Neurodevelopmental outcomes in children and adults with Fetal Valproate Spectrum Disorder: A contribution from the ConcePTION project

AIM

To describe the neurodevelopmental phenotype of older children and adults with a diagnosis of Fetal Valproate Spectrum Disorder (FVSD).

METHODS

In this cross-sectional study, 90 caregivers were recruited and completed a series of questionnaires regarding the neurodevelopmental outcomes of 146 individuals aged 7-37 years (M = 18.1), including individuals with a formal diagnosis of FVSD (n = 99), individuals exposed to Valproate but without an FVSD diagnosis (n = 24), and individuals not exposed to Valproate (N = 23). The mean dose of valproate exposure for individuals with an FVSD diagnosis was 1470 mg/day.

RESULTS

Individuals with a diagnosis of FVSD showed significantly higher levels of moderate (43.4%) and severe (14.4%) cognitive impairment than other groups (p = 0.003), high levels of required formal educational support (77.6%), and poorer academic competence than individuals not exposed to Valproate (p = 0.001). Overall psychosocial problems (p = 0.02), internalising problems (p = 0.05) and attention problems (p = 0.001), but not externalising problems, were elevated in individuals with a diagnosis of FVSD. Rates of neurodevelopmental disorders, particularly autistic spectrum disorders (62.9%) and sensory problems (80.6%) are particularly central to the FVSD phenotype. There was no evidence of a statistical dose-dependent effect, possibly due to the high mean dose of exposure having a uniformly negative impact across the sample. Individuals with FVSD had required a significant number of health and child development services.

INTERPRETATION

Children and young adults with a diagnosis of FVSD are at an increased risk of a range of altered neurodevelopmental outcomes, highlighting the need for a multidisciplinary approach to clinical management across the lifespan.

Implementing recommended breastfeeding practices in healthcare facilities in India during the COVID-19 pandemic: a scoping review of health system bottlenecks and potential solutions

Background

Breastfeeding practices in institutional settings got disrupted during the COVID-19 pandemic. We reviewed the challenges faced and the "work-around" solutions identified for implementing recommended breastfeeding practices in institutionalized mother-newborn dyads in resource constrained settings during the pandemic with the aim to identify learnings that could be potentially adapted to the Indian and relatable contexts, for building resilient health systems.

Methods

We conducted a scoping review of literature using the PRISMA ScR Extension guidelines. We searched the Medline via PubMed and Web of Science databases for literature published between 1st December 2019 and 15th April 2022. We included original research, reviews, and policy recommendations published in English language and on India while others were excluded. Further, we searched for relevant gray literature on Google (free word search), websites of government and major professional bodies in India. Three reviewers independently conducted screening and data extraction and the results were displayed in tabular form. Challenges and potential solutions for breastfeeding were identified and were categorized under one or more suitable headings based on the WHO building blocks for health systems.

Results

We extracted data from 28 papers that were deemed eligible. Challenges were identified across all the six building blocks. Lack of standard guidelines for crisis management, separation of the newborn from the mother immediately after birth, inadequate logistics and resources for infection prevention and control, limited health workforce, extensive use of formula and alternative foods, inconsistent quality of care and breastfeeding support, poor awareness among beneficiaries about breastfeeding practices (and especially, about its safety during the pandemic) were some of the challenges identified. The solutions primarily focused on the development of standard guidelines and operating procedures, restricted use of formula, use of telemedicine services for counseling and awareness and improving resource availability for risk mitigation through strategic mobilization.

Conclusion

The COVID-19 pandemic has provided rich learning opportunities for health system strengthening in India. Countries must strengthen learning mechanisms to identify and adapt best practices from within their health systems and from other relatable settings.

Stakeholders' Initial Experience With Telemedicine Services Introduced at 13 Government Medical Colleges in Uttar Pradesh, India During the COVID-19 Lockdown: A Qualitative Study

BACKGROUND

India went into a stringent lockdown in response to the coronavirus disease 2019 (COVID-19) pandemic in March 2020, and routine outpatient and elective health services were suspended. Thus, access to healthcare services got significantly disrupted. To mitigate the impact, 21 state-owned medical colleges in Uttar Pradesh, the most populous and among the most resource-constrained states in India, had to hastily launch telemedicine (TM) services. This created an opportunity to understand how stakeholders would react to such services and what initial challenges could be faced during service delivery. Through this study, we explored the experiences of stakeholders from 13 such "new-adopter" TM centres with the main objective to identify the perceived benefits and gaps related to TM services, and what "people-centric" TM services could look like going forward.

METHODS

We used an exploratory-descriptive qualitative design with a constructivist paradigm. Using interview schedules with open-ended questions and unstructured probes, we interviewed 13 nodal officers, 20 doctors, and 20 patients (i.e., one nodal officer and one to two doctors and patients from each of the 13 new-adopter centres) and stopped thereafter since we reached saturation of information. We analysed the data on NVivo (QSR International, Burlington, MA) and reported the findings using the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

RESULTS

The perceived benefits that were reported included non-dependency on physical contact, economic benefit, better management of patient load, and ease of access to healthcare services. The common gaps identified in the TM services were lack of physical clinical examination, impeded communication due to lack of face-to-face interaction, technological challenges (e.g., inconsistent internet connectivity and unavailability of smartphones), lack of human resources and resources to manage the TM centres, cumbersome compliance requirements coupled with unclarity on medico-legal implications, and limited awareness of services among clients. Need for adequate promotion of TM services through information-education-communication efforts and frontline workers, strengthening of logistics for long-term sustainability, setting up a dedicated TM department at the hospitals, capacity building of the existing staff, reducing gaps in communication between doctors and patients for better consultation, and improved access to the prescribed medicines were some of the suggestions from different stakeholders.

CONCLUSION

The stakeholders clearly appreciated the benefits of TM services offered through the new-adopter centres amidst the pandemic disruptions. However, there were certain gaps and unmet expectations, which, if addressed, could improve the TM centres' performance with further people-centricity and enhance healthcare access and the popularity of system-based services. Avenues for sustaining the TM services and their efficient scale-up should be explored.

