Association between proactive esophageal cooling and increased lab throughput

INTRODUCTION

Proactive esophageal cooling has been FDA cleared to reduce the likelihood of ablation-related esophageal injury resulting from radiofrequency (RF) cardiac ablation procedures. Data suggest that procedure times for RF pulmonary vein isolation (PVI) also decrease when proactive esophageal cooling is employed instead of luminal esophageal temperature (LET) monitoring. Reduced procedure times may allow increased electrophysiology (EP) lab throughput. We aimed to quantify the change in EP lab throughput of PVI cases after the introduction of proactive esophageal cooling.

METHODS

EP lab throughput data were obtained from three EP groups. We then compared EP lab throughput over equal time frames at each site before (pre-adoption) and after (post-adoption) the adoption of proactive esophageal cooling.

RESULTS

Over the time frame of the study, a total of 2498 PVIs were performed over a combined 74 months, with cooling adopted in September 2021, November 2021, and March 2022 at each respective site. In the pre-adoption time frame, 1026 PVIs were performed using a combination of LET monitoring with the addition of esophageal deviation when deemed necessary by the operator. In the post-adoption time frame, 1472 PVIs were performed using exclusively proactive esophageal cooling, representing a mean 43% increase in throughput (p < .0001), despite the loss of two operators during the post-adoption time frame.

CONCLUSION

Adoption of proactive esophageal cooling during PVI ablation procedures is associated with a significant increase in EP lab throughput, even after a reduction in total number of operating physicians in the post-adoption group.

Atrioesophageal Fistula Rates Before and After Adoption of Active Esophageal Cooling During Atrial Fibrillation Ablation

BACKGROUND

Active esophageal cooling reduces the incidence of endoscopically identified severe esophageal lesions during radiofrequency (RF) catheter ablation of the left atrium for the treatment of atrial fibrillation. A formal analysis of the atrioesophageal fistula (AEF) rate with active esophageal cooling has not previously been performed.

OBJECTIVES

The authors aimed to compare AEF rates before and after the adoption of active esophageal cooling.

METHODS

This institutional review board (IRB)-approved study was a prospective analysis of retrospective data, designed before collecting and analyzing the real-world data. The number of AEFs occurring in equivalent time frames before and after adoption of cooling using a dedicated esophageal cooling device (ensoETM, Attune Medical) were quantified across 25 prespecified hospital systems. AEF rates were then compared using generalized estimating equations robust to cluster correlation.

RESULTS

A total of 14,224 patients received active esophageal cooling during RF ablation across the 25 hospital systems, which included a total of 30 separate hospitals. In the time frames before adoption of active cooling, a total of 10,962 patients received primarily luminal esophageal temperature (LET) monitoring during their RF ablations. In the preadoption cohort, a total of 16 AEFs occurred, for an AEF rate of 0.146%, in line with other published estimates for procedures using LET monitoring. In the postadoption cohort, no AEFs were found in the prespecified sites, yielding an AEF rate of 0% (P < 0.0001).

CONCLUSIONS

Adoption of active esophageal cooling during RF ablation of the left atrium for the treatment of atrial fibrillation was associated with a significant reduction in AEF rate.

Differential effect of anticoagulation according to cognitive function and frailty in older patients with atrial fibrillation

BACKGROUND

In older patients with atrial fibrillation (AF), cognitive impairment and frailty are prevalent. It is unknown whether the risk and benefit of anticoagulation differ by cognitive function and frailty.

METHODS

A total of 1244 individuals with AF with age ≥65 years and a CHADSVASC score ≥2 were recruited from clinics in Massachusetts and Georgia between 2016 and 18 and followed until 2020. At baseline, frailty status and cognitive function were assessed. Hazard ratios of anticoagulation on physician adjudicated outcomes were adjusted by the propensity for receiving anticoagulation and stratified by cognitive function and frailty status.

RESULTS

The average age was 75.5 (± 7.1) years, 49% were women, and 86% were prescribed oral anticoagulants. At baseline, 528 (42.4%) participants were cognitively impaired and 172 (13.8%) were frail. The adjusted hazard ratios of anticoagulation for the composite of major bleeding or death were 2.23 (95% confidence interval: 1.08-4.61) among cognitively impaired individuals and 0.94 (95% confidence interval: 0.49-1.79) among cognitively intact individuals (P for interaction = 0.08). Adjusted hazard ratios for anticoagulation were 1.84 (95% confidence interval: 0.66-5.13) among frail individuals and 1.39 (95% confidence interval: 0.84-2.40) among not frail individuals (P for interaction = 0.67).

CONCLUSION

Compared with no anticoagulation, anticoagulation is associated with more major bleeding episodes and death in older patients with AF who are cognitively impaired.

Filamentous nuclear actin regulation of PML NBs during the DNA damage response is deregulated by prelamin A

Nuclear actin participates in a continuously expanding list of core processes within eukaryotic nuclei, including the maintenance of genomic integrity. In response to DNA damage, nuclear actin polymerises into filaments that are involved in the repair of damaged DNA through incompletely defined mechanisms. We present data to show that the formation of nuclear F-actin in response to genotoxic stress acts as a scaffold for PML NBs and that these filamentous networks are essential for PML NB fission and recruitment of microbodies to DNA lesions. Further to this, we demonstrate that the accumulation of the toxic lamin A precursor prelamin A induces mislocalisation of nuclear actin to the nuclear envelope and prevents the establishment of nucleoplasmic F-actin networks in response to stress. Consequently, PML NB dynamics and recruitment to DNA lesions is ablated, resulting in impaired DNA damage repair. Inhibition of nuclear export of formin mDia2 restores nuclear F-actin formation by augmenting polymerisation of nuclear actin in response to stress and rescues PML NB localisation to sites of DNA repair, leading to reduced levels of DNA damage.

Exploring the role of exposure to green and blue spaces in preventing anxiety and depression among young people aged 14-24 years living in urban settings: A systematic review and conceptual framework

Despite the growing problem of anxiety and depression amongst young people aged 14-24 years living in urban settings, reviews about the role of exposure to green and blue spaces or nature in preventing anxiety and depression tend to focus on children, adults or sometimes adolescents. This review aims to explore whether exposure to green and blue spaces reduces the risk of anxiety and depression among young people aged 14-24 years living in urban settings and provide a conceptual framework. The academic databases CINAHL plus, Global Health, MEDLINE, ProQuest: Dissertations and Theses, PsycINFO, Scopus and OpenGrey were searched for research published in English between January 2000 and June 2020. All study designs were eligible. All included studies were assessed for quality. Searches identified 9208 sources with 48 meeting the inclusion criteria for the review. Experimental studies provided evidence that walking or being in a green space improves mood and state anxiety immediately following the intervention. Non-randomised evaluations and observational studies suggest that social interaction, physical activity, and mindfulness mediate the relationship between exposure to green space and mental health. We propose that the absence of noise and restorative qualities of green spaces promotes mindfulness and interrupt rumination, which in turn reduce the risk of anxiety disorders and depression. This review and the resulting conceptual framework provide evidence to healthcare professionals about the value of contact with nature and green social prescribing. For policymakers, it provides evidence about the value of bringing the benefits of forests, vegetation and nature into cities, and ensuring that these spaces are accessible and safe for young people to use.

