. tarda infection in a perihepatic abscess in the setting of a patient with perforated cholecystitis and its successful eradication following antibiotic treatment.

Uncontrolled Confounders May Lead to False or Overvalued Radiomics Signature: A Proof of Concept Using Survival Analysis in a Multicenter Cohort of Kidney Cancer

Purpose

We aimed to explore potential confounders of prognostic radiomics signature predicting survival outcomes in clear cell renal cell carcinoma (ccRCC) patients and demonstrate how to control for them.

Materials and Methods

Preoperative contrast enhanced abdominal CT scan of ccRCC patients along with pathological grade/stage, gene mutation status, and survival outcomes were retrieved from The Cancer Imaging Archive (TCIA)/The Cancer Genome Atlas-Kidney Renal Clear Cell Carcinoma (TCGA-KIRC) database, a publicly available dataset. A semi-automatic segmentation method was applied to segment ccRCC tumors, and 1,160 radiomics features were extracted from each segmented tumor on the CT images. Non-parametric principal component decomposition (PCD) and unsupervised hierarchical clustering were applied to build the radiomics signature models. The factors confounding the radiomics signature were investigated and controlled sequentially. Kaplan-Meier curves and Cox regression analyses were performed to test the association between radiomics signatures and survival outcomes.

Results

183 patients of TCGA-KIRC cohort with available imaging, pathological, and clinical outcomes were included in this study. All 1,160 radiomics features were included in the first radiomics signature. Three additional radiomics signatures were then modelled in successive steps removing redundant radiomics features first, removing radiomics features biased by CT slice thickness second, and removing radiomics features dependent on tumor size third. The final radiomics signature model was the most parsimonious, unbiased by CT slice thickness, and independent of tumor size. This final radiomics signature stratified the cohort into radiomics phenotypes that are different by cancer-specific and recurrence-free survival; HR (95% CI) = 3.0 (1.5-5.7), p <0.05 and HR (95% CI) = 6.6 (3.1-14.1), p <0.05, respectively.

Conclusion

Radiomics signature can be confounded by multiple factors, including feature redundancy, image acquisition parameters like slice thickness, and tumor size. Attention to and proper control for these potential confounders are necessary for a reliable and clinically valuable radiomics signature.

Outcome and postoperative complications in 73 dogs with thyroid carcinoma with gross vascular invasion managed with thyroidectomy

Excellent outcomes have been reported following thyroidectomy for thyroid carcinoma in dogs, but outcomes for thyroid carcinomas with gross vascular invasion are poorly described. This study describes the clinical outcomes and complications in dogs with thyroid carcinomas with gross vascular invasion undergoing thyroidectomy. Medical records of dogs that underwent thyroidectomy between January 1st 2010 and December 31st 2019 were reviewed at 10 hospitals. Signalment, diagnostic data, primary and adjuvant treatments performed, and outcome were abstracted. Survival was calculated using Kaplan-Meier analysis. Multiple logistic regression was used to identify variables associated with disease-specific survival. Seventy-three dogs were included, of which 58 underwent unilateral thyroidectomy and 15 underwent bilateral thyroidectomy. Complications were reported in five dogs (three major, two minor; 6.8%) intraoperatively and 12 dogs (two major leading to death, 10 minor; 16.4%) postoperatively. Seven (9.6%) dogs developed locoregional recurrence at a median of 238 days postoperatively (range: 15-730 days). Distant metastasis was suspected or confirmed in nine dogs (12.3%) at a median of 375 days postoperatively (range: 50-890 days). Twenty-seven dogs (37%) received adjuvant therapy (chemotherapy: n = 21; radiotherapy: n = 6). Thirty-nine dogs were euthanized or died, with 20 deaths related to disease (n = 10) or of unknown cause (n = 10), 19 due to unrelated causes, and nine lost to follow-up. Median overall and disease-specific survival were 621 days and not reached respectively. One-year disease-specific survival rate was 82.5%. No variables were associated with disease-specific survival in our dataset. Surgery may be considered for loco-regional therapy in dogs with thyroid carcinoma with gross vascular invasion.

