Barriers and facilitators to implementing a multilevel, multicomponent intervention promoting colorectal cancer screening in health centers: a qualitative study of key informant perspectives

BACKGROUND

Colorectal cancer (CRC) continues to be a major cause of death in the U.S. despite the availability of effective screening tools. U.S. Latinos have lower rates of CRC screening and higher rates of death due to colorectal disease compared to non-Hispanic whites. Federally Qualified Health Centers (FQHCs) serve medically underserved populations, including many Latino patients. Given the low CRC screening rates, identifying culturally sensitive and cost-effective methods of promoting screening is a priority for many FQHCs.

METHODS

We interviewed FQHC leaders and providers using the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to implementation of a multilevel, multicomponent (ML-MC) CRC screening intervention (i.e., promotor navigation and group-based education) in FQHCs. A rapid qualitative analysis approach was used to identify themes organized according to the following CFIR constructs: intervention characteristics, outer and inner settings, and characteristics of the individual.

RESULTS

We completed interviews with 13 healthcare professionals in leadership positions at six FQHCs. The participating FQHCs perceived the ML-MC screening CRC program as feasible and expressed interest in implementing the program at their sites. Facilitators included financial incentives for increasing screening rates, the need for patient education programming, and involving promotores to support the work of clinical teams. Barriers included concerns about available resources to implement new programs, lack of federal reimbursement for health education, competing priorities of other health concerns, and the need for more resources for confirmatory screening and treatment following a positive screen.

CONCLUSIONS

FQHCs provide essential primary care to millions of underserved patients in the U.S. and have the ability and motivation to provide screenings for colorectal cancer. Partnering with an academic institution to deliver a group-based, promotor-led CRC screening intervention for patients not up to date with screening could help increase screening rates. By identifying the specific barriers and facilitators to implementing CRC intervention, findings suggest that group-based, promotor-led interventions are a promising approach.

From GWAS to functional variants: ARL14 cis-regulatory variants are associated with severe malaria

BACKGROUND

GWAS have identified several non-functional tagSNPs associated with severe malaria. We hypothesized that causal SNPs could play a significant role in severe malaria by altering promoter or enhancer activity. Here, we sought to identify such regulatory SNPs.

METHODS

SNPs in linkage disequilibrium with tagSNPs associated with severe malaria were identified and were further annotated using FUMA. Then, SNPs were prioritized using IW-scoring method to identify regulatory ones. Gene reporter assays were performed to assess the regulatory effect of a region containing candidates. The association between SNPs and severe malaria was assessed using logistic regression models in a Senegalese cohort.

RESULTS

Among 418 SNPs, the best candidates were rs116525449 and rs79644959, which were in full disequilibrium between them, and located within the ARL14 promoter. Our gene reporter assay results revealed that the region containing the SNPs exhibited cell-specific promoter or enhancer activity, while the SNPs influenced promoter activity. We detected an association between severe malaria and those two SNPs using the overdominance model and we replicated the association of severe malaria with the tagSNP rs116423146.

CONCLUSIONS

We suggest that these SNPs regulate ARL14 expression in immune cells and the presentation of antigens to T lymphocytes, thus influencing severe malaria development.

A Non-Coding Fc Gamma Receptor Cis-Regulatory Variant within the 1q23 Gene Cluster Is Associated with Plasmodium falciparum Infection in Children Residing in Burkina Faso

Antibodies play a crucial role in activating protective immunity against malaria by interacting with Fc-gamma receptors (FcγRs). Genetic variations in genes encoding FcγRs can affect immune cell responses to the parasite. In this study, our aim was to investigate whether non-coding variants that regulate FcγR expression could influence the prevalence of Plasmodium falciparum infection. Through bioinformatics approaches, we selected expression quantitative trait loci (eQTL) for FCGR2A, FCGR2B, FCGR2C, FCGR3A, and FCGR3B genes encoding FcγRs (FCGR), in whole blood. We prioritized two regulatory variants, rs2099684 and rs1771575, located in open genomic regions. These variants were identified using RegVar, ImmuNexUT, and transcription factor annotations specific to immune cells. In addition to these, we genotyped the coding variants FCGR2A/rs1801274 and FCGR2B/rs1050501 in 234 individuals from a malaria-endemic area in Burkina Faso. We conducted age and family-based analyses to evaluate associations with the prevalence of malarial infection in both children and adults. The analysis revealed that the regulatory rs1771575-CC genotype was predicted to influence FCGR2B/FCGR2C/FCGR3A transcripts in immune cells and was the sole variant associated with a higher prevalence of malarial infection in children. In conclusion, this study identifies the rs1771575 cis-regulatory variant affecting several FcγRs in myeloid and neutrophil cells and associates it with the inter-individual capacity of children living in Burkina Faso to control malarial infection.

Short tandem repeats are important contributors to silencer elements in T cells

The action of cis-regulatory elements with either activation or repression functions underpins the precise regulation of gene expression during normal development and cell differentiation. Gene activation by the combined activities of promoters and distal enhancers has been extensively studied in normal and pathological contexts. In sharp contrast, gene repression by cis-acting silencers, defined as genetic elements that negatively regulate gene transcription in a position-independent fashion, is less well understood. Here, we repurpose the STARR-seq approach as a novel high-throughput reporter strategy to quantitatively assess silencer activity in mammals. We assessed silencer activity from DNase hypersensitive I sites in a mouse T cell line. Identified silencers were associated with either repressive or active chromatin marks and enriched for binding motifs of known transcriptional repressors. CRISPR-mediated genomic deletions validated the repressive function of distinct silencers involved in the repression of non-T cell genes and genes regulated during T cell differentiation. Finally, we unravel an association of silencer activity with short tandem repeats, highlighting the role of repetitive elements in silencer activity. Our results provide a general strategy for genome-wide identification and characterization of silencer elements.

