CAnceR IN PreGnancy (CARING) - a retrospective study of cancer diagnosed during pregnancy in the United Kingdom

BACKGROUND

The incidence of cancer diagnosed during pregnancy is increasing. Data relating to investigation and management, as well as maternal and foetal outcomes is lacking in a United Kingdom (UK) population.

METHODS

In this retrospective study we report data from 119 patients diagnosed with cancer during pregnancy from 14 cancer centres in the UK across a five-year period (2016-2020).

RESULTS

Median age at diagnosis was 33 years, with breast, skin and haematological the most common primary sites. The majority of cases were new diagnoses (109 patients, 91.6%). Most patients were treated with radical intent (96 patients, 80.7%), however, gastrointestinal cancers were associated with a high rate of palliative intent treatment (63.6%). Intervention was commenced during pregnancy in 68 (57.1%) patients; 44 (37%) had surgery and 31 (26.1%) received chemotherapy. Live births occurred in 98 (81.7%) of the cases, with 54 (55.1%) of these delivered by caesarean section. Maternal mortality during the study period was 20.2%.

CONCLUSIONS

This is the first pan-tumour report of diagnosis, management and outcomes of cancer diagnosed during pregnancy in the UK. Our findings demonstrate proof of concept that data collection is feasible and highlight the need for further research in this cohort of patients.

Prenatal surgery in fetal myelomeningocele with severe ventriculomegaly

OBJECTIVES

Prenatal myelomeningocele (MMC) repair is performed to decrease risk for treatment of hydrocephalus after birth and to preserve motor function. Some centers may not consider patients candidates for surgery if severe ventriculomegaly is present and there is no expected benefit in decreased risk for hydrocephalus treatment. This study sought to compare postnatal outcomes of fetuses with MMC and severe ventriculomegaly (>15mm) who underwent prenatal repair, with fetuses with severe ventriculomegaly who underwent postnatal repair and fetuses with ventriculomegaly (<15mm) who underwent prenatal repair.

METHODS

This was a retrospective study of fetuses with MMC that underwent prenatal or postnatal repair between 2012 and 2021 at a single institution. The cohort was divided based on preoperative fetal ventricular size into two groups, those with severe ventriculomegaly (≥15 mm) and those without severe ventriculomegaly (<15 mm). Fetal ventricular size was measured by MRI prior to surgery using the standardized approach and the mean of the left and right ventricle was used for analysis. Motor function of lower extremities was assessed at the time of referral by ultrasound and if flexion-extension movements of the ankle were seen, it was considered as preserved S1 motor function. Postnatal outcomes including motor function of lower extremities assessed at birth and need for diversion procedure for hydrocephalus treatment during the first year of life were collected and compared between groups. Data was presented as median and range or number and percentages as appropriate. P value >0.05 was considered statistically significant. Multivariate regression analysis was used to adjust for potential confounders.

RESULTS

154 patients were included in this study: 145 patients underwent fetal surgery (101 fetoscopic and 44 open hysterotomy) and 9 patients with severe ventriculomegaly underwent postnatal repair. Among the 145 patients who underwent fetal surgery, 22 presented with severe ventriculomegaly. Prenatally repaired fetuses with severe ventriculomegaly at referral were at a significantly higher need for hydrocephalus treatment by 12 months than those without severe ventriculomegaly (62% vs. 29%, p<0.01). However, motor function assessment at birth was similar between both prenatally repaired groups (OR=0.92, 95% CI [0.33-2.59], p=0.88) adjusted for the anatomical level of the lesion. The prenatally repaired group with severe ventriculomegaly had better preserved motor function levels at birth compared to the postnatal repair group with severe ventriculomegaly (L3 with 11.1% S1 motor function; p=<0.01 and p=<0.01). Prenatally repaired patients with severe ventriculomegaly had an 18.9 times chance of having an intact motor function at birth [95% CI (1.2 - 290.1)] adjusted for ethnicity, presence of clubfeet at referral, and gestational age at delivery compared to postnatal repair. There was not a significant difference in the need for hydrocephalus treatment in the first year of life between prenatal and postnatal repair of patients with severe ventriculomegaly (61.9% vs 87.5%, p=0.18).