Ionotropic Receptor-dependent cool cells control the transition of temperature preference in Drosophila larvae

Temperature sensation guides animals to avoid temperature extremes and to seek their optimal temperatures. The larval stage of Drosophila development has a dramatic effect on temperature preference. While early-stage Drosophila larvae pursue a warm temperature, late-stage larvae seek a significantly lower temperature. Previous studies suggest that this transition depends on multiple rhodopsins at the late larval stage. Here, we show that early-stage larvae, in which dorsal organ cool cells (DOCCs) are functionally blocked, exhibit similar cool preference to that of wild type late-stage larvae. The molecular thermoreceptors in DOCCs are formed by three members of the Ionotropic Receptor (IR) family, IR21a, IR93a, and IR25a. Early-stage larvae of each Ir mutant pursue a cool temperature, similar to that of wild type late-stage larvae. At the late larval stage, DOCCs express decreased IR proteins and exhibit reduced cool responses. Importantly, late-stage larvae that overexpress IR21a, IR93a, and IR25a in DOCCs exhibit similar warm preference to that of wild type early-stage larvae. These data suggest that IR21a, IR93a, and IR25a in DOCCs navigate early-stage larvae to avoid cool temperatures and the reduction of these IR proteins in DOCCs results in animals remaining in cool regions during the late larval stage. Together with previous studies, we conclude that multiple temperature-sensing systems are regulated for the transition of temperature preference in fruit fly larvae.

Animals depend on their temperature-sensing systems to avoid noxious temperature extremes and to seek optimal temperatures to survive, mate, and reproduce. Some animals pursue different optimal temperatures during development. We use fruit flies as a model to investigate how temperature-sensing systems are modulated to guide animals to distinct optimal temperatures during development. While early-stage fruit fly larvae pursue a warm temperature, late-stage larvae seek a lower temperature. Previous studies find that this transition depends on multiple rhodopsin molecules. In this study, we find an additional mechanism that also contributes to this transition. At the early larval stage, a set of cool-sensing cells express a high level of cool responsive molecules, respond strongly to low temperatures, and drive animals to avoid cool regions. At the late larval stage, these cool-sensing cells become less sensitive to low temperatures due to the decreased expression of cool responsive molecules and, thus, animals remain in cool regions. Together with previous studies, we conclude that multiple temperature-sensing systems are regulated for the transition of temperature preference in fruit fly larvae.

Novel double beta-lactam therapy for Granulicatella adiacens infective endocarditis

Granulicatella adiacens, a nutritionally variant streptococci (NVS) is a well described organism associated with endocarditis. Previously communicated cases have documented the use of double beta-lactam therapy with ampicillin and ceftriaxone to treat patients with infective endocarditis due to Enterococcus faecalis and Streptocossus pneumoniae. We describe the first case of Granulicatella adiacens infective endocarditis in a patient successfully treated with the combination of intravenous ampicillin and ceftriaxone and document their synergistic activity.

Regulation of adipocyte differentiation by clusterin-mediated Krüppel-like factor 5 stabilization

Clusterin (CLU) is a heterodimeric glycoprotein involved in a range of biological processes. We investigated the function of CLU as a novel regulator of adipogenesis. CLU expression increased during 3T3-L1 preadipocyte differentiation. CLU overexpression promoted adipogenic differentiation of preadipocytes and increased the mRNA levels of adipogenic markers including peroxisome proliferator-activated receptor γ (Pparg) and CCAAT enhancer-binding protein α (Cebpa). Conversely, knockdown of CLU attenuated adipogenesis and reduced transcript levels of Pparg and Cebpa. However, the promoter activities of both the Pparg and the Cebpa gene were not affected by alteration of CLU expression on its own. Additionally, the protein level of Krüppel-like factor 5 (KLF5), an upstream transcription factor of Pparg and Cebpa involved in adipogenic differentiation, was upregulated by CLU overexpression, although the mRNA level of Klf5 was not altered by changes in the expression level of CLU. Cycloheximide chase assay showed that the increased level of KLF5 by CLU overexpression was due to decreased degradation of KLF5 protein. Interestingly, CLU increased the stability of KLF5 by decreasing KLF5 ubiquitination. CLU inhibited the interaction between KLF5 and F-box/WD repeat-containing protein 7, which is an E3 ubiquitin ligase that targets KLF5. The adipogenic role of CLU was also addressed in mesenchymal stem cells (MSCs) and Clu^-/- mouse embryonic fibroblasts (MEFs). Furthermore, CLU enhanced KLF5-mediated transcriptional activation of both the Cebpa and the Pparg promoter. Taken together, these results suggest that CLU is a novel regulator of adipocyte differentiation by modulating the protein stability of the adipogenic transcription factor KLF5.