Gene expression profiling of peripheral blood mononuclear cells from women with cervical lesions reveals new markers of cancer

Cervical cancer (CC) is a multifactorial disease of which human papillomavirus (HPV) is the main etiological agent. Despite cervical Pap smear screening and anti‑HPV vaccination, CC remains a major public health issue. Identification of specific gene expression signatures in the blood could allow better insight into the immune response of CC and could provide valuable information for the development of novel biomarkers. The present study performed a transcriptomic analysis of peripheral blood mononuclear cells (PBMCs) from Senegalese patients with CC (n=31), low‑grade cervical intraepithelial neoplasia (CIN1; n=27) and from healthy control (CTR) subjects (n=29). Individuals in the CIN1 and CTR groups exhibited similar patterns in gene expression. A total of 182 genes were revealed to be differentially expressed in patients with CC compared with individuals in the CIN1 and CTR groups. The IL1R2, IL18R1, MMP9 and FKBP5 genes were the most upregulated, whereas the T‑cell receptor α gene TRA was the most downregulated in the CC group compared with in the CIN1 and CTR groups. The pathway enrichment analysis of the differentially expressed genes revealed pathways directly and indirectly linked to inflammation. To the best of our knowledge, the present study is the first large transcriptomic study on CC performed using PBMCs from African women; the results revealed the involvement of genes and pathways related to inflammation, most notably the IL‑1 pathway, and the involvement of downregulation of the T‑cell receptor α, a key component of the immune response. Several of the stated genes have already been reported in other cancer studies as putative blood biomarkers, thus reinforcing the requirement for deeper investigation. These findings may aid in the development of innovative clinical biomarkers for CC prevention and should be further replicated in other populations.

Post-acute phase and sequelae management of epidermal necrolysis: an international, multidisciplinary DELPHI-based consensus

BACKGROUND

Long-term sequelae are frequent and often disabling after epidermal necrolysis (Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)). However, consensus on the modalities of management of these sequelae is lacking.

OBJECTIVES

We conducted an international multicentric DELPHI exercise to establish a multidisciplinary expert consensus to standardize recommendations regarding management of SJS/TEN sequelae.

METHODS

Participants were sent a survey via the online tool "Survey Monkey" consisting of 54 statements organized into 8 topics: general recommendations, professionals involved, skin, oral mucosa and teeth, eyes, genital area, mental health, and allergy workup. Participants evaluated the level of appropriateness of each statement on a scale of 1 (extremely inappropriate) to 9 (extremely appropriate). Results were analyzed according to the RAND/UCLA Appropriateness Method.

RESULTS

Fifty-two healthcare professionals participated. After the first round, a consensus was obtained for 100% of 54 initially proposed statements (disagreement index < 1). Among them, 50 statements were agreed upon as 'appropriate'; four statements were considered 'uncertain', and ultimately finally discarded.

CONCLUSIONS

Our DELPHI-based expert consensus should help guide physicians in conducting a prolonged multidisciplinary follow-up of sequelae in SJS-TEN.

Marine debris and associated organic pollutants in surface waters of Chiloé in the Northern Chilean Patagonia (42°-44°S)

We report the occurrence of plastics and associated persistent organic pollutants (POPs) in surface waters from Northern Chilean Patagonia. A total of 200 particles were found during the conducted survey. The highest number of particles found was 0.6 item m^-3. We found that 53 % of the collected particles corresponded to plastic, with an average of 0.19 ± 0.18 item m^-3. Microplastics (68 %) were the dominant size found in the area, followed by macroplastics (18 %) and mesoplastics (14 %). Most plastic particles were white (55 %) while others were <10 % each. Black and light blue represented 9 %; red, dark blue, and other colors 7 %; and green 6 %. Fragments were the most frequent shape of plastic debris (38 %), followed by Styrofoam (30 %) and fiber (27 %). Higher PBDE levels were found in the central zone, and those were higher than DDT, PeCB, HCB, and PCB levels. This study is the first report on POP occurrence in marine plastic debris from Chiloé Sea in the Northern Chilean Patagonia.

Genetic architecture of natural variation of cardiac performance from flies to humans

Deciphering the genetic architecture of human cardiac disorders is of fundamental importance but their underlying complexity is a major hurdle. We investigated the natural variation of cardiac performance in the sequenced inbred lines of the Drosophila Genetic Reference Panel (DGRP). Genome-wide associations studies (GWAS) identified genetic networks associated with natural variation of cardiac traits which were used to gain insights as to the molecular and cellular processes affected. Non-coding variants that we identified were used to map potential regulatory non-coding regions, which in turn were employed to predict transcription factors (TFs) binding sites. Cognate TFs, many of which themselves bear polymorphisms associated with variations of cardiac performance, were also validated by heart-specific knockdown. Additionally, we showed that the natural variations associated with variability in cardiac performance affect a set of genes overlapping those associated with average traits but through different variants in the same genes. Furthermore, we showed that phenotypic variability was also associated with natural variation of gene regulatory networks. More importantly, we documented correlations between genes associated with cardiac phenotypes in both flies and humans, which supports a conserved genetic architecture regulating adult cardiac function from arthropods to mammals. Specifically, roles for PAX9 and EGR2 in the regulation of the cardiac rhythm were established in both models, illustrating that the characteristics of natural variations in cardiac function identified in Drosophila can accelerate discovery in humans.

Integrated health and social care evaluation framework for mental health and drug addiction care

Background

Guiding the decision-making process in mental health investments is advisable. The objective of the study is to develop a framework for evaluating the quality of integrated health and social care in Mental Health and Drug Addiction (MH&DA)

Methods

A literature review helped to establish a definition of integrated care specific to MH&DA and to identify potential indicators for its evaluation. The quality of integrated care was assessed through focus groups (FGs) and interviews (INs) with three different profiles: professionals (2FGs & 2 INs), patients (3 FGs & 2 INs) and families/carers (2FGs & 2 INs). Additional indicators were also obtained from them.