CONCLUSIONS

Although fetuses with MMC and severe ventriculomegaly do not seem to benefit from fetal surgery in terms of postnatal hydrocephalus treatment, they benefit from increased chance of preserved motor function at birth. Results from this study highlight the benefits of having prenatal MMC repair for cases with severe ventriculomegaly at referral to preserve motor function. This article is protected by copyright. All rights reserved.

CAR T in patients with large B-cell lymphoma not fit for autologous transplant

Large B-cell lymphoma (LBCL) patients with comorbidities and/or advanced age are increasingly considered for treatment with CD19 CAR T, but data on the clinical benefit of CAR T in the less fit patient population are still limited. We analysed outcomes of consecutive patients approved for treatment with axicabtagene ciloleucel (axi-cel) or tisagenlecleucel (tisa-cel) by the UK National CAR T Clinical Panel, according to fitness for autologous stem cell transplant (ASCT). 81/404 (20%) of approved patients were deemed unfit for ASCT. Unfit patients were more likely to receive tisa-cel versus axi-cel (52% vs. 48%) compared to 20% versus 80% in ASCT-fit patients; p < 0.0001. The drop-out rate from approval to infusion was significantly higher in the ASCT-unfit group (34.6% vs. 23.5%; p = 0.042). Among infused patients, response rate, progression-free and overall survival were similar in both cohorts. CAR T was well-tolerated in ASCT-unfit patients with an incidence of grade ≥3 cytokine release syndrome and neurotoxicity of 2% and 11%, respectively. Results from this multicentre real-world cohort demonstrate that CD19 CAR T can be safely delivered in carefully selected older patients and patients with comorbidities who are not deemed suitable for transplant.

Exploring postgraduate epidemiology competencies: Preparing our students for a post-COVID world

OBJECTIVE

This research sought consensus from both experts and graduates on postgraduate epidemiology competencies.

METHODS

In 2021, a two-round online survey using a modified Delphi method was undertaken exploring competencies across six domains. Focus groups were conducted with recent postgraduate epidemiology graduates to assess their viewpoints on learning experiences and employability.

RESULTS

Forty-one experts participated in the first Delphi round. Nineteen factors reached consensus (>70% agreement) for importance and feasibility after two survey rounds in the following domains: general epidemiologic methods/concepts (n=8/13), advanced analytic/statistical skills (n=2/7), applied epidemiology/specialised fields (n=1/4), professional/transferrable skills (n=5/14), general public health knowledge/skills (n=2/4), independent research and work-integrated learning (n=1/3). Nine graduates participated in focus groups. A main theme was the substantial value gained in undertaking a dissertation, acknowledging its benefit for applying research skills and for networking opportunities.

CONCLUSIONS

To ensure that high-quality epidemiological research and practice continues, we need consensus on the set of essential skills required of graduating students.

IMPLICATIONS FOR PUBLIC HEALTH

Competencies for postgraduate epidemiology students require periodic review to safeguard a workforce that can meet emerging challenges and work across academia, research, policy, and practice.

A protracted outbreak of difficult-to-treat resistant Pseudomonas aeruginosa in a haematology unit: a matched case-control study demonstrating increased risk with use of fluoroquinolone

BACKGROUND

Between September 2016 and November 2020, 17 cases of difficult-to-treat resistant Pseudomonas aeruginosa (DTR-PA) were reported in haematology patients at a tertiary referral hospital in the North of England.

AIM

A retrospective case-control study was conducted to investigate the association between DTR-PA infection and clinical interventions, patient movement, antimicrobial use and comorbidities.

METHODS

Cases were patients colonized or infected with the outbreak strain of DTR-PA who had been admitted to hospital prior to their positive specimen. Exposures were extracted from medical records, and cases were compared with controls using conditional logistic regression. Environmental and microbiological investigations were also conducted.

FINDINGS

Seventeen cases and 51 controls were included. The final model included age [>65 years, adjusted OR (aOR) 6.85, P=0.232], sex (aOR 0.60, P=0.688), admission under the transplant team (aOR 14.27, P=0.43) and use of ciprofloxacin (aOR 102.13, P=0.030). Investigations did not indicate case-to-case transmission or a point source, although a common environmental source was highly likely.