Presence of Geriatric Conditions Is Prognostic of Major Bleeding in Older Patients with Atrial Fibrillation: a Cohort Study

BACKGROUND

In older patients with atrial fibrillation (AF), physical, cognitive, and psychosocial limitations are prevalent. The prognostic value of these conditions for major bleeding is unclear.

OBJECTIVE

To determine whether geriatric conditions are prospectively associated with major bleeding in older patients with AF on anticoagulation.

DESIGN

Multicenter cohort study with 2-year follow-up from 2016 to 2020 in Massachusetts and Georgia from cardiology, electrophysiology, and primary care clinics.

PARTICIPANTS

Diagnosed with AF, age 65 years or older, CHA2DS2-VASc score of 2 or higher, and taking oral anticoagulant (n=1,064). A total of 6507 individuals were screened.

MAIN MEASURES

A six-component geriatric assessment of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Main outcome was major bleeding adjudicated by a physician panel.

KEY RESULTS

At baseline, participants were, on average, 75.5 years old and 49% were women. Mean CHA2DS2-VASc score was 4.5 and the mean HAS-BLED score was 3.3. During 2.0 (± 0.4) years of follow-up, 95 (8.9%) participants developed an episode of major bleeding. After adjusting for key covariates and accounting for competing risk from death, cognitive impairment (hazard ratio [HR] 1.62, 95% confidence interval [CI]: 1.02-2.56) and frailty (HR 2.77, 95% CI 1.38-5.58) were significantly associated with the development of major bleeding.

CONCLUSIONS

In older patients with AF taking anticoagulants, cognitive impairment and frailty were independently associated with major bleeding.

P-147 LAPAROSCOPIC SURGERY IS SUITABLE FOR MOST PATIENTS FOR INGUINAL HERNIA REPAIR AND IS AN EXCELLENT OPTION IN EXPERT HANDS

Introduction

This study reviews the practice of a high-volume surgeon, comparing laparoscopic and open surgery for inguinal hernia. In suitable patients the default was laparoscopic Totally Extra Peritoneal (TEP) approach.

Materials & Methods

Data from patients referred over 5 years with inguinal hernias was collated prospectively and analysed retrospectively. Short and long-term outcomes of laparoscopic and open repairs were compared.

Results

205 patients underwent repair of 288 hernias (90.7% laparoscopic, 9.3% open). 83 patients underwent bilateral repair (95.2% laparoscopic). 22 patients underwent repair of 27 recurrent hernias (68% laparoscopic).

1 case (0.5%), started laparoscopically was converted to open. Complication rates were 13.4% vs 36.8% in the laparoscopic and open arms respectively (p&lt;0.01): superficial infection (1.6% vs 0%, p=0.58); haematoma (6.3% vs 15.8%, p=0.14); seroma (4.8% vs 5.3%, p=0.94); persisting numbness (0% vs 5.3%, p&lt;0.01) and chronic pain (1.1% vs 0%, p=0.65). No patients suffered mesh infections or explantation.

Mean stay was significantly longer in open group (p=0.03), median stay was 0 nights in both groups. At median follow up 1.8 years (Interquartile-range 0.9–3.6 years) recurrence rate was 1.1% (0 female, 2 male) and 15.8% (1 female, 2 male) in the laparoscopic and open arms respectively (p&lt;0.01). Open surgery was associated with significantly higher risk of recurrence (HR: 16.3, 95% CI: 2.7–97.8, p&lt;0.01).

Conclusions

This series demonstrates the vast majority of inguinal hernias, both primary and recurrent can be treated with laparoscopic TEP repair. Higher recurrence and complication rates were associated with open repair, with a caveat of strong selection bias.

OC-029 LAPAROSCOPIC INGUINAL HERNIA REPAIR IS FEASIBLE IN PATIENTS WHO HAVE HAD PREVIOUS ABDOMINO-PELVIC SURGERY WITH NO INCREASED RISK OF COMPLICATIONS COMPARED TO OPEN REPAIR

Introduction

This study aims to understand whether previous abdomino-pelvic (AP) surgery is a predictor of peri-operative complication in inguinal hernia surgery and if there are discrepancies between laparoscopic or open repairs.

Material & Methods

All patients operated on within a 5-year period were audited and subcategorised based upon history of AP surgery. Patients were also categorised into laparoscopic and open groups. Data collected included complication rates, recurrence rates and readmission within 30 days.

Results

205 patients underwent repair of 288 hernias. 80 (39%) patients had a history of AP surgery. 32 patients suffered a complication (15.6%). 85% of the repairs were laparoscopic in the AP group vs 96.4% in the non-AP group (p=0.02). Complication rates were 17.5% and 14.4% in the AP group and non-AP group respectively (p=0.55). These included superficial infection (0% vs 2.4%, p=0.16), haematoma (11.3% vs 4.8%, p=0.08), seroma (5.0% vs 4.8%, p=0.95), persisting numbness (0% vs 0.8%, p=0.42), and chronic pain (1.3% vs 0.8%, p=0.75). There were no mesh infections or explantation in either arm. A greater proportion of patients in AP group required overnight stays (32.5% vs 21%, p=0.08). At median follow up 1.8 years, recurrence rates were 3.8% vs 1.6%, p=0.33 in AP and non-AP groups respectively.

Conclusions

Laparoscopic inguinal hernia is feasible in most patients with a history of AP surgery. Compared to open repair, there were no significant differences in recurrence or complication rates in patients with previous AP surgery. Therefore, previous AP surgery should not be a contraindication for laparoscopic repair.

P-048 DOES BILATERAL REPAIR INCREASE COMPLICATION RATES COMPARED TO UNILATERAL REPAIR IN PATIENTS UNDERGOING LAPAROSCOPIC TOTALLY EXTRAPERITONEAL INGUINAL HERNIA SURGERY?

Introduction

There is ongoing debate over whether to fix asymptomatic contralateral inguinal hernias during repair of the presenting hernia. This study reviewed the practice of one high-volume hernia surgeon, comparing unilateral and bilateral laparoscopic repairs, to establish if bilateral repair is associated with an increased risk of post-operative complications compared to unilateral repair.

Material & Methods

All patients operated on within a 5-year period were audited and subcategorised depending on whether they underwent unilateral or bilateral repair. Data was collected on complication rates, rates of recurrence, readmission within 30 days and duration of operation.

Results

186 patients underwent repair of 265 hernias. 79 patients underwent bilateral repair. 25 patients suffered a complication (13.4%). Complication rates were 11.2% and 16.5% in the unilateral group and bilateral group respectively (p=0.50). These included superficial infection (1.9% vs 1.3%, p=0.75), haematoma (5.6% vs 7.6%, p=0.59), seroma (2.8 vs 7.6%, p=0.13), and chronic pain (0% vs 2.5%, p=0.01). There were no mesh infections, persisting numbness or explantation in either arm. In both groups, median nights stayed was 0. At median length of follow-up of 1.8 years, recurrence rates were 1.9% vs 0% in the unilateral and bilateral arms respectively (p=0.22).