An appraisal of peer-reviewed published literature on Influenza, 2000-2021 from countries in South-East Asia Region

Background

Influenza poses a major public health challenge in South-East Asia Region (SEAR). To address the challenge, there is a need to generate contextual evidence that could inform policy makers and program managers for response preparedness and impact mitigation. The World Health Organization has identified priority areas across five streams for research evidence generation at a global level (WHO Public Health Research Agenda). Stream 1 focuses on research for reducing the risk of emergence, Stream 2 on limiting the spread, Stream 3 on minimizing the impact, Stream 4 on optimizing the treatment and Stream 5 on promoting public health tools and technologies for Influenza. However, evidence generation from SEAR has been arguably low and needs a relook for alignment with priorities. This study aimed to undertake a bibliometric analysis of medical literature on Influenza over the past 21 years to identify gaps in research evidence and for identifying major areas for focusing with a view to provide recommendations to member states and SEAR office for prioritizing avenues for future research.

Methods

We searched Scopus, PubMed, Embase, and Cochrane databases in August 2021. We identified studies on influenza published from the 11 countries in WHO SEAR in the date range of 1 January 2000-31 December 2021. Data was retrieved, tagged and analyzed based on the WHO priority streams for Influenza, member states, study design and type of research. Bibliometric analysis was done on Vosviewer.

Findings

We included a total of 1,641 articles (Stream 1: n = 307; Stream 2: n = 516; Stream 3: n = 470; Stream 4: n = 309; Stream 5: n = 227). Maximum number of publications were seen in Stream 2, i.e., limiting the spread of pandemic, zoonotic, and seasonal epidemic influenza which majorly included transmission, spread of virus at global and local levels and public health measures to limit the transmission. The highest number of publications was from India (n = 524) followed by Thailand (n = 407), Indonesia (n = 214) and Bangladesh (n = 158). Bhutan (n = 10), Maldives (n = 1), Democratic People's Republic of Korea (n = 1), and Timor-Leste (n = 3) had the least contribution in Influenza research. The top-most journal was PloS One which had the maximum number of influenza articles (n = 94) published from SEAR countries. Research that generated actionable evidence, i.e., implementation and intervention related topics were less common. Similarly, research on pharmaceutical interventions and on innovations was low. SEAR member states had inconsistent output across the five priority research streams, and there was a much higher scope and need for collaborative research. Basic science research showed declining trends and needed reprioritization.

Interpretation

While a priority research agenda has been set for influenza at the global level through the WHO Global Influenza Program since 2009, and subsequently revisited in 2011 and again in 2016-2017, a structured contextualized approach to guide actionable evidence generation activities in SEAR has been lacking. In the backset of the Global Influenza Strategy 2019-2030 and the COVID-19 pandemic, attuning research endeavors in SEAR could help in improved pandemic influenza preparedness planning. There is a need to prioritize contextually relevant research themes within priority streams. Member states must inculcate a culture of within and inter-country collaboration to produce evidence that has regional as well as global value.

Plight of migrant construction-site workers during the COVID-19 lockdown in 2020: A qualitative exploration in Bhavnagar, Western India

BACKGROUND

During the unexpected lockdown implemented in early 2020 in reaction to the coronavirus 2019 (COVID-19) pandemic, a considerable section of India's population of migrant construction-site workers were stuck.

OBJECTIVE

Our objective was to explore the lived experiences and consequent perceptions of migrant workers related to the COVID-19 lockdown and the consequences on their lives.

METHODS

We conducted structured in-depth interviews (IDIs) with twelve migrant construction-site workers in Bhavnagar, Western India, from November to December 2020, using qualitative research methods. All IDIs were conducted with participant's consent, audio-recorded, transcribed in English, inductively coded, and thematically analyzed.

RESULTS

The primary financial challenges mentioned by the migrant workers in the interviews were unemployment, monetary issues, and a difficult sustenance. The social concerns were described as anxious migrant exodus, discrimination, mistreatment, lack of social assistance, inability to fulfil their family's expectations, lack of safe transportation arrangements by the authorities during the exodus, inadequacies in the public distribution system, law and order, and apathy of their employers. The psychological repercussions were described using terms like "fear," "worry," "loneliness," "boredom," "helplessness," and "trapped." Monetary compensation, job opportunities at the native place, and a well-managed migrant exodus were reportedly their key expectations from the government. Healthcare issues mentioned during the lockdown included a lack of facilities to treat common ailments, substandard care, and repeated COVID-19 testing prior to departure.

CONCLUSION

The study highlights the need to have rehabilitation mechanisms such as targeted cash transfers, ration kits, and safe transportation services for migrant workers through inter-sectoral coordination for mitigating hardship.

Barriers and enablers of breastfeeding in mother-newborn dyads in institutional settings during the COVID-19 pandemic: A qualitative study across seven government hospitals of Delhi, India

Introduction

The COVID-19 pandemic disrupted newborn care and breastfeeding practices across most healthcare facilities. We undertook this study to explore the barriers and enablers for newborn care and breastfeeding practices in hospitals in Delhi, India for recently delivered mother (RDM)-newborn dyads during the first wave of the COVID-19 pandemic (2020) and inductively design a "pathway of impaction" for informing mitigatory initiatives during the current and future pandemics, at least in the initial months.

Materials and methods

We used an exploratory descriptive design (qualitative research method) and collected information from seven leading public health facilities in Delhi, India. We conducted separate interviews with the head and senior faculty from the Departments of Pediatrics/Neonatology (n = 12) and Obstetrics (n = 7), resident doctors (n = 14), nurses (labor room/maternity ward; n = 13), and RDMs (n = 45) across three profiles: (a) COVID-19-negative RDM with healthy newborn (n = 18), (b) COVID-19-positive RDM with healthy newborn (n = 19), and (c) COVID-19 positive RDM with sick newborn needing intensive care (n = 8) along with their care-giving family members (n = 39). We analyzed the data using grounded theory as the method and phenomenology as the philosophy of our research.

Results

Anxiety among clients and providers, evolving evidence and advisories, separation of the COVID-positive RDM from her newborn at birth, providers' tendency to minimize contact duration and frequency with COVID-positive mothers, compromised counseling on breastfeeding, logistic difficulties in expression and transportation of COVID-positive mother's milk to her baby in the nursery, COVID restrictions, staff shortage and unavailable family support in wards and nursery, and inadequate infrastructure were identified as major barriers. Keeping the RDM-newborn together, harmonization of standard operating procedures between professional associations and within and between departments, strategic mobilization of resources, optimization of human resources, strengthening client-provider interaction, risk triaging, leveraging technology, and leadership-in-crisis-situations were notable enablers.