CONCLUSION

This study found that the use of fluoroquinolones is an independent risk factor for DTR-PA in haematology patients. Antimicrobial stewardship and review of fluoroquinolone prophylaxis should be considered as part of PA outbreak investigations in addition to standard infection control interventions.

The effects of a green Rooibos (Aspalathus linearis) extract on metabolic parameters and adipose tissue biology in rats fed different obesogenic diets

Current pharmaceutical treatments addressing obesity are plagued by high costs, low efficacy and adverse side effects. Natural extracts are popular alternatives, but evidence for their anti-obesity properties is scant. We assessed the efficacy of a green (minimally-oxidized) Rooibos (Aspalathus linearis) extract (GRT) to ameliorate the effects of obesogenic feeding in rats, by examining body weight, metabolic measures, adipose tissue cellularity and tissue-resident adipose stem cells (ASCs). Furthermore, we performed statistical correlations to explore the relationships and interactions between metabolic and adipose tissue measures. Using an in vivo/ex vivo study design, male Wistar rats were maintained for 17 weeks on one of 3 diets: CON (laboratory chow), OB1 (high-sugar, medium fat) or OB2 (high-fat, high-cholesterol) (n = 24 each). From weeks 11-17, half of the animals in each group received oral GRT supplementation (60 mg per kg body weight daily). Blood and tissue samples were collected, and ASCs from each animal were cultured. Diets OB1 and OB2 induced divergent metabolic profiles compared to CON, but metabolic measures within dietary groups were mostly unaffected by GRT supplementation. Notably, diets OB1 and OB2 uncoupled the positive association between visceral adiposity and insulin resistance, while GRT uncoupled the positive association between elevated serum cholesterol and liver damage. Obesogenic feeding and GRT supplementation induced adipocyte enlargement in vivo, but lipid accumulation in cultured ASCs did not differ between dietary groups. Larger adipocyte size in subcutaneous fat was associated with favourable glucose metabolism measures in all GRT groups. In conclusion, GRT affected the associations between systemic, adipose tissue-level and cellular measures against the background of obesogenic diet-induced metabolic dysregulation.

Poor Correlation Among Metal Hypersensitivity Testing Modalities and Inferior Patient-Reported Outcomes After Primary and Revision Total Knee Arthroplasties

Background

Metal allergy testing may influence clinical decision-making for patients undergoing a total knee arthroplasty (TKA). Limited data were found to examine the consistency of available testing modalities. This study compares different metal allergy test results and clinical outcomes after primary and revision TKAs in patients with and without metal hypersensitivity.

Methods

Primary (n = 28) and revision (n = 20) TKA patients receiving hypoallergenic implants for metal allergies diagnosed by skin patch testing (SPT), lymphocyte proliferation testing (LPT), or lymphocyte transformation testing (LTT) were retrospectively reviewed. The agreement between tests was assessed by percentage and kappa statistic within patients who used multiple testing modalities. Postoperative clinical outcomes of these patients were compared to those of patients without metal hypersensitivity matched by age (±5 years), body mass index (±5), gender, and follow-up duration (±2 years).

Results

SPT and LPT showed weak agreement for nickel and minimal agreement for cobalt. SPT and LTT showed minimal agreement for nickel; weak agreement for titanium, bone cement, vanadium, and zirconium; but strong agreement for chromium and cobalt. LPT and LTT agreement was weak. Compared to matched controls, metal hypersensitivity patients undergoing primary TKAs with hypoallergenic implants experienced less improvement in Knee Society Scores, Veterans RAND 12 physical component scores, and range of motion. Patients undergoing revision TKAs for multiple indications including metal hypersensitivity had worse clinical outcomes with significantly worse improvements in Knee Society functional scores compared to matched controls.