Results

Out of 2,226 publications identified, 87 (4%) were reviewed in full. According to the literature, integrated care in MH&DA is based on four main components: case management, comprehensive assessment, individualised care plan and care coordination among different providers. Based on these components, an operational definition of integrated care was developed and validated in the FGs and INs. Positive aspects identified were a respectful approach and positive experiences of coordination between social and community network. Regarding indicators about 400 were identified, after screening were reduced to 60: 25% corresponded to accessibility, 20% person-centred care, 16% each to care coordination and to effectiveness. In general, the main threats to the quality of care, identified in FGs and INs, matched the dimensions with the highest proportion of indicators (i.e., limited care resources, poor coordination and communication among professionals and services, and barriers in accessing specialized treatment).

Conclusions

According to literature, integrated care in MH&DA seems to be mainly evaluated in terms of accessibility and person-centred care. In a following phase, a large group of experts will be key to select the most relevant dimensions and indicators for the evaluation in a Delphi study.

Key messages

Combined cardiopulmonary test and exercise Doppler echocardiography in systemic sclerosis

Background

Cardiopulmonary exercise test (CPET) and exercise Doppler echocardiography (EDE) may be useful for the early detection of pulmonary hypertension in systemic sclerosis (SSc)

Aim

To assess the feasibility of CPET and EDE in detecting early changes in gas exchange and/or pulmonary hemodynamics in SSc

Methods

From 2016 to 2021, we evaluated 19 SSc patients (Group 1, age = 52.58±11.27, women 17 (89.5%)), and age 32.10±6.67, men 17 (89.4%) matched healthy controls (Group 2). Simultaneous CPET and EDE were performed. With CPET, we assessed peak oxygen uptake (VO2), peak respiratory quotient (RQ), respiratory equivalent ratio for carbonic gas (VE/VCO2), and maximal respiratory equivalent divided by maximal ventilatory ventilation (V̇E Max/VVM). With EDE, we assessed tricuspid regurgitant velocity (TRV) jet and pulmonary flow acceleration time (ACT) to derive systolic pulmonary arterial pressure (SPAP).

Results

Exercise duration was similar in the 2 groups (Group 1 = 9.2±2.93 vs Group 2 = 10.14±1.78 minutes). Among CPET parameters, SSc patients showed lower peak VO2 (Group 1 = 1.23±0.55 vs Group 2 = 2.45±0.7, p&lt;0.001), similar RQ (1.10±0.10 vs 1.17±0.09;. p=0.036), VE/VCO2 (Group 1 = 31.90±3.65 vs Group 2 = 23.79±2.64, p&lt;0.001) and V̇E Max/VVM (Group 1 = 1.93±0.60 vs Group 2 = 1.76±0.36, p=NS). With EDE, feasibility at peak stress was low for TRV (Group 1 = 42% vs Group 2 = 58%, p=NS), moderate for ACT (Group 1 = 53% vs Group 2 = 78%, p=NS) and high when at least one was technically adequate (Group 1 = 73% vs Group 2 = 100%, p&lt;0.001). Rest TRV (Group 1 = 2.48±0.14 vs Group 2 = 2.08±0.12 m/s, p=0.033) and ACT (Group 1 = 100.14±10.63 vs Group 2 = 108.86±6.38 ms, p=0.482) showed similar values in the 2 groups (será que ficou similar?). During stress, TRV increased more markedly in SSc (Group 1 = 3.33±0.32 vs Group 2 = 2.34±0.09 m/s, p=0.004) and ACT decreased (Group 1 = 81.9±6.54 vs 73.39±5.18 ms, p=0.304), with estimated peak SPAP higher in SSc (Group 1 = 53.34±7.88 vs Group 2 = 43.33±5.49, p&lt;0.001): see figure.

Conclusion

CPET and EDE offer complementary information on gas exchange and pulmonary hemodynamics in SSc and can detect early alterations missed by resting assessment. The success rate of EDE increases significantly with the combination of TRV and ACT.

Funding Acknowledgement

Type of funding sources: None.

Prediction of Treatment Response in Patients with Major Depressive Disorder: A Meta-Analysis of Functional Magnetic Resonance Imaging Studies

Introduction

Identifying the optimal treatment for individuals with major depressive disorder (MDD) is often a long and complicated process. Functional magnetic resonance imaging (fMRI) studies have been used to help predict and explain differences in treatment response among individuals with MDD.

Objectives

We conducted a comprehensive meta-analysis of treatment prediction studies utilizing fMRI in patients with MDD to provide evidence that neural activity can be used to predict response to antidepressant treatment.

Methods

A multi-level kernel density analysis was applied to these primary fMRI studies, in which we analyzed brain activation patterns of depressed patients (N= 364) before receiving antidepressant treatment.

Results

The results of this analysis demonstrated that hyperactivity in six brain regions significantly predicted treatment response in patients with MDD: the right anterior cingulate, right cuneus, left fusiform gyrus, left middle frontal gyrus, right cingulate gyrus, and left superior frontal gyrus.

Conclusions

This study provides evidence that neural activity, as measured by standard fMRI paradigms, can be used to successfully predict response to antidepressant treatment. This may be used in the future clinically to improve decision-making processes and treatment outcomes for patients.

Disclosure

No significant relationships.

Transcriptional Response in a Sepsis Mouse Model Reflects Transcriptional Response in Sepsis Patients

Mortality due to sepsis remains unacceptably high, especially for septic shock patients. Murine models have been used to better understand pathophysiology mechanisms. However, the mouse model is still under debate. Herein we investigated the transcriptional response of mice injected with lipopolysaccharide (LPS) and compared it to either human cells stimulated in vitro with LPS or to the blood cells of septic patients. We identified a molecular signature composed of 2331 genes with an FDR median of 0%. This molecular signature is highly enriched in regulated genes in peritoneal macrophages stimulated with LPS. There is significant enrichment in several inflammatory signaling pathways, and in disease terms, such as pneumonia, sepsis, systemic inflammatory response syndrome, severe sepsis, an inflammatory disorder, immune suppression, and septic shock. A significant overlap between the genes upregulated in mouse and human cells stimulated with LPS has been demonstrated. Finally, genes upregulated in mouse cells stimulated with LPS are enriched in genes upregulated in human cells stimulated in vitro and in septic patients, who are at high risk of death. Our results support the hypothesis of common molecular and cellular mechanisms between mouse and human sepsis.