Conclusion

The separation of the RDM and newborn led to a cascade of disruptions to newborn care and breastfeeding practices in the study institutions. Separating the newborn from the mother should be avoided during public health emergencies unless there is robust evidence favoring the same; routine institutional practices should be family centered.

Dynamic voltage attenuation identifies atrial fibrosis in a rabbit model: simultaneous assessment with optical mapping and contact electrogram mapping

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation. Academy of Medical Sciences.

Background

Bipolar voltage amplitude is a widely-used clinical parameter in atrial electrophysiology procedures. However, voltage amplitude is variable, and it has been shown that increasing activation rate decreases bipolar voltage amplitude in patients with atrial fibrillation. It is not known whether such voltage attenuation is a marker of the presence of atrial fibrosis which could therefore be used to improve intra-procedural assessment of atrial cardiomyopathy.

Purpose

We sought to investigate the effect of increasing activation rate on bipolar voltage amplitude in both healthy and fibrotic left atrial tissue.

Methods

10 New Zealand Rabbits were fed a high cholesterol diet (0.75%) for a period of 12 weeks to create an atrial fibrosis model. 10 Animals were fed normal chow. After terminal anaesthesia the heart was excised, and optical and voltage mapping of the excised left atrial tissue was performed. Blebbistatin was used to maintain cardiac stasis and the voltage sensitive dye RH237 was used for optical mapping. Voltage and optical recordings were made during pacing was from 3 different directions at rates from 2-6Hz and at 3 sites across the atrial tissue. Voltage amplitude was recorded as the mean amplitude over 10 beats during steady-state pacing. Optical recordings were used to measure conduction velocity and action potential characteristics. Only pacing runs showing 1:1 conduction were included in analysis. Atrial fibrosis was assessed using Masson’s Trichrome staining.

Results

The degree of atrial fibrosis was significantly greater in the atrial fibrosis model compared to healthy controls (15±3.24% vs. 9.74±4.98%, p=0.0069). Median voltage at base rate pacing of 2Hz was not significantly different between control and fibrotic atria (11.63mV, IQR 6.35mV vs. 10.3mV, IQR 6.81mV, p=0.71, respectively). Median voltage was significantly lower at 6Hz than at 2Hz in the control group (9.84mV, IQR 6.87mV, p=0.046). The degree of voltage attenuation between study groups was not significantly different between when pacing at 3hz or 4hz, whereas pacing at 5Hz and 6Hz showed significantly greater attenuation in fibrotic atria. At 5Hz the median reduction in amplitude from baseline in control vs fibrotic atria was 0.88mV, IQR 2.36mV vs 1.92mV, IQR 1.63mV (p=0.031). At 6 Hz the median reduction was 0.94mV, IQR 1.69mV vs 2.68mV, IQR 1.11mV, p=0.013 in control and fibrotic groups respectively.

Discussion

High cholesterol diet increased atrial fibrosis in a rabbit model. Bipolar voltage amplitude attenuation occurred in both control and fibrotic atria however the degree of voltage attenuation was significantly greater in fibrotic atria. These findings support the further evaluation of dynamic voltage attenuation for intraprocedural identification of atrial fibrosis.

Atrial tissue characterisation using electroanatomic voltage mapping and cardiac magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background

Atrial voltage mapping and atrial cardiac magnetic resonance imaging are two contemporary methods for quantification of atrial fibrosis. However, the absence of a gold standard for measuring atrial fibrosis has precluded their direct comparison. Nevertheless, understanding the relative performance of voltage mapping and atrial late gadolinium enhancement for identification of atrial cardiomyopathy remains critical to correctly targeting clinical application of these techniques.

Purpose

To assess the relative performance of electroanatomic voltage mapping and atrial late gadolinium enhancement imaging using three surrogate markers chosen to distinguish pre-procedural utility (progression to recurrent atrial fibrillation following ablation) from potential utility for providing atrial fibrillation mechanistic insights (paroxysmal vs. persistent status of atrial fibrillation and relationship with co-morbidities associated with atrial fibrillation).

Methods

123 patients underwent atrial late gadolinium enhancement imaging and electroanatomic voltage mapping prior to atrial fibrillation ablation. Atrial late gadolinium enhancement imaging was assessed with CEMRG software and electroanatomic voltage mapping processed with OpenEP software using previously published thresholds. Low voltage tissue was defined at (1) <0.5mV, (2) <1.17mV, and (3) <1.3mV. Atrial fibrosis using late gadolinium enhancement was defined using four thresholds (1) signal intensity >3.3 standard deviations above the blood pool mean; (2) image intensity ratio (IIR) 1.2x blood pool mean; (3) IIR 1.32x blood pool mean; and (4) IIR 0.97x blood pool mean.

Results

Patients with persistent atrial fibrillation and those with CHA2DS2VaSc >2 had increased low voltage area for each of the thresholds tested, but there was no increase in atrial late gadolinium enhancement area at any of the imaging thresholds tested.

Increased atrial fibrosis using IIR>0.97 was independently associated with recurrence of atrial fibrillation (OR 1.05 (CI 1.01-1.09), p=0.009) in both univariate and multivariate analysis. Low voltage area <1.13mV and low voltage area <1.17mV were associated with increased risk of recurrence (OR 1.02 (CI 1.01-1.04), p=0.01, and OR 1.03 (CI 1.01-1.04), p=0.009) in univariate analysis but neither voltage threshold remained statistically significant in multivariate analysis controlling for clinical variables.

Conclusion

Increased fibrosis burden measured with atrial magnetic resonance imaging, but not with low voltage area, is independently associated with recurrence of atrial fibrillation following catheter ablation. However, increased low voltage area measured with electroanatomic mapping is associated with persistent atrial fibrillation status and CHADS2VaSc score. These findings support the use of magnetic resonance imaging for pre-procedure assessment and the use of electroanatomic mapping for intraprocedural mechanism-based assessment of atrial cardiomyopathy.