Conclusions

Metal allergy tests produce conflicting results. Hypersensitivity patients may experience inferior clinical outcomes even with hypoallergenic implants. Clinician awareness may influence the choice of testing and improve preoperative counseling of this patient population.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

AB1050 CHARACTERISTICS OF PATIENTS WITH COINCIDENT GOUT AND ADVANCED CHRONIC KIDNEY DISEASE

Background

Patients with chronic kidney disease (CKD) are at increased risk for developing gout1 and vice versa.2 Those with both gout and CKD present distinct challenges for patients and physicians because of the high prevalence of other comorbidities and restrictions on gout medication use, including non-steroidal anti-inflammatories3,4 and some oral urate-lowering therapies (ULTs).5 This unique patient population has not been well characterized using real-world data.

Objectives

This retrospective chart review study of patients with coincident gout and CKD was conducted to better understand patient characteristics and treatment patterns of this population. This study is unique in that patient data were obtained from nephrologists, allowing a glimpse of how they view gout and its management.

Methods

111 nephrologists provided de-identified medical record data of their most-recently seen advanced (stage 3─5) CKD patients. Patients met study criteria for gout if any of the following were true: gout listed as a comorbidity, ULT use, or visible tophi or gout flares documented. A patient’s gout was determined to be uncontrolled if they had serum uric acid >6 mg/dL in addition to ≥1 visible tophus, ≥2 gout flares in the past year, or gouty arthritis (≥1 tender or swollen joint). Characteristics of this unique population were examined, along with gout management patterns. Differences between patients with controlled and uncontrolled gout were also investigated using data from patients’ most recent evaluation.

Results

173 patients with stages 3-5 CKD and who met study criteria for gout were included. Mean age was 58.3±18.1 years and BMI averaged 32.0 ± 11.8 kg/m2. A higher than expected proportion of patients were female (47%). The most common comorbidities were hypertension (85%), diabetes mellitus (47%), anemia of CKD (42%), CKD-mineral bone disorder (41%), ischemic heart disease (23%), and congestive heart failure (21%). Mean CKD duration was 4.1 ± 5.5 years, mean estimated glomerular filtration rate (eGFR) at most recent visit was 32.3 ± 13.9 ml/min/1.73 m2, and 62% were using a ULT. 23 patients (13%) had uncontrolled gout (48% female, 63.1 ± 16.4 years, mean eGFR 32.0 ± 14.6 ml/min/1.73 m2), all of whom had been prescribed a ULT. Compared with controlled gout patients, uncontrolled patients had higher rates of pulmonary hypertension (14% vs. 4%), gout-related chronic pain in the 12-months prior to data collection (63% vs. 42%), and joint involvement (joint swelling, tenderness, flexibility loss, and/or damage/lesions on x-ray; 26% vs. 9%). Colchicine was also used more frequently in uncontrolled gout patients (26% vs. 7%).

Conclusion

The coincident gout with advanced CKD population described here shows unique differences from the general gout population, including a high proportion of females (47%). Given that women have a lower likelihood of developing gout at the same serum uric acid level,6 this finding was particularly surprising (general gout population: 67% male7). Importantly, nearly 40% of included patients were not utilizing a ULT, leaving them susceptible to developing the painful and debilitating sequalae of uncontrolled gout. Additionally, 41% of the study population had a CKD-related mineral bone disorder, indicating that patients with coincident gout and CKD may have bones that are more vulnerable to gout-related bone damage. Our study confirms a high prevalence of gout and its associated comorbidities in patients with advanced CKD and suggests another nephrology education opportunity to highlight the potential benefits of gout monitoring, earlier intervention, and management.

References

[1]Safiri S, et al. Arthritis Rheumatol 2020;72:1916-27.

[2]Feig DI. Curr Opin Nephrol Hypertens 2009; 18: 526–530.

[3]Stamp LK, et al. Nat Rev Rheumatol. 2021; 17(10): 633–641.

[4]Wallace SL, et al. J Rheumatol 1991; 18(2): 264-9.

[5]Abdelatif AA and Elkhalili N. Am J Ther 2014; 21: 523-34.

[6]Bhole V, et al. Arthritis Rheum 2010;62:1069-76.

[7]Francis-Sedlak M, et al. Rheumatol Ther 2021;8:183-97.