A novel xeno-organoid approach: exploring the crosstalk between human iPSC-derived PGC-like and rat testicular cells

Specification of germ cell-like cells from induced pluripotent stem cells has become a clinically relevant tool for research. Research on initial embryonic processes is often limited by the access to foetal tissue, and in humans, the molecular events resulting in primordial germ cell (PGC) specification and sex determination remain to be elucidated. A deeper understanding of the underlying processes is crucial to describe pathomechanisms leading to impaired reproductive function. Several protocols have been established for the specification of human pluripotent stem cell towards early PGC-like cells (PGCLC), currently representing the best model to mimic early human germline developmental processes in vitro. Further sex determination towards the male lineage depends on somatic gonadal cells providing the necessary molecular cues. By establishing a culture system characterized by the re-organization of somatic cells from postnatal rat testes into cord-like structures and optimizing efficient PGCLC specification protocols, we facilitated the co-culture of human germ cell-like cells within a surrogate testicular microenvironment. Specified conditions allowed the survival of rat somatic testicular and human PGCLCs for 14 days. Human cells maintained the characteristic expression of octamer-binding transcription factor 4, SRY-box transcription factor 17, and transcription factor AP-2 gamma and were recovered from the xeno-organoids by cell sorting. This novel xeno-organoid approach will allow the in vitro exploration of early sex determination of human PGCLCs.

Anterior skull base olfactory tumours, which is what? A case report and review

Intracranial schwannomas not originating from cranial nerves are rare. In this paper, we report a case of a 50-year-old male who presented with worsening headaches, diplopia and nausea over two years. Radiological imaging revealed a large tumour arising from the olfactory groove region with a preoperative diagnosis of olfactory groove meningioma (OGM). Intraoperatively, the tumour originated from the region of the attachment of the falx to the crista galli. The patient recovered without complication and histopathology reported an unexpected diagnosis of WHO Grade 1 schwannoma. However, as olfactory groove schwannomas (OGSs) cannot be distinguished from olfactory ensheathing cell tumours (OECTs), it is possible that the tumour could have been either an OGS or an OECT. Distinguishing between OGSs, OECTs and OGMs preoperatively is difficult. OGMs exhibit distinct histopathological features from OGSs/OECTs, however, OGSs and OECTs currently cannot be distinguished from each other. Here, we review the literature to discuss the differentiating features and cellular origins of these three tumours.

Postoperative Chylothorax after Modified Radical Neck Dissection for Thyroid Carcinoma: A Missable Rare Complication of Thyroid Surgery

Background and objectives: Currently, few studies have been conducted on postoperative chylothorax, specifically in total thyroidectomy with modified radical neck dissection (MRND) in papillary thyroid carcinoma patients. This study provides the actual incidence, etiology, and clinical features of postoperative chylothorax and reports the clinical outcomes after treatment, which were dependent upon the severity of the complications. Materials and Methods: The medical charts of 111 papillary thyroid cancer (PTC) patients who underwent total thyroidectomy with modified radical neck dissection from January 2016 to December 2018 were reviewed retrospectively. The results were compared in three groups: the no chylothorax group, the subclinical (asymptomatic) group, and the clinical (symptomatic) group. Results: Chylothorax occurred in 23 patients (20.7%, 23/111). Nineteen (82.6%, 19/23) were subclinical chylothorax cases, which implies a small amount of chyle leakage with no respiratory symptoms. Four (17.4%, 4/23) were clinical, meaning they had either respiratory symptoms, such as dyspnea, desaturation, or a large amount of chylothorax in the images. The incidence was significantly higher in patients who underwent left modified radical neck dissection, and this corresponds to the side in which chylothorax occurred. There were also statistical differences in the drainage color, peak amount, or drain removal time. Conclusions: Postoperative chylothorax is a rare complication following neck dissection. However, it can be fatal if the condition progresses. Therefore, patients who undergo total thyroidectomy with modified radical neck dissection, especially on the left side, should be monitored for respiratory symptoms, and serial chest x-ray images obtained.