Co-Exposure of Cardiomyocytes to IFN-γ and TNF-α Induces Mitochondrial Dysfunction and Nitro-Oxidative Stress: Implications for the Pathogenesis of Chronic Chagas Disease Cardiomyopathy

Infection by the protozoan Trypanosoma cruzi causes Chagas disease cardiomyopathy (CCC) and can lead to arrhythmia, heart failure and death. Chagas disease affects 8 million people worldwide, and chronic production of the cytokines IFN-γ and TNF-α by T cells together with mitochondrial dysfunction are important players for the poor prognosis of the disease. Mitochondria occupy 40% of the cardiomyocytes volume and produce 95% of cellular ATP that sustain the life-long cycles of heart contraction. As IFN-γ and TNF-α have been described to affect mitochondrial function, we hypothesized that IFN-γ and TNF-α are involved in the myocardial mitochondrial dysfunction observed in CCC patients. In this study, we quantified markers of mitochondrial dysfunction and nitro-oxidative stress in CCC heart tissue and in IFN-γ/TNF-α-stimulated AC-16 human cardiomyocytes. We found that CCC myocardium displayed increased levels of nitro-oxidative stress and reduced mitochondrial DNA as compared with myocardial tissue from patients with dilated cardiomyopathy (DCM). IFN-γ/TNF-α treatment of AC-16 cardiomyocytes induced increased nitro-oxidative stress and decreased the mitochondrial membrane potential (ΔΨm). We found that the STAT1/NF-κB/NOS2 axis is involved in the IFN-γ/TNF-α-induced decrease of ΔΨm in AC-16 cardiomyocytes. Furthermore, treatment with mitochondria-sparing agonists of AMPK, NRF2 and SIRT1 rescues ΔΨm in IFN-γ/TNF-α-stimulated cells. Proteomic and gene expression analyses revealed that IFN-γ/TNF-α-treated cells corroborate mitochondrial dysfunction, transmembrane potential of mitochondria, altered fatty acid metabolism and cardiac necrosis/cell death. Functional assays conducted on Seahorse respirometer showed that cytokine-stimulated cells display decreased glycolytic and mitochondrial ATP production, dependency of fatty acid oxidation as well as increased proton leak and non-mitochondrial oxygen consumption. Together, our results suggest that IFN-γ and TNF-α cause direct damage to cardiomyocytes’ mitochondria by promoting oxidative and nitrosative stress and impairing energy production pathways. We hypothesize that treatment with agonists of AMPK, NRF2 and SIRT1 might be an approach to ameliorate the progression of Chagas disease cardiomyopathy.

Liver transplant with controlled donors after circulatory death with normothermic regional perfusion and brain dead donors: A multicenter cohort study of transfusion, one-year graft survival and mortality

BACKGROUND

Controlled donation after circulatory death (cDCD) has expanded the donor pool for liver transplantation (LT). However, transfusion requirements and perioperative outcomes should be elucidated. The aim of this multicenter study was to assess red blood cell (RBC) transfusions, one-year graft and patient survival after LT after cDCD with normothermic regional perfusion (NRP) compared with donors after brain death (DBD).

METHODS

591 LT carried out in ten centers during 2019 were reviewed. Thromboelastometry was used to manage coagulation and blood product transfusion in all centers. Normothermic regional perfusion was the standard technique for organ recovery.

RESULTS

447 patients received DBD and 144 cDCD with NRP. Baseline MCF Extem was lower in the cDCD group There were no differences in the percentage of patients (63% vs. 61% p = 0.69), nor in the number of RBC units transfused (4.7 (0.2) vs 5.5 (0.4) in DBD vs cDCD, p = 0.11. Twenty-six patients (6%) died during admission for LT in the DBD group compared with 3 patients (2%) in the cDCD group (p = 0.15). To overcome the bias due to a worse coagulation profile in cDCD recipients, matched samples were compared. No differences in baseline laboratory data, or in intraoperative use of RBC or one-year outcome data were observed between DBD and cDCD recipients.

CONCLUSIONS

cDCD with NRP is not associated with increased RBC transfusion. No differences in graft and patient survival between cDCD and DBD were found. Donors after controlled circulatory death with NRP can increasingly be utilized with safety, improving the imbalance between organ donors and the ever-growing demand.

Quantifying the burden of premature mortality at national level in France in 2016

Background

Efforts to accurately measure premature mortality are important to monitor the impact of diseases and injuries on population health and to set policy priorities. This is an ongoing study with a strong collaboration between Santé Publique France and the French National Health Insurance, whose main objective is to provide the first national estimates of Years of Life Lost (YLLs) for all causes of death in France.

Methods

The French national health data system (SNDS) contains detailed nationwide causes of death data, reported using ICD-10 codes. We used the underlying cause, as defined by the Center for Epidemiology on Medical Causes of deaths, of all deaths for year 2016 (the last year available). For this preliminary study without redistribution of ill-defined deaths (IDDs), national sex-specific life expectancy tables were used to estimate YLLs by age class, sex, and cause of death categories at national level. We identified and quantified IDDs and also compared YLLs to crude mortality.

Results

In 2016, we estimated approximately 7.3 million YLLs (586,519 registered deaths), of which 35.1% were due to neoplasms, 17.8% to cardiovascular diseases (respectively 34.5% and 17.3% in men; 35.8% and 18.4% in women) and 10.3% to injuries (4.9% among people aged 65 or more at time of death; 34.5% among people aged 25-44). Approximately 27% of the deaths registered were IDDs, representing approximately 1.8 million YLLs.

Conclusions

These preliminary results confirm the importance of YLLs as a metric to target preventive strategies according to age. Moreover, by quantifying IDDs, we highlight that data gaps are important even in settings with highly developed health information systems. Next steps include applying an IDD redistribution methodology, aspirational life table and computing subnational YLLs. The French collaborative initiative should address those gaps and propose national and subnational burden metrics in the following months.