Conclusions

There was no significant difference in rates of complications between the bilateral and unilateral arms. Opportunistic repair may reduce risk of future surgeries and morbidity and does not appear to be associated with increased complications. Surgeons may wish to consider this when consenting patients.

POS0152 DIRECT AND INDIRECT EFFECT OF TNF INHIBITORS ON SPINAL MOBILITY IN PEOPLE WITH AXIAL SPONDYLOARTHRITIS AND THE MEDIATOR ROLE OF DISEASE ACTIVITY

Background

Although it may be difficult to detect changes in spinal mobility on the short term, spinal mobility is considered an important measure to assess the efficacy of drugs used to treat axial spondyloarthritis (axSpA). However, few studies evaluated the long-term impact of biologic treatment on spinal mobility.

Objectives

To describe the long-term effect of TNF inhibitors (TNFi) on spinal mobility in patients with axSpA, and to determine whether the use of TNFi treatment influences spinal mobility, and if this due to a direct or indirect effect (mediated by disease activity).

Methods

We performed a retrospective observational study, using data collected from patients with a clinical diagnosis of axSpA treated with TNFi at a tertiary care centre where disease activity and metrology assessments are routinely done. Adult patients with at least two Bath Ankylosing Spondylitis Metrology Index (BASMI) measurements were included. Disease activity was measured using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score C-reactive protein (ASDAS). The longitudinal association between TNFi and improvement in BASDAI/ASDAS was tested using a linear mixed effects model with BASMI as dependent variable. To test whether TNFi had a direct effect on BASMI, not mediated by disease activity, we tested that TNFi treatment was not conditionally independent of BASMI given BASDAI/ASDAS (Figure 1). We tested whether the nodes TNFi and BASMI were disconnected if we removed BASDAI and ASDAS. To test this conditional independence, we first built a linear mixed effects model for BASMI given BASDAI or ASDAS when the patient was under TNFi and used this model to predict a 95% confidence interval (CI) for BASMI given the data for BASDAI/ASDAS when the patient was without TNFi. We checked whether the true value of BASMI lay within this 95% CI and performed a hypothesis test for binomial distribution where H0: p=0.95. To test for the indirect effect of TNFi on BASMI reduction, mediated through the disease activity, we regressed BASMI on BASDAI/ASDAS, TNFi (if there was a direct effect), demographics, presence of radiographic (r-) axSpA and HLA-B27 positivity, using a linear mixed effects model adjusted for within-patient correlation.

Figure 1.

Indirect effect of TNFi on BASMI (represented by the full line), through the influence of TNFi on disease activity, adjusted by other confounders and direct effect of TNFi on BASMI (dashed line), independently of disease activity.

Results

Data from 188 patients and 1326 visits were analysed. Mean age was 45.6 (SD 11.6) years, mean disease duration was 15.8 (SD 9.64) years, 152 (80.9%) were male, 120 (73.6%) had r-axSpA, and 83 (74.8%) were HLA-B27 positive. Mean follow-up time was 8.0 (SD 4.4) years, ranging from 0.8 to 18.2 years. Treatment with TNFi was significantly associated with long-term improvement in BASMI (B=-0.423, 95% CI=[-0.553,-0.292], p<0.001). An indirect effect of TNFi on BASMI improvement was observed, mediated by reduction in disease activity, measured by BASDAI (B=0.146, 95% CI=[0.092, 0.200], p<0.001) or ASDAS (B=0.405, 95% CI=[0.260, 0.549], p<0.001). Using conditional independence tests, a direct effect of TNFi on BASMI improvement was also observed, independently of disease activity, when BASDAI was used (p<0.001) as a covariate, but not when ASDAS was used (p=0.3104). The direct effect of TNFi (B=-0.300, 95% CI=[-0.576,-0.025], p<0.001) on BASMI was estimated in the BASDAI-adjusted mixed effects model.

Conclusion

TNFi are effective at improving BASMI in patients with axSpA, in a real-life setting. This effect is mainly explained by the reduction in disease activity. However, a direct effect of TNFi on BASMI could also be demonstrated, when disease activity was measured by BASDAI, suggesting that ASDAS captures additional factors that can influence spinal mobility. These potential factors deserve further investigation, but they could for example include biomechanical properties of tendons and myofascial tissue.

Disclosure of Interests

Ana Sofia Pinto: None declared, Bohao Yao: None declared, Claire Harris: None declared, Rhys Hayward: None declared, Andrew Keat: None declared, Pedro Machado Speakers bureau: Received consulting/speaker’s fees from Abbvie, BMS, Celgene, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this

manuscript, Consultant of: Received consulting/speaker’s fees from Abbvie, BMS, Celgene, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this

manuscript

AB1081 FLARES OF RHEUMATOID ARTHRITIS FOLLOWING CORONAVIRUS VACCINATION

Background

With the emergence of the Coronavirus vaccine and the clear and important role it provides in maintaining the health of individuals and the population (1), it is important that our patients receive or are recommended the vaccine. We here document a case series of patients who have long-term quiescent rheumatoid arthritis who then experienced a flare of disease activity after receiving a vaccine. This information is important to understand as it allows informed discussions regarding the side effect profile of the vaccine and also the influence this may have on the patient’s disease control and future management options.

Objectives

To understand the changes to control of rheumatoid arthritis in those experiencing a flare of disease after receiving the coronavirus vaccine.

Methods

Patients were reviewed in clinic as part of standard care. Individuals with Rheumatoid Arthritis who had experienced a flare defined as a self-reported disease activity score of >5.1 in otherwise stable disease were noted and their response to treatment reviewed. This was a review of usual clinical practice and did not alter the treatment undertaken or monitoring of the patent. Information obtained was through the consultation with a rheumatologist and the data was collected retrospectively through review of clinical notes and clinic letters.

Results

The table below outlines the patient details and treatment responses.

All flares occurred within two weeks of receiving the vaccine. Of the patients who flared, two required short term steroid treatment; three an increase in the usual medications and one who had been in disease remission to re-start previous therapy. More patients in the Pfizer vaccine group required an escalation of usual care compared to the AstraZeneca vaccine group.

Table 1Antibody statusVaccine brandTime since diagnosisTime since last flareFlare after 1st or 2nd doseUsual treatmentFlare managementSeropositive, anti-CCP positiveAstraZeneca13 years3 years1stEtanercept, MethotrexateIntramuscular MethylprednisoloneSeropositive, anti-CCP positiveAstraZeneca11 years4 years1stEtanercept, SulfasalazineIntramuscular Methylprednisolone, local joint injectionSeronegative, anti-CCP negativeAstraZenica13 years2 years1stMethotrexateIncrease methotrexate doseSeronegative, anti-CCP positivePfizer23 years11 years1stInfliximabLocal joint injection, reduce interval of infusionsSeronegative, anti-CCP positivePfizer7 years3 years2ndSulfasalazine, hydroxychloroquineIncrease Sulfasalazine doseSeropositive, anti-CCP positivePfizer7 years4 years2ndnilRe-start methotrexate, hydroxychloroquine

Conclusion

We report 6 cases of rheumatoid arthritis flare soon after receipt of the coronavirus vaccine. In all, disease control was returned with minimal changes to treatment, 42% of those requiring either no treatment or an intramuscular steroid injection alone. Therefore, we recommend that clinicians should counsel patients of this potential effect, but continue to advocate the vaccine, as the risk of complications to their underlying arthritis is very low and seemingly easily treatable.