Inhibitory effect of alpha-lipoic acid on mitochondrial dysfunction and interleukin-8 expression in interleukin-1beta-stimulated ataxia teleangiectasia fibroblasts

Ataxia telangiectasia (A-T) is an inherited neurodegenerative disease caused by mutation in the ataxia telangiectasia mutated (ATM) gene, leading to loss of function in the encoded protein ATM. Because ATM functions to reduce oxidative stress by up-regulating antioxidant enzymes, oxidative stress is a prevalent A-T phenotype and a mediator of the inflammation that drives A-T pathology. Reactive oxygen species (ROS) levels and the expression of pro-inflammatory cytokine interleukin-8 (IL-8) were higher in A-T cells than in normal cells. ROS are related to mitochondrial dysfunction and activation of nuclear factor kappa B (NF-κB) to induce IL-8 expression. Alpha-lipoic acid (α-LA), a naturally occurring thiol compound, shows an antioxidant effect in various cells. This study is aimed to determine if α-LA confers protection against NF-κB activation, IL-8 expression, and mitochondrial dysfunction in A-T cells which are exposed to the inflammatory cytokine IL-1β. A-T fibroblasts were treated with or without α-LA. The levels of intracellular and mitochondrial ROS, mRNA and protein levels of IL-8, mitochondrial membrane potential (MMP), ATP levels, and DNA binding activity of NF-κB were determined. As a result, IL-1β increased NF-κB activation, IL-8 expression, intracellular and mitochondrial ROS levels, but decreased MMP and ATP level in A-T cells. Pretreatment of A-T cells with α-LA inhibited IL-1β-induced activation of NF-κB, IL-8 expression, and mitochondrial dysfunction by reducing ROS levels. In conclusion, supplementation with α-LA may be beneficial for reducing the oxidative stress-induced mitochondrial dysfunction and IL-8 production associated with A-T.

AB1121 IMPLEMENTING HIGH VALUE CARE IN INPATIENT ANTINUCLEAR ANTIBODY TESTING

Background:

Antinuclear Antibody (ANA) testing forms the basis on which many rheumatological diseases are subsequently diagnosed. ANA testing quantifies the dilution of plasma to produce the titer and staining pattern and this can be a part of an ANA order set that reflexively cascades to sub-serology if positive. Studies have shown that a low titer ANA may potentially translate into an erroneous diagnosis: if one estimates a 1 percent prevalence of ANA associated disease in the general population then 30% of those individuals would have a false positive result of ANA detected at 1:40 titer [1]. We theorized that there is no need for several methods to coexist within a single inpatient hospital setting especially since diagnostic value of staining patterns alone is limited.

Objectives:

To compare the utility and yield of “ANA screening reflex to profile” (ARP) and “ANA reflex to titer” (ART) order sets in the inpatient setting of a community tertiary care hospital. We aim to identify the appropriateness of the ANA testing ordered including cost-effectiveness of ordering ARP over ART in order to implement the identified quality measures towards improving utilization of ANA testing.

Methods:

We identified all inpatient ANA reflex testing orders performed at Community Regional Medical Center, Fresno, California completed between 11/2018 till 07/2019. This included ART and ARP orders with 6 sub-serologies: SSA, SSB, dsDNA, Smith, Scl-70 and U1RNP. A Health Information Management report was generated which included patient’s age, gender, length of hospital stay, dates of testing ordered, principal diagnosis and type of ANA testing ordered. Descriptive statistics were computed and analyzed.

Results:

We reviewed a total of 1,012 ANA lab orders performed between 11/01/2018 until 07/30/2019 performed on 700 patients. According to the laboratory standard using Immunofluorescence Assay, an ANA titer starting from 1:40 is reported as positive. Out of the 1,012 tests, 334 tests were positive i.e. 33%. The ART order by itself contributed to 29.9% of the positive testing while ARP formed 70% of the positive testing. 56 of the 910 ARP (6%) performed had one or more sub-serology antibody positive while in 178 ARP orders (20%) only the ANA titer was positive with negative serology. The most common sub-serology antibody noted positive was dsDNA forming 54% of the positive serology results. Multiple testing was noted with 218 orders of ARP and ART being ordered on the same patient within the same week, which shows 21.5% of ANA lab orders were repetitive. Length of stay was noted to be more than 3 days for 89% of the patients who had repetitive testing, majority of those tests (99%) on the same day by the same medical provider. It cost $5.0 for an ART order that resulted negative and $5.0 for an ARP panel that resulted negative. It cost $10.0 for those patients who had both ART and ARP ordered with negative results. A positive ART result added $12.0 additional to the cost of each positive ANA profile ($67.36) when both tests were ordered together.