Key messages

Methodological and data requirements to compute YLLs constitute a challenge even in settings with developed health information systems, highlighting the need of national institutional collaborations. Highlight data gaps in terms of ill-defined deaths in mortality database.

Blunted heart rate reserve with dobutamine stress echocardiography predicts outcome in diabetes and/or chronic kidney disease

Background

A blunted heart rate reserve (HRR) during dobutamine stress echo (DSE) is an index of the altered cardiac sympathetic reserve, which is frequently present in diabetes mellitus (DM) or chronic kidney disease (CKD).

Aim

To assess the prognostic value of HRR during DSE.

Methods

We recruited 280 patients (mean age 62.9±13.1 years; 128 (45.7%) male; 28.2% on beta-blockers at the time of testing) who underwent DSE for known or suspected coronary artery disease and/or heart failure and were followed-up. Four subsets were identified: Group 1 (111 pts without DM or CKD); group 2 (37 with DM without CKD); group 3 (90 with CKD with or without DM); and group 4 (42 with CKD on dialysis). HRR was calculated by EKG as the peak/rest HR ratio.

Results

Ischemia was identified in 34/280 (12.1%) pts. During a median follow-up time of 40.3±30.5 months, 120 events occurred: 46 deaths, 15 non-fatal myocardial infarctions, 23 hospital admissions for acute decompensated heart failure, and 36 myocardial revascularizations. Multivariable comparison of HRR among the 4 groups using post hoc test showed a blunted HRR in group 3 (1.66±0.32) and 4 (1.65±0.27) when compared with group 1 (HRR 1.85±0.35), p&lt;0.01. Group 2 (1.73±0.28) was not different from any group (p=ns). Groups 3 and 4 were not different between them (p=ns). A post hoc Tukey test for HRR separated in tercils, 1st: HRR &lt;1.59, 2nd: 1.59 &lt; HRR &lt;1.86 and 3rd: HRR &gt;1.86 (p&lt;0.000). Kaplan-Meier curves showed blunted HRR as an independent predictor of event-free survival in the overall group - 1st: 66.08±5.9 months, 95% CI 54.3–77.7; 2nd: 69.52±6.5, 95% CI 56.6–82.3; 3rd: 90.05±5.3, 95% CI 79.5–100.5. See Figure. HRR was comparable in patients with and without inducible ischemia and off or on beta-blockers.

Conclusion

A blunted HRR during DSE is frequent in patients with DM and CKD, independent of inducible ischemia and use of beta-blockers, and is a useful non-imaging predictor of adverse events.

Funding Acknowledgement

Type of funding sources: None.

Experience with the use of siltuximab in patients with SARS-CoV-2 infection

OBJECTIVE

The study aims to describe characteristics and clinical outcome of patients with SARS-CoV-2 infection that received siltuximab according to a protocol that aimed to early block the activity of IL-6 to avoid the progression of the inflammatory flare.

METHODS

Retrospective review of the first 31 patients with SARS-CoV-2 treated with siltuximab, in Hospital Clinic of Barcelona or Hospital Universitario Salamanca, from March to April 2020 with positive polymerase-chain reaction (PCR) from a nasopharyngeal swab.

RESULTS

The cohort included 31 cases that received siltuximab with a median (IQR) age of 62 (56-71) and 71% were males. The most frequent comorbidity was hypertension (48%). The median dose of siltuximab was 800 mg ranging between 785 and 900 mg. 7 patients received siltuximab as a salvage therapy after one dose of tocilizumab. At the end of the study, a total of 26 (83.9) patients had been discharged alive and the mortality rate was 16.1% but only 1 out of 24 that received siltuximab as a first line option (4%).

CONCLUSIONS

Siltuximab is a well-tolerated alternative to tocilizumab when administered as a first line option in patients with COVID-19 pneumonia within the first 10 days from symptoms onset and high C-reactive protein.

Frequency of outpatient care adverse events in an occupational mutual insurance company in Spain

BACKGROUND

Occupational mutual insurance companies (OMICs), in collaboration with the Spanish Social Security System, provide healthcare and manage the economic benefits for the workers in Spain. They have ambulatory care centers that attend outpatient trauma pathology, although most of the studies published have focused on surgical and hospital activity. The aim of this study was to detect adverse events (AEs) in outpatient trauma care in the context of an OMIC.

METHODS

A cohort study designed to identify harmful safety incidents (adverse events, AEs) in 2017 was conducted. A random sample of 313 medical records among patients who were visited more than 3 medical and nursing attendances during their outpatient process. The AEs detected were classified according to category, severity and preventability.

RESULTS

We identified 48 AEs (15.3% of medical records, 95% CI 11.3-19.3), most of them procedure-related, while 27 (56.2%) were preventable and 46 mild (95.8%).

CONCLUSIONS

The AEs identified are double than those found in primary care general consultations in Spain and are close to the lower range of studies on surgical AEs in traumatology and orthopedics. Preventable AEs were within expected limits. Over half of AEs are preventable, within that group, the mild AEs have an increased rate of preventability. These results highlight the relevance of research of patient safety in the outpatient care of trauma and orthopaedic procedures in an OMIC for patient safety and contribute to introduce improvements in outpatient care.

Tuberculosis infection in HIV vs. non-HIV patients

OBJECTIVES

Tuberculosis (TB) is the most common opportunistic infection and cause of mortality among people living with HIV, and it is possible that it may also influence the evolution of the HIV infection. We assessed the differences between HIV-positive and -negative people infected with TB.

METHODS

The present study is a cross-sectional retrospective study by electronic record revision. We included patients admitted to a tertiary hospital with a diagnosis of TB between 2011 and 2016, comparing those with HIV coinfection with non-HIV patients, according to demographic and clinical characteristics.

RESULTS

This study included 591 patients, of whom 32% were HIV-coinfected. HIV-TB patients were younger, with a predominance of male gender. Considering TB risk factors, there was a higher prevalence of homelessness and intravenous drug use in the HIV group. In the non-HIV group, direct contact with other patients with TB and immunosuppression were more prevalent. Relative to TB characteristics, the HIV-coinfected group presents with a higher prevalence of disseminated disease and a higher occurrence of previous TB infection. Cancer was the most frequent cause of immunosuppression in the HIV group and the number testing positive for TB via microbiological culture was lower. Assessment of microbiological resistance and in-hospital mortality showed similar numbers in both groups.