References

[1]Tenforde MW, Olson SM, Self WH, Talbot HK, Lindsell CJ, Steingrub JS, et al. Effectiveness of Pfizer-BioNTech and Moderna Vaccines Against COVID-19 Among Hospitalized Adults Aged ≥65 Years - United States, January-March 2021. MMWR. Morbidity and mortality weekly report. 2021; 70 (18): 674-679. Available from: doi: 10.15585/mmwr.mm7018e1

Disclosure of Interests

None declared

73 Computed Tomography Imaging to Determine Reduction in Intracrainal Pressure Before & After Posterior Vault Expansion in Apert Syndrome

Introduction

Apert syndrome is an autosomal dominant malformation syndrome, accounting for 4.5% of all craniosynostoses. Raised intracranial pressure (ICP) in Apert syndrome has a multifactorial aetiology, with an incidence of up to 45% if left untreated [1, 2]. Raised ICP can be determined clinically, with non-invasive and invasive methods. In this study, we want to assess whether the use of CT scans is reliable in identifying changes in ICP.

Method

Pre and postoperative CT scans for 13 Apert syndrome patients who had posterior vault expansion were assessed and graded for severity of intracranial pressure (ICP). The grading system used was departmental specific and the assessment was carried out by a single clinician on different brain structures. This process was repeated on the same patients, using the same CT scans, 4 months later to determine consistency and repeatability. The relationship between the pre and postoperative scans was explored using the chi squared test. Intra-observer variability was assessed using Kappa statistics [SS1].

Results

There was no statistically significant difference between the pre and postoperative CT scan grading. Across instances, only one assessed structure had a p-value &lt;0.05. The Kappa interobserver reliability test did not identify a strong agreement in the comparison of the two instances of data analysis.

Conclusions

Assessment of CT scans is not a reliable method to determine changes in intracranial pressure in Apert syndrome patients who have had a posterior vault expansion.

Comparison of risk factors for coronary event in people with unattributed and non-coronary chest pain: an electronic health record cohort study

Background

Patients presenting to primary care with chest pain are often not given a cause. Patients with such unattributed chest pain have an increased risk of future cardiovascular disease (CVD) compared to patients with diagnosed non-coronary chest pain. It is unknown whether risk factors for CVD determined in the general population are the same for the population with unattributed or non-coronary chest pain.

Purpose

To determine if key risk factors for a coronary event in patients with unattributed chest pain are similar to those for patients with non-coronary chest pain and previously identified in the general population.

Methods

The study used primary care information from the Clinical Practice Research Datalink Aurum linked to hospital inpatient and mortality data. Patients aged ≥18 years with an incident record of unattributed or non-coronary chest pain in 2002–2018 and no diagnosis of CVD were included. We included as potential risk factors those established for CVD in the general population and non-coronary explanations for chest pain. Flexible parametric models estimated hazard ratios (95% confidence intervals (CI)) between factors and incident coronary event (defined as myocardial infarction, angina, coronary heart disease, percutaneous intervention, and coronary artery bypass graft surgery).

Results

There were 375,240 patients with unattributed chest pain (53% female: mean age 49; 47% male: mean age 47) and 245,329 patients with non-coronary chest pain (58% female: mean age 47; 42% male: mean age 44). Median duration of follow-up was 5 years. In the unattributed chest pain group, there were 111 (95% CI: 109, 112) and 140 (138, 142) coronary events per 10,000 person-years in females and males, respectively. Lower rates of coronary event were observed in the non-coronary chest pain group (females: 73 (72, 75); males: 96 (94, 98)). Within females (Figure), in both chest pain groups the strongest risk factors were type I and type II diabetes, atrial fibrillation, and hypertension whereas no associations were observed for migraine and chronic kidney disease. Whilst alternative explanations for non-coronary chest pain also increased the risk of coronary events, associations were less strong than for established general population risk factors. Similar findings were found in males although family history of coronary event was a stronger risk factor in the non-coronary chest pain group compared to the unattributed chest pain group.

Conclusions

The pool of factors found to increase the risk of coronary events in patients presenting with recorded unattributed or non-coronary chest pain are similar but not identical to those identified for the general population. Further research is needed to develop prognostic models to identify patients at the most risk of a coronary event as models developed in the general population are unlikely to be applicable given the increased underlying risk of coronary events in these populations.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Study funded by the British Heart Foundation, reference PG/19/46/34307. KJ also supported by matched funding awarded to the NIHR Applied Research Collaboration (West Midlands). Risk factors for coronary event

Contemporary procedure characteristics and outcomes of accessory atrioventricular pathway ablations in an integrated community-based health care system using a tiered approach

Background

Since the early descriptions of large series of accessory atrioventricular pathway ablations in adults and adolescents over 20 years ago, there have been limited published reports based on more recent experiences of large referral centers. We aimed to characterize accessory pathway distribution and features in a large community-based population that influence ablation outcomes using a tiered approach to ablation.

Methods

Retrospective analysis of 289 patients (age 14–81) who underwent accessory ablation from 2015–2019 was performed. Pathways were categorized into anteroseptal, left freewall, posteroseptal, and right freewall locations. We analyzed patient and pathway features to identify factors associated with prolonged procedure time parameters.

Results

Initial ablation success rate was 94.7% with long-term success rate of 93.4% and median follow-up of 931 days. Accessory pathways were in left freewall (61.6%), posteroseptal (24.6%), right freewall (9.6%), and anteroseptal (4.3%) locations. Procedure outcome was dependent on pathway location. Acute success was highest for left freewall pathways (97.1%) with lowest case times (144 ± 68 min) and fluoroscopy times (15 ± 19 min). Longest procedure time parameters were seen with anteroseptal, left anterolateral, epicardial-coronary sinus, and right anterolateral pathway ablations.

Conclusions

In this community-based adult and adolescent population, majority of the accessory pathways are in the left freewall and posteroseptal region and tend to be more easily ablated. A tiered approach with initial use of standard ablation equipment before the deployment of more advance tools, such as irrigated tips and 3D mapping, is cost effective without sacrificing overall efficacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02132-0.

Exposure to green space and prevention of anxiety and depression among young people in urban settings: a global scoping review

Purpose

There is a mental health crisis, particularly among young people. Despite many young people living in urban settings, reviews about the association between exposure to green or natural environments and mental health tend to focus on either children or adults. The aim of this review is to examine the scope of the global literature for this age group, to inform a systematic review on the role of exposure to green space in preventing anxiety and depression amongst young people aged 14–24 years.

Design/methodology/approach

Seven databases were searched for quantitative and qualitative sources published from January 2000 to June 2020. This identified 201 sources and their characteristics are described here. Gaps in the literature are also highlighted.

Findings

The number of relevant studies published per year has increased over time. Most studies are set in North America (28%) or Europe (39%). The most common study designs were observational (34%) or experimental (28%). A wide range of exposures and interventions are described.