Conclusion:

Our study findings reflect the need for using higher yield ANA testing that has been standardized. It demonstrated that physicians ordering the testing were not familiar with the ART vs. ARP, and the laboratory orders needed to be re-structured. We removed the ART from the inpatient Electronic Medical Record i.e. Epic system so that only the ARP order remained. This would prevent repetitive testing and reduce healthcare costs through reduction by at least $12.0 per positive ANA result and may also translate into reduced length of hospital stay. We were able to add Centromere Antibody (Ab) to the ANA profile sub serologies to standardize it further as it is an important part of Scleroderma diagnosis.

References:

[1]Range of antinuclear antibodies in “healthy” individuals. AU, Tan EM, et al. Arthritis Rheum. 1997; 40(9):1601

Disclosure of Interests:

None declared

Vision-based tracking system for augmented reality to localize recurrent laryngeal nerve during robotic thyroid surgery

We adopted a vision-based tracking system for augmented reality (AR), and evaluated whether it helped surgeons to localize the recurrent laryngeal nerve (RLN) during robotic thyroid surgery. We constructed an AR image of the trachea, common carotid artery, and RLN using CT images. During surgery, an AR image of the trachea and common carotid artery were overlaid on the physical structures after they were exposed. The vision-based tracking system was activated so that the AR image of the RLN followed the camera movement. After identifying the RLN, the distance between the AR image of the RLN and the actual RLN was measured. Eleven RLNs (9 right, 4 left) were tested. The mean distance between the RLN AR image and the actual RLN was 1.9 ± 1.5 mm (range 0.5 to 3.7). RLN localization using AR and vision-based tracking system was successfully applied during robotic thyroidectomy. There were no cases of RLN palsy. This technique may allow surgeons to identify hidden anatomical structures during robotic surgery.

P6419Machine learning in critical care: the role of diabetes and age in acute coronary syndromes

Background

Patients with diabetes and non-ST elevation acute coronary syndrome (NSTE-ACS) have an increased risk of mortality and adverse outcomes following percutaneous coronary intervention (PCI).

Purpose

We aimed to investigate the impact of early, within 24 hours PCI compared with only routine medical treatment on clinical outcomes in a large international cohort of patients with NSTE-ACS and diabetes.

Methods

We identified 1,250 patients with diabetes and NSTE-ACS from a registry-based population between October 2010 and April 2016. The primary endpoint was 30-day all-cause mortality. The secondary endpoint was the composite outcome of 30-day all-cause mortality and left ventricular dysfunction (ejection fraction <40%). We undertook analyses to explore the heterogeneity of treatment effects using meta-classification (MC) algorithms followed by propensity score matching and inverse-probability-of-treatment weighting (IPTW) from a landmark of 24 hours from hospitalization.

Results

Of 1,250 NSTE-ACS first-day survivors with diabetes (median age 67 years; 59%, men), 470 (37.6%) received early PCI and 780 routine medical treatment. The overall 30-day all-cause mortality rates were higher in the routine medical treatment than the early PCI group (6.3% vs. 2.5%). The prediction results of the MC algorithms accounted for only one interaction term that was statistically significant: age ≥65 years. After propensity-matched analysis as well as IPTW, early PCI was associated with reduced 30-day all-cause mortality in the older age (OR: 0.35; 95% CI: 0.14 to 0.92 and 0.43; 95% CI: 0.21 to 0.86, respectively), whereas younger age had no association with the primary endpoint. Similar results were also obtained for the secondary endpoint.

Conclusions

Among patients with diabetes hospitalized for NSTE-ACS, an early, within 24 hours, PCI strategy is associated with reduced odds of 30-day mortality only for patients aged 65 years or over. MC algorithms provide accurate identification of treatment effect modifiers.