CONCLUSIONS

There are few papers comparing clinical course of TB between HIV-infected and non-infected patients. Our study differs from others in the literature as we focused on a country with middling incidence of TB and further characterized the differences between HIV-infected and non-infected patients which can contribute to the management of these patients.

Tocilizumab reduces the risk of ICU admission and mortality in patients with SARS-CoV-2 infection

Objectives

In some patients the immune response triggered by SARS-CoV-2 is unbalanced, presenting an acute respiratory distress syndrome which in many cases requires intensive care unit (ICU) admission. The limitation of ICU beds has been one of the major burdens in the management around the world; therefore, clinical strategies to avoid ICU admission are needed. We aimed to describe the influence of tocilizumab on the need of transfer to ICU or death in non-critically ill patients.

Material and methods

A retrospective study of 171 patients with SARS-CoV-2 infection that did not qualify as requiring transfer to ICU during the first 24h after admission to a conventional ward, were included. The criteria to receive tocilizumab was radiological impairment, oxygen demand or an increasing of inflammatory parameters, however, the ultimate decision was left to the attending physician judgement. The primary outcome was the need of ICU admission or death whichever came first.

Results

A total of 77 patients received tocilizumab and 94 did not. The tocilizumab group had less ICU admissions (10.3% vs. 27.6%, P=0.005) and need of invasive ventilation (0 vs 13.8%, P=0.001). In the multivariable analysis, tocilizumab remained as a protective variable (OR: 0.03, CI 95%: 0.007-0.1, P=0.0001) of ICU admission or death.

Conclusions

Tocilizumab in early stages of the inflammatory flare could reduce an important number of ICU admissions and mechanical ventilation. The mortality rate of 10.3% among patients receiving tocilizumab appears to be lower than other reports. This is a non-randomized study and the results should be interpreted with caution.

A socio-emotional analysis of technology use by people with intellectual disabilities

BACKGROUND

Access to information and communication technologies (ICTs) is often thought to enhance the lives of people with intellectual disabilities (ID) and is considered an important aspect of digital inclusion. However, inclusion practices often fail to address societal inequalities that lead to and sustain exclusion. The aim of this research was to enhance understandings of the relationships people with ID form with technology by critically analysing the underlying assumptions of inclusion practices.

METHOD

We employed a post-qualitative approach to reanalyse previously collected data from face-to-face interviews with 10 Australian adults with ID who attended a community literacy programme about their technology use in their daily lives. Two of social theorist Sara Ahmed's key concepts were used to analyse these data: (1) 'stickiness' of emotions, where certain (socially dominant) emotions are considered to attach to objects over time (e.g. mobile phone use is normal/good) and (2) 'fit' between people and objects, where there is a sense of comfort when objects are designed for people like you - those outside the 'norm' experience discomfort and a sense of being 'othered' in their interactions with such objects which do not fit them.

RESULTS

Our analysis identified how people with ID often attributed positive feelings to technology even when they had seemingly negative interactions with their devices (e.g. they could not use certain features, caregivers acted as gatekeepers to access). The positive associations were likely the outcome of implicitly held understandings that society highly values technology (Ahmed's stickiness of emotions). Although some participants accessed technology without difficulty, others experienced discomfort due to difficulties using devices that were not designed for them (Ahmed's fit between people and objects). Importantly, some participants had access to technology and the technical skill to use ICTs, but other factors, such as not having many friends, impacted their ability to use their devices in meaningful ways.

CONCLUSION

Our analysis suggests that digital inclusion practices focused on providing access to technology may unintentionally harm in ways that are not immediately apparent when working with people with ID. Harms might include further marginalisation or 'othering' of people with ID. It is important to recognise that well-meaning attempts to encourage use of ICTs may be counterproductive if they lead to experiences of marginalisation. To avoid this, inclusion practices could focus beyond access to devices, and the ability to use them, to include considerations of the multiple socio-emotional effects. What is a good fit is not entirely predeterminable, exploration of the possibilities for what will work well for any individual requires experimentation and creativity, and a careful attention to unintended effects. Beyond this, the development of new technology should consider how to diversify devices that often fail to fit people with disabilities.

Loperamide exerts a direct bactericidal effect against M. tuberculosis, M. bovis, M. terrae and M. smegmatis

Tuberculosis (TB) is caused by Mycobacterium tuberculosis. TB is highly prevalent, characterized by the constant occurrence of drug-resistant cases, and confounded by the incidence of respiratory disease caused by non-tuberculous mycobacteria (NTB). Expanding the spectrum of drugs for the treatment of TB is indispensable. Loperamide, an antidiarrhoeal drug, enhances immune-driven antimycobacterial activity, and we aimed to evaluate its bactericidal activity against M. tuberculosis, Mycobacterium bovis BCG, Mycobacterium terrae and Mycobacterium smegmatis. Loperamide exhibited an inhibitory effect against all mycobacterial species tested, with MICs of 100 and 150 μg ml^-1 . Thus, loperamide is a mycobactericidal drug with potential as adjunctive therapy for TB and NTB infections.

Quality indicators of a cardiac rehabilitation program in women with coronary heart disease

Introduction

Cardiac rehabilitation programs (CRP) are well known to improve functional status and prognosis after a cardiovascular event. This programs are class IA recommendation. However, many studies have demonstrated that women are less likely to stick to a CRP.

Purpose

To compare baseline characteristics between men and women participating in a cardiac rehabilitation program and to determine whether there are gender differences in the benefits obtained after the program.

Methods

Using data from our Department of CRP, we analysed a total of 1091 patients referred between 2015 and 2018 to our center CRP after a cardiovascular diagnosis. Clinical, analytical and echocardiographic outcomes were collected. We defined benefit as the achievement of the target levels established for each cardiovascular risk factor (CVRF) as well as improvement in the exercise capacity. This capacity was evaluated with exercise tests and maximum O2 uptake at the beginning and at the end of the CPR.