Research limitations/implications

This review included literature from predominantly high-income countries and has shown the under-representation of low-middle income countries and lack of ethnic diversity in study populations. It has also highlighted the lack of clinical measures of anxiety and depression as outcomes.

Originality/value

This inter-disciplinary review has contributed to the field by describing the geographic distribution of the literature and the broad range of exposures to green spaces being reported. Unlike previous scoping reviews, this review focused specifically on young people and on measures of anxiety and depression and their pre-cursers.

Runx2 (Runt-Related Transcription Factor 2) Links the DNA Damage Response to Osteogenic Reprogramming and Apoptosis of Vascular Smooth Muscle Cells

[Figure: see text].

Poly(ADP-Ribose) Links the DNA Damage Response and Biomineralization

Biomineralization of the extracellular matrix is an essential, regulated process. Inappropriate mineralization of bone and the vasculature has devastating effects on patient health, yet an integrated understanding of the chemical and cell biological processes that lead to mineral nucleation remains elusive. Here, we report that biomineralization of bone and the vasculature is associated with extracellular poly(ADP-ribose) synthesized by poly(ADP-ribose) polymerases in response to oxidative and/or DNA damage. We use ultrastructural methods to show poly(ADP-ribose) can form both calcified spherical particles, reminiscent of those found in vascular calcification, and biomimetically calcified collagen fibrils similar to bone. Importantly, inhibition of poly(ADP-ribose) biosynthesis in vitro and in vivo inhibits biomineralization, suggesting a therapeutic route for the treatment of vascular calcifications. We conclude that poly(ADP-ribose) plays a central chemical role in both pathological and physiological extracellular matrix calcification.

•

Poly(ADP-ribose) is found close to ECM calcification in developing bone and arteries

•

Poly(ADP-ribose) is produced in response to oxidative stress and delivered to the ECM

•

Poly(ADP-ribose) forms dense liquid droplets with calcium ions

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Inhibiting PARP enzyme activity blocks calcification in vitro and in vivo

Rates of Potentially Inappropriate Dosing of Direct-Acting Oral Anticoagulants and Associations With Geriatric Conditions Among Older Patients With Atrial Fibrillation: The SAGE-AF Study

Background

Direct‐acting oral anticoagulant (DOAC) dosing guidelines for atrial fibrillation recommend dose alteration based on age, renal function, body weight, and drug‐drug interactions. There is paucity of data describing the frequency and factors associated with prescription of potentially inappropriate doses.

Methods and Results

In the ongoing SAGE‐AF (Systematic Assessment of Geriatric Elements in Atrial Fibrillation) study, we performed geriatric assessments (frailty, cognitive impairment, sensory impairments, social isolation, and depression) for participants with atrial fibrillation (age ≥65 years, CHA₂DS₂VASc ≥2, no anticoagulant contraindications). We developed an algorithm to analyze DOAC dose appropriateness accounting for drug‐drug interactions, age, renal function, and body weight. We also examined whether geriatric impairments were related to inappropriate dosing. Of 1064 patients prescribed anticoagulants, 460 received a DOAC. Participants were aged 74±7 years, 49% were women, and 82% were white. A quarter (23%; n=105) of participants received inappropriate DOAC dose, of whom 82 (78%) were underdosed and 23 (22%) were overdosed. Among participants receiving an inappropriate dose, 12 (11%) were identified using the drug‐drug interactions criteria and would have otherwise been misclassified. In multivariable regression analyses, older age, higher CHA₂DS₂VASc score, and history of renal failure were associated with inappropriate DOAC dosing (P<0.05). Geriatric conditions were not associated with inappropriate dosing.

Conclusions

In this cohort, over 20% of older patients with atrial fibrillation treated with DOACs were prescribed an inappropriate dose, with most being underdosed. Drug‐drug interactions were common. Factors that influence prescription of guideline‐nonadherent doses may be perception of higher bleeding risk or presence of renal failure in addition to lack of familiarity with dosing guidelines.

Prelamin A mediates myocardial inflammation in dilated and HIV-associated cardiomyopathies

Cardiomyopathies are complex heart muscle diseases that can be inherited or acquired. Dilated cardiomyopathy can result from mutations in LMNA, encoding the nuclear intermediate filament proteins lamin A/C. Some LMNA mutations lead to accumulation of the lamin A precursor, prelamin A, which is disease causing in a number of tissues, yet its impact upon the heart is unknown. Here, we discovered myocardial prelamin A accumulation occurred in a case of dilated cardiomyopathy, and we show that a potentially novel mouse model of cardiac-specific prelamin A accumulation exhibited a phenotype consistent with inflammatory cardiomyopathy, which we observed to be similar to HIV-associated cardiomyopathy, an acquired disease state. Numerous HIV protease therapies are known to inhibit ZMPSTE24, the enzyme responsible for prelamin A processing, and we confirmed that accumulation of prelamin A occurred in HIV+ patient cardiac biopsies. These findings (a) confirm a unifying pathological role for prelamin A common to genetic and acquired cardiomyopathies; (b) have implications for the management of HIV patients with cardiac disease, suggesting protease inhibitors should be replaced with alternative therapies (i.e., nonnucleoside reverse transcriptase inhibitors); and (c) suggest that targeting inflammation may be a useful treatment strategy for certain forms of inherited cardiomyopathy.

Geriatric Conditions and Prescription of Vitamin K Antagonists vs. Direct Oral Anticoagulants Among Older Patients With Atrial Fibrillation: SAGE-AF

Background: Geriatric conditions are common among patients with atrial fibrillation (AF) and relate to complications of oral anticoagulation (OAC).

Objective: To examine the prevalence of geriatric conditions among older patients with AF on OAC and relate type of OAC to geriatric conditions.

Methods: Participants had a diagnosis of AF, were aged ≥65 years, CHA₂DS₂VASC ≥ 2, and had no OAC contraindications. Participants completed a 6-component geriatric assessment that included validated measures of frailty (CHS Frailty Scale), cognitive function (MoCA), social support (MOS), depressive symptoms (PHQ9), vision, and hearing. Type of OAC prescribed was documented in medical records.

Results: 86% of participants were prescribed an OAC. These participants were on average aged 75.7 (SD: 7.1) years, 49% were women, two thirds were frail or pre-frail, and 44% received a DOAC. DOAC users were younger, had lower CHA₂DS₂VASC and HAS-BLED scores, and were less likely to be frail. In Massachusetts, pre-frailty was associated with a significantly lower odds of DOAC vs. VKA use (OR = 0.64, 95%CI 0.45, 0.91). Pre-frailty (OR = 0.33, 95%CI 0.18–0.59) and social isolation (OR = 0.38, 95%CI 0.14–0.99) were associated with lower odds of DOAC receipt in patients aged 75 years or older. Social isolation was associated with higher odds of DOAC use (OR = 2.13, 95%CI 1.05–4.29) in patients aged 65–74 years.

Conclusions: Geriatric conditions were common and related to type of OAC prescribed, differentially by age group. Research is needed to evaluate whether a geriatric examination can be used clinically to better inform OAC decision-making in older patients with AF.