Non-invasive delineation of ventricular tachycardia substrates for cardiac stereotactic body radiotherapy: utility of in-silico pace-mapping

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): EPSRC

Background

Cardiac stereotactive body radiotherapy (CSBRT) is an emerging, non-invasive ablation modality that targets ventricular tachycardia (VT) substrates in patients with limited conventional treatment options. Success of CSBRT hinges primarily on the correct identification of VT targets, which requires non-invasive planning. Current non-invasive, pre-procedure strategies employ multi-electrode electrocardiographic imaging (ECGi). Given its significant cost and potential challenges in detecting endocardial, intramural and/or septal VT sites, there is a need to optimise VT delineation strategies for CSBRT; patient-specific simulations may show promise at guiding such planning non-invasively.

Purpose

We aim to perform non-invasive, in-silico pace-mapping on an image-based computational model to identify VT substrates for CSBRT. We intend to show the utility of our fast computational pipeline - relying on CT imaging data only - to provide further insights on inaccessible, scar-related VT episodes.

Methods

A detailed computational torso model of a CSBRT candidate with incessant VT was generated from CT imaging data. Extracellular content volumes (ECVs) were used to identify different tissue types (healthy, border zone and non-conducting), and scale model tissue conductivities accordingly. In-silico pace-mapping was performed by simulating ~360 paced beats across the LV, and computing corresponding 12-lead ECGs within a fast electrophysiological (EP) simulation environment combining reaction-eikonal and lead field methods. QRS complexes from simulated paced beats were used to construct the virtual correlation pace-map against the measured QRS of the clinically-induced VT, along with a ‘reference-less’ virtual pace-map constructed from neighbouring paced-beat QRSs (within a 20 mm radius). An epicardial activation map of the clinically-induced VT was reconstructed from ECGi measurement, and used for comparison against our virtual pace-maps.

Results

Correlations between simulated paced-beat QRS complexes and the clinically-induced VT QRS were higher in mid-apical, infero-septal segments - segment 9 (85.71%), 10 (87.95%) and 15 (89.58%) - identifying septal origin and pathway of the induced re-entrant circuit. A possible septal VT isthmus was also identified by a high gradient in the virtual reference-less pace-map in segment 9 (> 2.5%/mm). Our in-silico predictions were in agreement with the clinical regions identified for CSBRT (segment 9 and 15), and provided additional information on the 3D and septal dynamics of the VT episode.

Conclusions

Our in-silico pace-mapping study successfully localised VT substrates in a patient unable to receive standard ablative procedures, and provided further clinical insight on the induced VT dynamics. Our rapid in-silico pace-mapping approach may be utilised to support optimal identification of VT target volumes for CSBRT.

What's up with WhatsApp in supplementing surgical education: an objective assessment

INTRODUCTION

This is the first study aimed at objectively quantifying the benefit of virtual education using WhatsApp-based discussion groups.

METHODS

A prospective, non-randomised interventional study was undertaken in the Department of General Surgery, at a tertiary care centre in Kolkata, India, with 200 undergraduate students over a period of 5 days each for 2 weeks, with the first week acting as a control arm. A WhatsApp group was created consisting of 197 eligible undergraduates, faculty members and the authors of this study. Each day, three questions were posted on this group. The second week involved an hour-long WhatsApp-based discussion between the participants and the faculty. Responses were recorded and compared for improvements between the two weeks. Participant feedback was collected and analysed.

RESULTS

Statistically significant improvements were observed in the study group compared with the control group in rates of one in three, two in three and three in three correct responses (p=0.01649, 0.01146 and 0.00946, respectively). A total of 68 (51.92%) feedback respondents were satisfied with the programme. Convenience of use was the principal reason behind satisfaction in 79 respondents (60.31%), whereas 62 participants (47.33%) reported lack of hands-on training as a major drawback.

CONCLUSIONS

WhatsApp was found to be a satisfactory supplement to traditional medical teaching. It can be implemented to fill lapses in medical education, especially in light of the COVID-19 pandemic, which has caused great disruption to traditional teaching methods. Research is needed to assess the feasibility of incorporating it into the curriculum.

Technology-enabled multidisciplinary team in-reach for oral corticosteroid stewardship and optimizing care of suspected airways disease exacerbations

Overuse of corticosteroids is an important problem not only in asthma but also the management of other airways diseases including bronchiectasis and COPD and results in associated risks of serious side effects and irreversible harm. We report a pilot using an in-reach solution to review patients, optimise their care and facilitate early discharge. We discharged >20% of our patients immediately, which is potentially a significant reduction in hospital bed use and, most importantly, through this approach we were able to establish early diagnosis and reduce inappropriate oral corticosteroid use.

What's up with WhatsApp in supplementing surgical education: an objective assessment

INTRODUCTION

This is the first study aimed at objectively quantifying the benefit of virtual education using WhatsApp-based discussion groups.

METHODS

A prospective, non-randomised interventional study was undertaken in the Department of General Surgery, at a tertiary care centre in Kolkata, India, with 200 undergraduate students over a period of 5 days each for 2 weeks, with the first week acting as a control arm. A WhatsApp group was created consisting of 197 eligible undergraduates, faculty members and the authors of this study. Each day, three questions were posted on this group. The second week involved an hour-long WhatsApp-based discussion between the participants and the faculty. Responses were recorded and compared for improvements between the two weeks. Participant feedback was collected and analysed.

RESULTS

Statistically significant improvements were observed in the study group compared with the control group in rates of one in three, two in three and three in three correct responses (p=0.01649, 0.01146 and 0.00946, respectively). A total of 68 (51.92%) feedback respondents were satisfied with the programme. Convenience of use was the principal reason behind satisfaction in 79 respondents (60.31%), whereas 62 participants (47.33%) reported lack of hands-on training as a major drawback.

CONCLUSIONS

WhatsApp was found to be a satisfactory supplement to traditional medical teaching. It can be implemented to fill lapses in medical education, especially in light of the COVID-19 pandemic, which has caused great disruption to traditional teaching methods. Research is needed to assess the feasibility of incorporating it into the curriculum.