Results

Between 2015 and 2018, 189 (17.3%) of them women with a mean age of 62 years were enrolled in the CRP. There were no significant gender differences in mean age or incidence of CVRF. Likewise, there weren't differences in cardiovascular diagnosis, risk stratification, left ventricular ejection fraction or exercise test performed before the program.

In the results after CRP there were no important gender differences in the percentage of patients who achieved the quality indicators described as HbA1c &lt;7.0%, systolic arterial pressure &lt;140 mmHg, diastolic arterial pressure &lt;90 mmHg. Percentage of LDL cholesterol &lt;70 mg/dl was significantly higher in male patients. Both in men and women an improvement of the second exercise test result was observed.

Conclusions

1. Men and women who suffer from a coronary heart disease have similar clinical characteristics.

2. Among patients with coronary heart disease who attended a cardiac rehabilitation program there were no significant gender differences in the benefits obtained after the program.

Funding Acknowledgement

Type of funding source: None

Characterization and validation of olive FAD and SAD gene families: expression analysis in different tissues and during fruit development

Stearoyl-ACP desaturases (SADs) and fatty acid desaturases (FADs) play a critical role in plant lipid metabolism and also affect oil fatty acid composition introducing double bonds into the hydrocarbon chains to produce unsaturated fatty acids. In the present study, the genomic sequences of three SAD and three FAD candidate genes were characterized in olive and their expression was evaluated in different plant tissues. OeSAD genes corresponded to olive SAD1 and SAD2 and to a newly identified OeSAD4, sharing the conserved protein structure with other plant species. On the other hand, the full-length genomic sequences of two microsomal OeFAD genes (FAD2-1 and FAD2-2) and the plastidial FAD6, were released. When the level of expression was tested on different tissues of cv. Leccino, OeSAD1 and OeSAD2 were mainly expressed in the fruits, while OeFAD genes showed the lowest expression in this tissue. The mRNA profiling of all genes was directly studied in fruits of Leccino and Coratina cultivars during fruit development. In both genotypes, the expression level of OeSAD1 and OeSAD2 had the highest value during and after the pit-hardening period, when oil accumulation in fruit mesocarp is intensively increasing. Furthermore, the expression level of both OeFAD2 genes, which were the main candidates for oleic acid desaturation, were almost negligible during fruit ripening. These results have made possible to define candidate genes of the machinery regulation of fatty acid composition in olive oil, providing information on their sequence, gene structure and chromosomal location.

Integration of high-throughput reporter assays identify a critical enhancer of the Ikzf1 gene

The Ikzf1 locus encodes the lymphoid specific transcription factor Ikaros, which plays an essential role in both T and B cell differentiation, while deregulation or mutation of IKZF1/Ikzf1 is involved in leukemia. Tissue-specific and cell identity genes are usually associated with clusters of enhancers, also called super-enhancers, which are believed to ensure proper regulation of gene expression throughout cell development and differentiation. Several potential regulatory regions have been identified in close proximity of Ikzf1, however, the full extent of the regulatory landscape of the Ikzf1 locus is not yet established. In this study, we combined epigenomics and transcription factor binding along with high-throughput enhancer assay and 4C-seq to prioritize an enhancer element located 120 kb upstream of the Ikzf1 gene. We found that deletion of the E120 enhancer resulted in a significant reduction of Ikzf1 mRNA. However, the epigenetic landscape and 3D topology of the locus were only slightly affected, highlighting the complexity of the regulatory landscape regulating the Ikzf1 locus.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

1 Assessing the energy status of porcine embryos by means of biodynamic imaging

Assisted reproductive technologies are powerful tools for enhancing production in livestock or treating infertility in humans. Unfortunately, the success rate of the technologies is rather low. A major reason for the poor efficiency is the lack of methods to reliably assess the developmental potential of the embryos before transfer into recipients. Therefore, a noninvasive method to ensure the selection of only the best embryos for transfer would be highly desirable. Biodynamic imaging is a compelling new microscopy that uses intracellular Doppler spectroscopy to perform label-free, noninvasive optical measurements of cellular fitness. The aim of this study was to investigate whether biodynamic imaging can be used to assess the energy status of the embryos, which may be indicative of their viability. Porcine oocytes matured invitro were parthenogenetically activated by an electrical pulse and cultured for 2 days. The parthenotes were then divided into two groups, and approximately half of them were incubated for an additional 2 days in the presence of 20mM sodium azide. Sodium azide is an inhibitor of oxidative phosphorylation and is known to block ATP production. The rest of the embryos were cultured without sodium azide and used as a control to indicate normal ATP levels. At the end of the culture period embryos that reached the 8- to 16-cell stage were evaluated by our biodynamic imaging system to assess their energy status, after which they were lysed and their ATP contents were determined by means of a bioluminescence assay. A total of 68 embryos (32 treated with the inhibitor and 36 control) were evaluated. The ATP content analysis showed that the control embryos had significantly more ATP than those treated with sodium azide as determined by Student's t-test (5.04±1.07 vs. 1.31±0.57; P&lt;0.05). A correlative study was then completed where biodynamic biomarkers were used to classify embryos to estimate the ability of biodynamic imaging to identify embryos with high or low energy status. A set of 13 biomarkers representing each embryo as a feature vector was used to train a classifier. We found that the cross-validated classifier had a sensitivity and specificity of ~80%. In addition, a receiver-operator curve constructed by varying the ATP threshold of the independent bioluminescence assay had an area-under-the-curve of 0.81. These results indicate that biodynamic imaging is able to determine the energy status of the embryos noninvasively and has great potential in the assessment of embryo viability.