Physical, cognitive, and psychosocial conditions in relation to anticoagulation satisfaction among elderly adults with atrial fibrillation: The SAGE-AF study

BACKGROUND

Successful anticoagulation is critical for stroke prevention in adults with atrial fibrillation (AF). Anticoagulation satisfaction is a key indicator of treatment success. While physical, cognitive, and psychosocial limitations are common in elderly AF patients, their associations with anticoagulation satisfaction are unknown.

OBJECTIVE

Examine whether anticoagulation satisfaction differs among AF patients with and without physical, cognitive, and psychosocial conditions.

METHODS

The study comprised AF patients greater than or equal to 65 years old who were prescribed an oral anticoagulant (warfarin 57%; direct oral anticoagulant [DOAC] 43%). Frailty, cognitive function, social support, depressive symptoms, vision, hearing, and anxiety were assessed using validated measures. Anticoagulation satisfaction was measured using the anticlot treatment scale.

RESULTS

Participants (n = 1037, 50% female) were on average 76 years old. The following conditions were prevalent: frailty (14%), cognitive impairment (42%), social isolation (13%), vision impairment (35%), hearing impairment (36%), depression (29%), and anxiety (24%). Average anticlot treatment burden scale was 55 out of 60 (lower burden scales indicating higher perceived burden). Patients with high perceived burden were older, more likely to be female, and receive warfarin. After adjusting for confounders, visual impairment (adjusted odds ratio [95% confidence interval]: 1.7 [1.2-2.4]), depressive symptoms (2.4 [1.6-3.7]), and anxiety (1.8 [1.2-2.7]) were significantly associated with high perceived burden. Different conditions were associated with high perceived burden in warfarin vs DOAC users.

CONCLUSION

Physical, cognitive, and psychosocial limitations are prevalent and associated with high perceived anticoagulation burden among elderly AF adults. These conditions merit consideration in anticoagulation prescribing.

Clinical Outcomes During Admissions for Heart Failure Among Adults With Congenital Heart Disease

Background

Heart failure (HF) admissions in adults with congenital heart disease (CHD) are becoming more common. We compared in‐hospital and readmission events among adults with and without CHD admitted for HF.

Methods and Results

We identified all admissions with the primary diagnosis of HF among adults in the California State Inpatient Database between January 1, 2005 and January 1, 2012. International Classification of Disease (ICD) codes identified the type of CHD lesion, comorbidities, and in‐hospital and 30‐day readmissions events. Adjusted odds ratio (AOR, 95% CI) was calculated after adjusting for admission year, age, sex, race, household income, primary payor, and Charlson comorbidity index. Of 203 759 patients admitted for HF, 539 had CHD other than atrial septal defect. Compared with patients admitted for HF without CHD, those with CHD were younger, more often male, and had fewer comorbidities as determined by Charlson comorbidity index. On multivariate analysis, CHD patients admitted for HF had higher odds of length of stay ≥7 days (AOR 2.5 [95% CI 2.0–3.1]), incident arrhythmias (AOR 2.8 [95% CI 1.7–4.5]), and in‐hospital mortality (AOR 1.9 [95% CI 1.1–3.1]). Also, CHD patients had lower odds of readmission for HF (AOR 0.6 [95% CI 0.3–0.9]), but similar odds of other 30‐day readmission events. Complex CHD patients had higher odds of length of stay ≥7 days (AOR 1.9 [95% CI 1.1–3.3]) than patients with noncomplex CHD lesions, but similar odds of all other clinical outcomes.

Conclusions

Among patients admitted with the primary diagnosis of HF in California, adults with CHD have substantially higher odds of longer length of stay, incident arrhythmias, and in‐hospital mortality compared with non‐CHD patients. These results suggest a need for HF risk stratification strategies and management protocols specific for patients with CHD.

Essential but sparse collagen hydroxylysyl post-translational modifications detected by DNP NMR

The sparse but functionally essential post-translational collagen modification 5-hydroxylysine can undergo further transformations, including crosslinking, O-glycosylation, and glycation. Dynamic nuclear polarization (DNP) and stable isotope enriched lysine incorporation provide sufficient solid-state NMR sensitivity to identify these adducts directly in skin and vascular smooth muscle cell extracellular matrix (ECM), without extraction procedures, by comparison with chemical shifts of model compounds. Thus, DNP provides access to the elucidation of structural consequences of collagen modifications in intact tissue.

In situ characterization of advanced glycation end products (AGEs) in collagen and model extracellular matrix by solid state NMR

Non-enzymatic glycation of extracellular matrix with (U-13C5)-d-ribose-5-phosphate (R5P), enables in situ 2D ssNMR identification of many deleterious protein modifications and crosslinks, including previously unreported oxalamido and hemiaminal (CH3-CH(OH)NHR) substructures. Changes in charged residue proportions and distribution may be as important as crosslinking in provoking and understanding harmful tissue changes.

Extracellular Matrix Proteomics Reveals Interplay of Aggrecan and Aggrecanases in Vascular Remodeling of Stented Coronary Arteries

Supplemental Digital Content is available in the text.

Background:

Extracellular matrix (ECM) remodeling contributes to in-stent restenosis and thrombosis. Despite its important clinical implications, little is known about ECM changes post–stent implantation.

Methods:

Bare-metal and drug-eluting stents were implanted in pig coronary arteries with an overstretch under optical coherence tomography guidance. Stented segments were harvested 1, 3, 7, 14, and 28 days post-stenting for proteomics analysis of the media and neointima.

Results:

A total of 151 ECM and ECM-associated proteins were identified by mass spectrometry. After stent implantation, proteins involved in regulating calcification were upregulated in the neointima of drug-eluting stents. The earliest changes in the media were proteins involved in inflammation and thrombosis, followed by changes in regulatory ECM proteins. By day 28, basement membrane proteins were reduced in drug-eluting stents in comparison with bare-metal stents. In contrast, the large aggregating proteoglycan aggrecan was increased. Aggrecanases of the ADAMTS (a disintegrin and metalloproteinase with thrombospondin motifs) family contribute to the catabolism of vascular proteoglycans. An increase in ADAMTS-specific aggrecan fragments was accompanied by a notable shift from ADAMTS1 and ADAMTS5 to ADAMTS4 gene expression after stent implantation. Immunostaining in human stented coronary arteries confirmed the presence of aggrecan and aggrecan fragments, in particular, at the contacts of the stent struts with the artery. Further investigation of aggrecan presence in the human vasculature revealed that aggrecan and aggrecan cleavage were more abundant in human arteries than in human veins. In addition, aggrecan synthesis was induced on grafting a vein into the arterial circulation, suggesting an important role for aggrecan in vascular plasticity. Finally, lack of ADAMTS-5 activity in mice resulted in an accumulation of aggrecan and a dilation of the thoracic aorta, confirming that aggrecanase activity regulates aggrecan abundance in the arterial wall and contributes to vascular remodeling.

Conclusions:

Significant differences were identified by proteomics in the ECM of coronary arteries after bare-metal and drug-eluting stent implantation, most notably an upregulation of aggrecan, a major ECM component of cartilaginous tissues that confers resistance to compression. The accumulation of aggrecan coincided with a shift in ADAMTS gene expression. This study provides the first evidence implicating aggrecan and aggrecanases in the vascular injury response after stenting.