Adaptive design with bayesian informed interim decisions: application to a randomized trial of mechanical circulatory support

Background

Cardiovascular trials increasingly require large sample sizes and long follow-up periods. Several approaches have been developed to optimize sample size such as adaptive group sequential trials, samples size re-estimation based on the promising zone, and the win ratio. Traditionally, the log-rank or the Cox proportional hazards model is used to test for treatment effects, based on a constant hazard rate and proportional hazards alternatives, which however, may not always hold. Large sample sizes and/or long follow up periods are especially challenging for trials evaluating the efficacy of acute care interventions.

Purpose

We propose an adaptive design wherein using interim data, Bayesian computation of predictive power guides the increase in sample size and/or the minimum follow-up duration. These computations do not depend on the constant hazard rate and proportional hazards assumptions, thus yielding more robust interim decision making for the future course of the trial.

Methods

PROTECT IV is designed to evaluate mechanical circulatory support with the Impella CP device vs. standard of care during high-risk PCI. The primary endpoint is a composite of all-cause death, stroke, MI or hospitalization for cardiovascular causes with initial minimum follow-up of 12 months and initial enrolment of 1252 patients with expected recruitment in 24 months.

The study will employ an adaptive increase in sample size and/or minimum follow-up at the Interim analysis when ∼80% of patients have been enrolled. The adaptations utilize extensive simulations to choose a new sample size up to 2500 and new minimal follow-up time up to 36 months that provides a Bayesian predictive power of 85%.

Bayesian calculations are based on patient-level information rather than summary statistics therefore enabling more reliable interim decisions. Constant or proportional hazard assumptions are not required for this approach because two separate Piece-wise Constant Hazard Models with Gamma-priors are fitted to the interim data. Bayesian predictive power is then calculated using Monte-Carlo methodology. Via extensive simulations, we have examined the utility of the proposed design for situations with time varying hazards and non-proportional hazards ratio such as situations of delayed treatment effect (Figure) and crossing of survival curves. The heat map of Bayesian predictive power obtained when the interim Kaplan-Meier curves reflected delayed response shows that for this scenario an optimal combination of increased sample size and increased follow-up time would be needed to attain 85% predictive power.

Conclusion

A proposed adaptive design with sample size and minimum follow-up period adaptation based on Bayesian predictive power at interim looks allows for de-risking the trial of uncertainties regarding effect size in terms of control arm outcome rate, hazard ratio, and recruitment rate.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abiomed, Inc Figure 1

1242 A Surfacing Staghorn: Spontaneous Expulsion of a Large Renal Calculus from A Nephrocutaneous Fistula

An 83-year-old lady presented to the urology department with right flank pain in the context of a previously known right renal staghorn calculus. On examination, she was found to have a visible discharging sinus in her right flank, and the renal calculus had become visible at the skin surface. Non-contrast CT imaging confirmed that her staghorn calculus had eroded through the skin via a nephrocutaneous fistula. The stone was manually extracted percutaneously on the ward, and she was treated with intravenous antibiotics. She subsequently passed a further stone through the tract and made a good recovery.

This is a highly unusual presentation of nephrolithiasis in a developed country in the 21st century. Review of the literature suggests that surgical management is almost always indicated in patients with staghorn calculi. However surgical management options are not without risk and conservative management of staghorn disease may be appropriate in select patient groups: those with multiple co-morbidities at high risk for GA, in cases of patient refusal of surgery, or in patients with aberrant anatomical factors

Our case highlights a potential complication of conservatively managed staghorn stone disease. To our knowledge our case is the first of spontaneous expulsion of renal stone of this size to be reported in the developed world.

Adult North Star Network (ANSN): Consensus Guideline For The Standard Of Care Of Adults With Duchenne Muscular Dystrophy

There are growing numbers of adults with Duchenne Muscular Dystrophy living well into their fourth decade. These patients have complex medical needs that to date have not been addressed in the International standards of care. We sought to create a consensus based standard of care through a series of multi-disciplinary workshops with specialists from a wide range of clinical areas: Neurology, Cardiology, Respiratory Medicine, Gastroenterology, Endocrinology, Palliative Care Medicine, Rehabilitation, Renal, Anaesthetics and Clinical Psychology. Detailed reports of evidence reviewed and the consensus building process were produced following each workshop and condensed into this final document which was approved by all members of the Adult North Star Network including service users. The aim of this document is to provide a framework to improve clinical services and multi-disciplinary care for adults living with Duchenne Muscular Dystrophy.

A perspective on the role of uncertainty in sustainability science and engineering

The Trans-Atlantic Research and Development Interchange on Sustainability Workshop (TARDIS) is a meeting on scientific topics related to sustainability. The 2019 workshop theme was "On the Role of Uncertainty in Managing the Earth for Global Sustainability." This paper presents the perspectives on this topic derived from talks and discussions at the 2019 TARDIS workshop. There are four kinds of uncertainties encountered in sustainability ranging from clear enough futures to true surprises. The current state-of-the-art in assessing and mitigating these uncertainties is discussed.

P920Understanding arrhythmia mechanisms in patients with atrial septal defects

Background

Atrial arrhythmias represent a major cause of morbidity and hospitalization in patients with atrial septal defects (ASD). Optimum treatment strategies are unknown since the mechanisms of arrhythmia are undefined in this cohort.

Purpose

We investigated whether percutaneous ASD closure reduces atrial arrhythmias and subsequently examined the electrical and structural changes underpinning arrhythmogenesis in ASD patients.

Methods

Meta-analysis was used to study the effect of closure on arrhythmias. Bi-atrial electrical dysfunction was assessed through invasive measurement of atrial voltage, refractory periods (ERP) over three drive trains (600, 450 and 300ms) and local conduction velocity (CV) with subsequent assessment of ERP and CV restitution. Structural remodelling was assessed through non-invasive quantification of fibrosis using cardiac MRI (CMR). Origin of ectopy was evaluated invasively using isoprenaline infusion and non-invasively using 24-hour Holter monitoring. Comparison was made to normal heart controls.

Results

Meta-analysis

Meta-analysis of 25 studies found that percutaneous closure was associated with a weak reduction in atrial arrhythmias only in patients >40 years old (OR 0.777, 95% CI 0.616-0.979, P = 0.032).