Determination of Minerals and Trace Elements in Milk, Milk Products, Infant Formula, and Adult Nutrition: Collaborative Study 2011.14 Method Modification

Official Method SM 2011.14/ISO 15151:2018/IDF 229:2018 uses microwave digestion of samples and inductively coupled plasma–atomic emission spectrometry for determination of nine elements, including Ca, Cu, Fe, K, Mg, Mn, Na, P, and Zn. The method was evaluated in a collaborative study of 25 products, including 13 fortified nutritional products (powders, ready-to-feed liquids, and liquid concentrates), five product placebos, six dairy products (liquids, powders, butter, and processed cheese), and the National Institute for Standards and Technology (NIST) Standard Reference Material (SRM) 1849a, in compliance with AOAC INTERNATIONAL Standard Method Performance Requirement (SMPR®) 2014.004. This study significantly expanded the applicability of Official Method 2011.14 beyond the original scope of chocolate milk powder, dietetic milk powder, infant cereal, peanut butter, and wheat gluten. The study included 14 collaborators from 11 countries, and results were compared to SMPR 2014.004. Accuracy of the method was demonstrated using NIST SRM 1849a, yielding recoveries across all laboratories of 98–101% for the nine elements. Precision for the 13 fortified nutritional product samples was 2.2–3.9% for repeatability (relative SD of repeatability) and 6.0–12.2% for reproducibility (RSDR). Excluding Mn, which was present at a wide range of concentrations, the reproducibility was 6.0–9.5%, meeting the performance requirements of SMPR 2014.004. Placebo samples (not fortified with Cu, Fe, Mn, or Zn) yielded acceptable repeatability of 1.8–2.9% for Ca, K, Mg, Na, and P (minerals) but 5.4–29.4% for the low levels of Cu, Fe, Mn, and Zn (trace elements). Reproducibility for the placebos showed the same pattern, with acceptable reproducibility (5.4–10.3%) for minerals but not for the low levels of the trace elements (13.2–82.8%). In the six dairy product samples, repeatability ranged from 1.6 to 3.6% for the minerals, Zn, and the low range of Mn but from 9.4 to 24.6% for Cu, Fe, and the high range of Mn, where concentrations were low as for the nutritional placebos. Reproducibility in the dairy samples was 5.3–8.8% for the minerals but 11.4–55.0% for the trace elements. The mean concentrations of Cu, Fe, and Zn in the dairy products were similar with those in the placebo products, while Zn was present at levels more similar with the fortified nutritional products. Thus, the method met the SMPR criteria except where the trace minerals were present at very low levels. Based on these results, the AOAC Stakeholder Panel for Infant Formula and Adult Nutritionals recommended Final Action status of the expanded applicability of the method. The method was adopted as Final Action by the AOAC Official Methods Board.

Arterial Ischemic Stroke Secondary to Cardiac Disease in Neonates and Children

OBJECTIVE

We describe the risk factors for peri-procedural and spontaneous arterial ischemic stroke (AIS) in children with cardiac disease.

METHODS

We identified children with cardiac causes of AIS enrolled in the International Pediatric Stroke Study registry from January 2003 to July 2014. Isolated patent foramen ovale was excluded. Peri-procedural AIS (those occurring during or within 72 hours of cardiac surgery, cardiac catheterization, or mechanical circulatory support) and spontaneous AIS that occurred outside of these time periods were compared.

RESULTS

We identified 672 patients with congenital or acquired cardiac disease as the primary risk factor for AIS. Among these, 177 patients (26%) had peri-procedural AIS and 495 patients (74%) had spontaneous AIS. Among non-neonates, spontaneous AIS occurred at older ages (median 4.2 years, interquartile range 0.97 to 12.4) compared with peri-procedural AIS (median 2.4 years, interquartile range 0.35 to 6.1, P < 0.001). About a third of patients in both groups had a systemic illness at the time of AIS. Patients who had spontaneous AIS were more likely to have a preceding thrombotic event (16 % versus 9 %, P = 0.02) and to have a moderate or severe neurological deficit at discharge (67% versus 33%, P = 0.01) compared to those with peri-procedural AIS.

CONCLUSIONS

Children with cardiac disease are at risk for AIS at the time of cardiac procedures but also outside of the immediate 72 hours after procedures. Many have acute systemic illness or thrombotic event preceding AIS, suggesting that inflammatory or prothrombotic conditions could act as a stroke trigger in this susceptible population.

Gene expression profiling in blood from cerebral malaria patients and mild malaria patients living in Senegal

Background

Plasmodium falciparum malaria remains a major health problem in Africa. The mechanisms of pathogenesis are not fully understood. Transcriptomic studies may provide new insights into molecular pathways involved in the severe form of the disease.

Methods

Blood transcriptional levels were assessed in patients with cerebral malaria, non-cerebral malaria, or mild malaria by using microarray technology to look for gene expression profiles associated with clinical status. Multi-way ANOVA was used to extract differentially expressed genes. Network and pathways analyses were used to detect enrichment for biological pathways.

Results

We identified a set of 443 genes that were differentially expressed in the three patient groups after applying a false discovery rate of 10%. Since the cerebral patients displayed a particular transcriptional pattern, we focused our analysis on the differences between cerebral malaria patients and mild malaria patients. We further found 842 differentially expressed genes after applying a false discovery rate of 10%. Unsupervised hierarchical clustering of cerebral malaria-informative genes led to clustering of the cerebral malaria patients. The support vector machine method allowed us to correctly classify five out of six cerebral malaria patients and six of six mild malaria patients. Furthermore, the products of the differentially expressed genes were mapped onto a human protein-protein network. This led to the identification of the proteins with the highest number of interactions, including GSK3B, RELA, and APP. The enrichment analysis of the gene functional annotation indicates that genes involved in immune signalling pathways play a role in the occurrence of cerebral malaria. These include BCR-, TCR-, TLR-, cytokine-, FcεRI-, and FCGR- signalling pathways and natural killer cell cytotoxicity pathways, which are involved in the activation of immune cells. In addition, our results revealed an enrichment of genes involved in Alzheimer’s disease.

Conclusions

In the present study, we examine a set of genes whose expression differed in cerebral malaria patients and mild malaria patients. Moreover, our results provide new insights into the potential effect of the dysregulation of gene expression in immune pathways. Host genetic variation may partly explain such alteration of gene expression. Further studies are required to investigate this in African populations.