Novel nesprin-1 mutations associated with dilated cardiomyopathy cause nuclear envelope disruption and defects in myogenesis

Nesprins-1 and -2 are highly expressed in skeletal and cardiac muscle and together with SUN (Sad1p/UNC84)-domain containing proteins and lamin A/C form the LInker of Nucleoskeleton-and-Cytoskeleton (LINC) bridging complex at the nuclear envelope (NE). Mutations in nesprin-1/2 have previously been found in patients with autosomal dominant Emery–Dreifuss muscular dystrophy (EDMD) as well as dilated cardiomyopathy (DCM). In this study, three novel rare variants (R8272Q, S8381C and N8406K) in the C-terminus of the SYNE1 gene (nesprin-1) were identified in seven DCM patients by mutation screening. Expression of these mutants caused nuclear morphology defects and reduced lamin A/C and SUN2 staining at the NE. GST pull-down indicated that nesprin-1/lamin/SUN interactions were disrupted. Nesprin-1 mutations were also associated with augmented activation of the ERK pathway in vitro and in hearts in vivo. During C2C12 muscle cell differentiation, nesprin-1 levels are increased concomitantly with kinesin light chain (KLC-1/2) and immunoprecipitation and GST pull-down showed that these proteins interacted via a recently identified LEWD domain in the C-terminus of nesprin-1. Expression of nesprin-1 mutants in C2C12 cells caused defects in myoblast differentiation and fusion associated with dysregulation of myogenic transcription factors and disruption of the nesprin-1 and KLC-1/2 interaction at the outer nuclear membrane. Expression of nesprin-1α₂ WT and mutants in zebrafish embryos caused heart developmental defects that varied in severity. These findings support a role for nesprin-1 in myogenesis and muscle disease, and uncover a novel mechanism whereby disruption of the LINC complex may contribute to the pathogenesis of DCM.

Validation of a GPU-Based 3D dose calculator for modulated beams

A superposition/convolution GPU-accelerated dose computation algorithm (the Calculator) has been recently incorporated into commercial software. The algorithm requires validation prior to clinical use. Three photon energies were examined: conventional 6 MV and 15 MV, and 10 MV flattening filter free (10 MVFFF). For a set of IMRT and VMAT plans based on four of the five AAPM Practice Guideline 5a downloadable datasets, ion chamber (IC) measurements were performed on the water-equivalent phantoms. The average difference between the Calculator and IC was -0.3 ± 0.8% (1SD). The same plans were projected on a phantom containing a biplanar diode array. We used the forthcoming criteria for routine gamma analysis, 3% dose-error (global (G) normalization, 2 mm distance to agreement, and 10% low dose cutoff). The γ (3%G/2 mm) average passing rate was 98.9 ± 2.1%. Measurement-guided three-dimensional dose reconstruction on the patient CT dataset (excluding the Lung) resulted in a similar average agreement rate with the Calculator: 98.2 ± 2.0%. The mean γ (3%G/2 mm) passing rate comparing the Calculator to the TPS (again excluding the Lung) was 99.0 ± 1.0%. Because of the significant inhomogeneity, the Lung case was investigated separately. The calculator has an alternate heterogeneity correction mode that can change the results in the thorax for higher-energy beams (15 MV). As this correction is nonphysical and was optimized for simple slab geometries, its application leads to mixed results when compared to the TPS and independent Monte Carlo calculations, depending on the CT dataset and the plan. The Calculator vs. TPS 15 MV Guideline 5a IMRT and VMAT plans demonstrate 96.3% and 93.4% γ (3%G/2 mm) passing rates respectively. For the lower energies, which should be predominantly used in the thoracic region, the passing rates for the same plans and criteria range from 98.6 to 100%. Overall, the Calculator accuracy is sufficient for the intended use.

Benefits and challenges of EMR implementations in low resource settings: a state-of-the-art review

BACKGROUND

The intent of this review is to discover the types of inquiry and range of objectives and outcomes addressed in studies of the impacts of Electronic Medical Record (EMR) implementations in limited resource settings in sub-Saharan Africa.

METHODS

A state-of-the-art review characterized relevant publications from bibliographic databases and grey literature repositories through systematic searching, concept-mapping, relevance and quality filter optimization, methods and outcomes categorization and key article analysis.

RESULTS

From an initial population of 749 domain articles published before February 2015, 32 passed context and methods filters to merit full-text analysis. Relevant literature was classified by type (e.g., secondary, primary), design (e.g., case series, intervention), focus (e.g., processes, outcomes) and context (e.g., location, organization). A conceptual framework of EMR implementation determinants (systems, people, processes, products) was developed to represent current knowledge about the effects of EMRs in resource-constrained settings and to facilitate comparisons with studies in other contexts.

DISCUSSION

This review provides an overall impression of the types and content of health informatics articles about EMR implementations in sub-Saharan Africa. Little is known about the unique effects of EMR efforts in slum settings. The available reports emphasize the complexity and impact of social considerations, outweighing product and system limitations. Summative guides and implementation toolkits were not found but could help EMR implementers.

CONCLUSION

The future of EMR implementation in sub-Saharan Africa is promising. This review reveals various examples and gaps in understanding how EMR implementations unfold in resource-constrained settings; and opportunities for new inquiry about how to improve deployments in those contexts.

Barriers and facilitators to Electronic Medical Record (EMR) use in an urban slum

OBJECTIVE

Rapid urbanization has led to the growth of urban slums and increased healthcare burdens for vulnerable populations. Electronic Medical Records (EMRs) have the potential to improve continuity of care for slum residents, but their implementation is complicated by technical and non-technical limitations. This study sought practical insights about facilitators and barriers to EMR implementation in urban slum environments.

METHOD

Descriptive qualitative method was used to explore staff perceptions about a recent open-source EMR deployment in two primary care clinics in Kibera, Nairobi. Participants were interviewed using open-ended, semi-structured questions. Content analysis was used when exploring transcribed data.

RESULTS

Three major themes - systems, software, and social considerations - emerged from content analysis, with sustainability concerns prevailing. Although participants reported many systems (e.g., power, network, Internet, hardware, interoperability) and software (e.g., data integrity, confidentiality, function) challenges, social factors (e.g., identity management, training, use incentives) appeared the most important impediments to sustainability.

DISCUSSION

These findings are consistent with what others have reported, especially the importance of practical barriers to EMR deployments in resource-constrained settings. Other findings contribute unique insights about social determinants of EMR impact in slum settings, including the challenge of multiple-identity management and development of meaningful incentives to staff compliance.

CONCLUSIONS

This study exposes front-line experiences with opportunities and shortcomings of EMR implementations in urban slum primary care clinics. Although the promise is great, there are a number of unique system, software and social challenges that EMR advocates should address before expecting sustainable EMR use in resource-constrained settings.

Evaluation of a system for providing information resources to nurses

The authors describe a study to plan and implement an information system for nurses. The objectives were to (1) determine the clinical information needs of nurses; (2) adapt an existing clinical information system (CLINT) to address their expressed needs; and (3) evaluate nurses’ use of and satisfaction with the enhanced system.