Electrical Remodelling

On invasive assessment (21 ASDs; 21 controls), proportion of right atrial low voltage (<0.5mV) and scar (<0.05mV) was greater in ASD vs control patients (P = 0.02 and P = 0.039). In ASD patients, these parameters were greater in the right atrium vs the left atrium (P = 0.002 and P = 0.01). Right atrial ERP restitution slopes were steeper in ASD vs control patients (P = 0.016). Maximum right atrial CV and CV restitution slopes were greater in ASD vs control patients (P= 0.005 and P < 0.001 respectively) and CV decrement occurred at longer coupling intervals in the right atrium in ASD patients (P = 0.015).

Structural Remodelling

On CMR assessment (36 ASDs; 36 controls), bi-atrial fibrosis was greater in ASD vs control patients (P < 0.001). In ASD patients right atrial fibrosis was burden greater in patients with vs without atrial arrhythmias (P = 0.034).

Arrhythmia Triggers

On 24-hour Holter monitoring and during invasive isoprenaline infusion right and left atrial ectopy was equally prevalent in ASD vs control patients.

Conclusion

This study highlights the importance of right atrial electrical dysfunction to the occurrence of arrhythmias in ASD patients with extensive right atrial remodelling (fibrosis, low voltage, steeper ERP and CV restitution) seen in ASD patients compared to normal heart controls.

From the results of the meta-analysis it appears that percutaneous closure alone is insufficient to treat arrhythmias in ASD patients. Given the predominance of right atrial remodelling, right-sided ablation as an adjunct to conventional left-sided ablation should be investigated as a strategy to treat atrial arrhythmias in these patients.

Abstract Figure.

Lactulose synergizes with CpG-ODN to modulate epithelial and immune cells cross talk

Lactulose, a non-digestible oligosaccharide and functional food, promotes Bifidobacteria growth. Here we show that lactulose, beyond its prebiotic action, may have direct immunomodulatory effects as well. In synergy with CpG-ODN, a bacterial DNA mimetic, lactulose enhances basolateral concentrations of IFN-γ, IL-10, and galectin-9 in the co-culture model of epithelial and immune cells.

3D spatial distribution of ore mineral phases using high resolution synchrotron micro-computed tomography (μCT) combined with optical microscopy

Ore minerals in dolomites and Graphite Mica Schist (GMS) were studied by synchrotron radiation micro-computed tomography (SR-μCT) and optical microscopy. High resolution μCT images of ore minerals were obtained at Imaging Beamline (BL-4), Indus-2 synchrotron radiation source for the comprehensive volume characterization of minerals. Optical microscopy was used for mineral identification, mineral/rock characterization and quantification of ore mineral assemblages was also confirmed by XRD. 3D images from SR-μCT have shown spatial distribution of major minerals and crystals of different minerals in the volume of samples. The results obtained shows that the GMS and dolomitic hosted rocks mined from region near Udaipur, Rajasthan contains sulfide mineral phases. SR-μCT facilitates visualization of the association of the various metallic minerals with the host rock. The presence of economically important metallic minerals galena, sphalerite and pyrite found in the samples through SR-μCT has implications on exploration and processing of ores.

Direct Formation and Structural Characterization of Electride C12A7

Ca12Al14O33 (C12A7 or Mayenite) is a material whose caged clathrate structure and occluded anionic species leads to significant functionality. The creation of occluded anionic vacancies leads to the injection of localized electrons at the center of the cage, converting the wide band gap insulator to a semi- or metallic conducting material. The conversion to the electride historically requires the synthesis of oxy-C12A7, consolidation, and then reduction to introduce anionic vacancies. This report develops and characterizes an electride formation procedure from three starting points: unconsolidated oxy-C12A7, heterogenous solid-state reactants (CaCO₃ and Al₂O₃), and homogenous non-carbonaceous polymer assisted sol-gel reactants. Electride-C12A7 formation is observed in a vacuum furnace where the reactants are in direct contact with a carbon source. Process time and temperature-dependent structural characterization provides insight into the source of high temperature C12A7 stability, the mechanism of anionic vacancy formation, and the magnitude of ultimate conductivity that cannot be explained by current reduction theories. A new theory is presented where mixed O- and C-occupied cages lead to high temperature stability, oxidation of C species creates anionic vacancies, and an equilibrium between the reducing power of the electride-C12A7 and of the C species leads to the ultimate conductivity achieved by the process. This represents a shift in understanding of the carbonaceous reduction process and the first report of high purity electride-C12A7 formation from heterogenous solid-state reactants and homogenous non-carbonaceous polymer assisted sol-gel reactants.

Splenic trauma in the twenty-first century: changing trends in management

Over the past three decades, management of blunt splenic trauma has changed radically. Use of improved diagnostic techniques and proper understanding of disease pathology has led to nonoperative management being chosen as the standard of care in patients who are haemodynamically stable. This review was undertaken to assess available literature regarding changing trends of management of blunt splenic trauma, and to identify the existing lacunae in nonoperative management. The PubMed database was searched for studies published between January 1987 and August 2017, using the keywords 'blunt splenic trauma' and 'nonoperative management'. One hundred and fifty-three articles were reviewed, of which 82 free full texts and free abstracts were used in the current review. There is clear evidence in published literature of the greater success of nonoperative over operative management in patients who are haemodynamically stable and the increasing utility of adjunctive therapies like angiography with embolisation. However, the review revealed a lack of universal guidelines for patient selection criteria and diagnostic and grading procedures needed for nonoperative management. Indications for splenic artery embolisation, the current role of splenectomy and spleen-preserving surgeries, together with the place of minimal access surgery in blunt splenic trauma remain grey areas. Moreover, parameters affecting the outcomes of nonoperative management and its failure and management need to be defined. This shows a need for future studies focused on these shortcomings with the ultimate aim being the formulation and implementation of universally accepted guidelines for safe and efficient management of blunt splenic trauma.

A novel digital method to assess air space loss associated with acute lung injury in experimental acute pancreatitis

BACKGROUND/OBJECTIVES

Respiratory dysfunction and/or failure from acute lung injury (ALI) are common in acute pancreatitis (AP), but assessment of ALI in experimental AP has lacked standardisation.

METHODS

A range of experimental AP models induced in C57BL/6 mice with corresponding controls (n = 6/group). Full double lung or right lung specimens were taken for histopathological assessment and slides analysed by a pre-set pipeline using Aperio Scanner (Leica), ImageJ software and CellProfiler software. Findings were compared to other routinely assessed parameters.

RESULTS

Overall histopathological changes were similar between both lungs. Mean lung field occupancy was significantly different between moderate and severe CER-AP (21.9% v 27.5%, p < 0.05) and corresponded with lung MPO and local injury severity parameters and was mirrored for all models tested.

CONCLUSION

We have developed a novel, simple method for assessment of ALI to improve measurement of systemic organ injury in experimental AP and contribute to preclinical drug development.

Detection and classification of Bacteria using Raman Spectroscopy Combined with Multivariate Analysis

<p class="p1">Vibrational spectroscopic techniques have advantages over conventional microbiological approaches towards identification &amp; detection of pathogens. Since unique spectral fingerprint is obtained, one can identify very closely related bacteria using such methods. In this study Raman microspectroscopy in combination with chemometric method has been used to classify four strains of <em>E</em>. <em>coli </em>(two pathogenic &amp; two non-pathogenic). Different multivariate approaches such as hierarchical cluster analysis, principal component analysis &amp; linear discriminant analysis were explored to obtain efficient classification of the Raman signals obtained from the four strains of <em>E.coli</em>. It was observed that multivariate analysis was able to classify the bacteria at strain level. Linear discrimination analysis using PC scores (PC-LDA) was found to give very good result with as high as 100% accuracy. This hybrid technique (Raman spectroscopy &amp; multivariate analysis) has tremendous potential to be developed as a tool for bacterial identification.<span class="Apple-converted-space"> </span></p>

Changes of haemogram and serum biochemistry in neonatal piglet diarrhoea associated with porcine rotavirus type A

Porcine rotavirus type A (RVA) is a major cause of neonatal piglet mortality in India. The effect of the disease on haemogram and serum biochemical profile is not well established in piglets. Accordingly, we assessed the haemogram and serum biochemical profile in the neonatal piglet diarrhoea with RVA infection (n = 17). The diagnosis of RVA was confirmed using RNA-polyacrylamide gel electrophoresis (RNA-PAGE), commercially available enzyme-linked immunosorbent assay (ELISA) kit and reverse transcription-polymerase chain reaction (RT-PCR). Non-infected healthy piglets (n = 6) served as control. The concentrations of total protein, albumin, alanine amino transaminase (ALT), aspartate amino transaminase (AST), blood urea nitrogen (BUN) and creatinine in serum were measured by spectrophotometric method. Haemogram was done in the blood using sodium ethylenediaminetetraacetic acid (Na₂ EDTA) as anticoagulant. The mean values of total protein, albumin and globulin concentrations were significantly (P < 0.001) decreased and concentrations of ALT, AST, BUN and creatinine were significantly increased (P < 0.001) in the RVA-infected piglets. Haemogram showed marked haemoconcentration (P < 0.001), leukopenia (P < 0.01) and neutropenia (P < 0.01) in the presence of RVA infection than healthy piglets. The results indicated a possible extra-intestinal spread of RVA in piglets during neonatal diarrhoea. The finding might be helpful to clinicians and while treating such type of clinical cases, incorporation of organ protective drugs will be helpful for better response in the treatment schedule.

Retinoic acid prevents synaptic deficiencies induced by alcohol exposure during gastrulation in zebrafish embryos

In this study, we examined the effects of alcohol exposure during gastrulation on zebrafish embryos, specifically focusing on excitatory synaptic activity associated with neurons (Mauthner cells) that are born during gastrulation. Furthermore, we determined whether co-treatment of alcohol and retinoic acid (RA) could prevent the effects of alcohol exposure during gastrulation. We exposed zebrafish embryos to ethanol (150mM), RA (1nM), or a combination of RA (1nM) plus ethanol (150mM) for 5.5h from 5.25h post fertilization (hpf) to 10.75 hpf (gastrulation). Ethanol treatment resulted in altered hatching rates, survivability and body lengths. Immunohistochemical analysis of Mauthner cells (M-cells) suggested that ethanol treatment resulted in smaller M-cell bodies and thinner axons, while electrophysiological recordings of AMPA miniature excitatory postsynaptic currents (mEPSCs) associated with M-cells showed that ethanol treated animals had a significantly reduced mEPSC frequency. Other mEPSC parameters such as amplitude, rise times and decay kinetics were not altered by exposure to alcohol. Locomotor studies showed that ethanol treatment resulted in altered C-bend escape responses. For instance, the C-bends of alcohol-treated fish were larger than control embryos. Thus, ethanol treatment during gastrulation altered a range of features in embryonic zebrafish. Importantly, co-treatment with RA prevented all of the effects of ethanol including survivability, body length, M-cell morphology, AMPA mEPSC frequency and escape response movements. Together these findings show that ethanol exposure during the brief period of gastrulation has a significant effect on neuronal morphology and activity, and that this can be prevented with RA co-treatment.

Proinflammatory cytokine interferon-γ and microbiome-derived metabolites dictate epigenetic switch between forkhead box protein 3 isoforms in coeliac disease

Coeliac disease (CD) is an autoimmune enteropathy triggered by gluten and characterized by a strong T helper type 1 (Th1)/Th17 immune response in the small intestine. Regulatory T cells (T_reg ) are CD4⁺ CD25⁺⁺ forkhead box protein 3 (FoxP3⁺ ) cells that regulate the immune response. Conversely to its counterpart, FoxP3 full length (FL), the alternatively spliced isoform FoxP3 Δ2, cannot properly down-regulate the Th17-driven immune response. As the active state of CD has been associated with impairments in T_reg cell function, we aimed at determining whether imbalances between FoxP3 isoforms may be associated with the disease. Intestinal biopsies from patients with active CD showed increased expression of FOXP3 Δ2 isoform over FL, while both isoforms were expressed similarly in non-coeliac control subjects (HC). Conversely to what we saw in the intestine, peripheral blood mononuclear cells (PBMC) from HC subjects did not show the same balance between isoforms. We therefore hypothesized that the intestinal microenvironment may play a role in modulating alternative splicing. The proinflammatory intestinal microenvironment of active patients has been reported to be enriched in butyrate-producing bacteria, while high concentrations of lactate have been shown to characterize the preclinical stage of the disease. We show that the combination of interferon (IFN)-γ and butyrate triggers the balance between FoxP3 isoforms in HC subjects, while the same does not occur in CD patients. Furthermore, we report that lactate increases both isoforms in CD patients. Collectively, these findings highlight the importance of the ratio between FoxP3 isoforms in CD and, for the first time, associate the alternative splicing process mechanistically with microbial-derived metabolites.