Thirty-nine nurses on a medical teaching unit in a tertiary hospital in Canada participated in the project. A needs assessment influenced the design of the nursing interface to CLINT and the development of educational and participatory strategies to promote its use. Data were collected before, after, and throughout the implementation period. Qualitative and quantitative methods, including focus groups, online questionnaires, and automated usage data collection, were used to describe nurses’ use of and satisfaction with the system.

The results suggested that peer mentorship, organizational support, and collaboration were the most effective strategies for promoting system use. The hospital information system (IHIS), Netscape, drug information and basic texts were the most frequently used databases. Nurses were satisfied with the system and reported progress in changing clinical practice. CLINT helped them to keep up with educational and professional development.

In conclusions, nurses are willing to use information systems that are relevant to their needs and user friendly. There is, however, a paucity of resources available for evidence-based clinical decision making.

Rosiglitazone treatment and cardiovascular disease in the Veterans Affairs Diabetes Trial

AIMS

To evaluate the relationship between patterns of rosiglitazone use and cardiovascular (CV) outcomes in the Veterans Affairs Diabetes Trial (VADT).

METHODS

Time-dependent survival analyses, case-control and 1 : 1 propensity matching approaches were used to examine the relationship between patterns of rosiglitazone use and CV outcomes in the VADT, a randomized controlled study that assessed the effect of intensive glycaemic control on CV outcomes in 1791 patients with type 2 diabetes (T2D) whose mean age was 60.4 ± 9 years. Participants were recruited between 1 December 2000 and 31 May 2003, and were followed for 5-7.5 years (median 5.6) with a final visit by 31 May 2008. Rosiglitazone (4 mg and 8 mg daily) was initiated per protocol in both the intensive-therapy and standard-therapy groups. Main outcomes included a composite CV outcome, CV death and myocardial infarction (MI).

RESULTS

Both daily doses of rosiglitazone were associated with lower risk for the primary composite CV outcome [4 mg: hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.49-0.81 and 8 mg: HR 0.60, 95% CI 0.49-0.75] after adjusting for demographic and clinical covariates. A reduction in CV death was also observed (HR 0.25, p < 0.001, for both 4 and 8 mg/day rosiglitazone); however, the effect on MI was less evident for 8 mg/day and not significant for 4 mg/day.

CONCLUSIONS

In older patients with T2D the use of rosiglitazone was associated with decreased risk of the primary CV composite outcome and CV death. Rosiglitazone use did not lead to a higher risk of MI.

Demonstration of the need for cardiovascular and pulmonary normative data for cancer survivors

Despite evidence that cancer and its treatments severely reduce cardiorespiratory fitness (CRF), normative data for cancer survivors do not exist. The present study identifies age and gender-specific CRF distributions in a cancer population. The use of cancer-specific normative CRF data may help stratify initial fitness status and assess improvements in response to exercise interventions in cancer survivors. Data from 703 cancer survivors were analyzed for this study. Quintiles were compiled for peak oxygen consumption (VO2peak), forced vital capacity (FVC), and forced expiratory volume (FEV1) for males and females in 5 age groups (19-39, 40-49, 50-59, 60-69, and ≥70 years of age). VO2peak values for the cancer population were significantly lower than the general US population. The cancer population average in each age group fell within the "very poor" classification of VO2peak values for the general population. FVC values in the cancer population were similar to the general population. Cancer survivors had very low age group-specific VO2peak values compared to the apparently healthy general US population. Previously, CRF values of cancer survivors were compared to normative values for the apparently healthy general population, which yielded imprecise classifications of initial fitness and changes in fitness, resulting in patient discouragement.

Effects of treadmill training on combined goserelin acetate and doxorubicin-induced osteopenia in female rats

OBJECTIVES

This study examined individual and combined effects of the cancer treatments goserelin acetate (GA) and doxorubicin (DOX) on bone and determined if treadmill running (TM) provides osteoprotection.

METHODS

Ten-week-old female Sprague-Dawley rats were randomly assigned to sedentary (SED) or TM groups. SED received GA, DOX, combined GA and DOX (GA+DOX), or placebo and maintained normal cage activity. TM received GA, DOX, GA+DOX, or placebo and participated in a progressive motorized treadmill protocol. After 8 weeks, tibiae were evaluated using micro computed tomography.

RESULTS

Negative drug effects were observed in cancellous bone (bone volume/tissue volume, trabecular number, trabecular thickness, trabecular spacing; P<0.05). An additive bone volume/tissue volume and trabecular spacing effect was observed in SED GA+DOX (vs. SED+GA and SED+DOX, P<0.05) but not in TM GA+DOX (vs. TM+GA and TM+DOX, P>0.05). Negative drug effects were observed in cortical bone (cross-sectional volume, cortical volume, marrow volume; P<0.05), but combined GA+DOX did not exacerbate these effects. Additionally, there were no protective cortical bone effects observed in TM.

CONCLUSIONS

Combined GA+DOX exacerbates cancellous osteopenia in the tibia, and treadmill running provided only minor protection.

Effect of SMURF2 targeting on susceptibility to MEK inhibitors in melanoma

BACKGROUND

The mitogen-activated protein-kinase pathway consisting of the kinases RAF, MEK, and ERK is central to cell proliferation and survival and is deregulated in more than 90% of melanomas. MEK inhibitors are currently trialled in the clinic, but despite efficient target inhibition, cytostatic rather than cytotoxic activity limits their efficacy.

METHODS

We assessed the cytotoxicity to MEK inhibitors (PD184352 and selumetinib) in melanoma cells by toluidine-blue staining, caspase 3 cleavage, and melanoma-sphere growth. Western blotting and quantitative real-time polymerase chain reaction were applied to determine SMAD-specific E3 ubiquitin protein ligase 2 (SMURF2), PAX3, and MITF expression. Human melanoma samples (n = 77) from various stages were analyzed for SMURF2 and PAX3 expression. RNA interference was performed to target SMURF2 during MEK inhibition in vivo in melanoma xenografts in mice and zebrafish. All statistical tests were two-sided.

RESULTS

Activation of transforming growth factor β (TGF-β) signalling sensitized melanoma cells to the cytotoxic effects of MEK inhibition. Melanoma cells resistant to the cytotoxic effects of MEK inhibitors counteracted TGF-β signalling through overexpression of the E3 ubiquitin ligase SMURF2, which resulted in increased expression of the transcription factors PAX3 and MITF. High MITF expression protected melanoma cells against MEK inhibitor cytotoxicity. Depleting SMURF2 reduced MITF expression and substantially lowered the threshold for MEK inhibitor-induced apoptosis. Moreover, SMURF2 depletion sensitized melanoma cells to the cytotoxic effects of selumetinib, leading to cell death at concentrations approximately 100-fold lower than the concentration required to induce cell death in SMURF2-expressing cells. Mice treated with selumetinib alone at a dosage of 10mg/kg body weight once daily produced no response, but in combination with SMURF2 depletion, selumetinib suppressed tumor growth by 97.9% (95% confidence interval = 38.65% to 155.50%, P = .005).

CONCLUSIONS

Targeting SMURF2 may be a novel therapeutic approach for increasing the antitumor efficacy of MEK inhibitors.