Chikungunya virus infection in West Bengal, India

BACKGROUND

Chikungunya virus has recently re-emerged in India.

OBJECTIVES

Assess prevalence of Chikungunya.

MATERIALS AND METHODS

Study conducted from April 2011 to September 2011. Two hundred and six patients (206) of both sexes (100 males and 106 females) of all age groups studied. Serum separated and CHIKV MAC IgM ELISA and Hemagglutination inhibition assay done.

RESULTS

76 cases (36.89%) sero-positive by both the methods.

CONCLUSION

Re-emergence and resurgence of the Chikungunya virus requires continuous monitoring.

Candidate Elastic Quantum Critical Point in LaCu_{6-x}Au_{x}

The structural properties of LaCu_{6-x}Au_{x} are studied using neutron diffraction, x-ray diffraction, and heat capacity measurements. The continuous orthorhombic-monoclinic structural phase transition in LaCu_{6} is suppressed linearly with Au substitution until a complete suppression of the structural phase transition occurs at the critical composition x_{c}=0.3. Heat capacity measurements at low temperatures indicate residual structural instability at x_{c}. The instability is ferroelastic in nature, with density functional theory calculations showing negligible coupling to electronic states near the Fermi level. The data and calculations presented here are consistent with the zero temperature termination of a continuous structural phase transition suggesting that the LaCu_{6-x}Au_{x} series hosts an elastic quantum critical point.

Tension pneumoperitoneum: a very rare complication of acute gangrenous appendicitis

Tension pneumoperitoneum is a very rare consequence of acute gangrenous appendicitis. We report a case of a 32-year-old woman who presented with abdominal pain, progressively increasing abdominal distension, profound hemodynamic instability and ventilatory compromise. The diagnosis of tension pneumoperitoneum was confirmed by computed tomography, which showed compression of the intra-abdominal viscera and liver (saddlebag sign) by a large volume of intraperitoneal free air. Urgent needle decompression was done as an emergency measure. Exploratory laparotomy, planned due to persistent peritonitis, revealed gangrenous appendicitis with perforation near its base. Appendicectomy with excision of gangrenous portion of caecum was performed. The purpose of the reporting this case is to highlight that the tension pneumoperitoneum can be, very rarely, associated with gangrenous appendicitis and timely diagnosis is very important for the emergency management of this deadly condition.

Molecular signature of extended spectrum β-lactamase producing Klebsiella pneumoniae isolated from bovine milk in eastern and north-eastern India

The present study reports on 23 extended spectrum β-lactamase producing Klebsiella pneumoniae (KP), isolated from milk samples (n=340) of healthy cows (n=129) and cows with subclinical (n=159) and clinical (n=52) mastitis, from three different states of India viz. West Bengal, Jharkhand and Mizoram. Seven of them were AmpC type β-lactamase producers, as well. The ESBL producing KP were significantly (P=0.006, χ2=10.04, df=2) and more frequently detected in milk samples of mastitic cows than healthy ones. The β-lactamase genes - blaCTX-M, blaTEM and blaSHV were detected in 19, 8 and 3 isolates, respectively. In all but one CTX-M positive isolates, the genetic platform - ISEcp1-blaCTX-M-orf477 was detected. Ten of the isolates carried plasmid mediated quinolone resistance gene - qnrS and 1 isolate possessed qnrB. Again 11 of them were found to have sulfonamide resistance gene - sul1 and 12 possessed class I integron. Sequencing of the class 1 integron revealed the presence of dfrA12/dfrA17 and aadA2/aadA5 gene cassettes conferring resistance to trimethoprim and aminoglycosides, respectively. All the isolates, characterized by enterobacterial repetitive intergenic consensus (ERIC) PCR, yielded distinct fingerprinting profile. However, most of the isolates from Jharkhand were clustered along with two isolates each from West Bengal and Mizoram indicating their clonal relatedness even though isolated from geographically different areas. Isolation of ESBL producing KP from bovine milk samples implies its public health significance; as such pathogens may enter the human food chain causing severe health hazards.

Unplanned urology readmissions in a district general hospital: are we meeting the standard?

Background

Recent changes in practice standards and remuneration to UK Trusts have been refined to penalise institutions for patient readmission within 30 days of discharge. The purpose of this study was to determine if the target rate of less than 6.5% was attained within the setting of a district general hospital (DGH) and also to comment on readmission trends.

Materials and methods

A retrospective study was performed over 12 months examining all unplanned readmissions to hospital 30 days following discharge from Urology. Elective as well as emergency cases were audited.

Results

A total of 4124 patients were treated and discharged by the department over 12 months. One hundred and eighty-four (4.4%) patients were readmitted: 93 (51%) patients following acute presentations and 91 (49%) following elective procedures. The commonest causes for unplanned readmission were haematuria, 29 cases (16%), acute urinary retention, 28 cases (15%) and ureteric colic, 25 cases (14%). Readmission rates following flexible cystoscopy and TRUS biopsy were 1% and 3%, respectively. Only six of 70 patients (9%) were readmitted following TURP. Five (3%) of the 184 readmissions required a second procedure.

Conclusion

Our department met the predetermined standard in achieving an unplanned readmission rate of less than 6.5%. This study also highlighted the need for discharge policies for common acute presentations.

Traumatic abdominal wall hernia with concealed colonic perforation

Traumatic abdominal wall hernia (TAWH) is a rare clinical entity in terms of aetiology. It occurs following a blunt abdominal injury with energy high enough to cause disruption of the musculoaponeurotic layer but not the elastic skin layer. It is often associated with underlying intra-abdominal injuries, which can be diagnosed either clinically or radiologically. We report a case of TAWH in a young man with associated large bowel transection, which remained undiagnosed in the preoperative period owing to its masked features. He was managed surgically, with no recurrence to date. Considering the high volume of blunt abdominal trauma cases that present to the accident and emergency department, only few cases of TAWH have been reported in the literature. Confusion still exists regarding the timing and mode of management of this condition.