Disclosure of Interests

Leonard Stern Speakers bureau: Horizon Therapeutics, Consultant of: Horizon Therapeutics, Richard Johnson Shareholder of: Colorado Research Partners LLC and XORTX Therapeutics, Speakers bureau: Horizon Therapeutics, Consultant of: Horizon Therapeutics, Payam Shakouri Speakers bureau: Horizon Therapeutics and Relypsa, Consultant of: Horizon Therapeutics, Amod Athavale Grant/research support from: Horizon Therapeutics, Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Brad Marder Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Sreedhar Mandayam Shareholder of: Medingenii Capital LLC and Prosalus Capital LLC, Speakers bureau: Otsuka and Alexion, Consultant of: US Renal Care and Aurinia, Grant/research support from: Travere, Norvartis, Omeros, Roche, Vertex, Equillium, Goldfinch Bio, and Pfizer

Routine use of automated strain analysis and 3D echocardiography provides a more comprehensive assessment of cardiac chambers than conventional 2D echocardiography and is time-saving

Funding Acknowledgements

Type of funding sources: None.

Background. In most laboratories three-dimensional echocardiography (3DE) and longitudinal strain (Lstrain) analysis are not part of the routine studies. Although these modalities have been shown to provide additional clinical information and prognostic value compared to conventional two-dimensional echocardiography (2DE), their acquisition and analysis are perceived as being time-consuming.  Recently, new automated tools have been developed to perform accurate, fast and reproducible analyses of heart chambers’ geometry and function. However, their cost-effectiveness when compared to conventional 2DE remains to be demonstrated.

Aim. We designed a prospective, multicenter, observational study aimed to compare the time required for the acquisition and analysis of conventional transthoracic 2DE vs advanced echocardiography (AEcho, i.e. 3DE+ Lstrain) for the assessment of cardiac chambers and myocardial mechanics.

Methods. According to current guidelines, 196 consecutive patients referred for clinically indicated echocardiography underwent complete 2DE and Doppler echocardiography. In addition, 3DE datasets of the left atrium (LA), left and right ventricle (LV, RV) were acquired using automated 3DE software package (Heart Model). Acquisition time for both 2DE and 3DE images were recorded. Conventional 2DE analyses of LA (biplane volume), LV (biplane volumes and mass) and RV (both linear dimensions, areas, and longitudinal function) were performed following current guidelines, and the time required for acquisition and analysis was recorded. The time spent for AEcho analysis (both 3DE volumetric analysis and Lstrain of LA, LV and RV) was also recorded.

Results. Feasibility of AEcho was 86% (169 patients). The additional time for 3D dataset acquisition over conventional 2DE was 38 ± 0.16 sec. Quantitative analysis of the cardiac chambers by 2DE required an average of 5.55 ± 1.51 min vs 4.25 ± 1.23 min using AEcho (p &lt; 0.001). Total time for both 3D dataset acquisition and AEcho assessment was 5.03 ± 1.28 min vs 5.55 ± 1.51 min of 2DE analysis alone (p &lt; 0.001). Globally, AEcho provided a more comprehensive assessment of heart chambers than 2DE (Table). Moreover, the time spent for 3DE dataset acquisition and AEcho analysis on top of standard 2DE acquisition was significantly shorter compared to the 2DE acquisition and analysis (18:50 ± 4.23 vs 19:42 ± 4.24 min, p &lt; 0.001) (Table).

Conclusions. Our data showed that the use of new AEcho automated tools are highly feasible resulting in significant time-savings compared to standard 2DE evaluation, while providing significant additional information. Abstract Table

A critical qualitative inquiry of the social practices of older adult gamblers

Background

Older adults' participation in gambling is increasing internationally. Older adults have been identified as a group at greater risk of gambling harm. This may be due to their increased vulnerability due to life circumstances, such as retiring from paid work and social isolation. Current literature has focused on individual characteristics that may influence older adults gambling attitudes, behaviours, and experiences of harm, however, there has been little qualitative research that has explored other factors such as the influence of social practices surrounding gambling. This study explored how social practices influenced older adults' participation in gambling, and how these social practices may contribute to gambling risk.

Methods

A critical qualitative inquiry was conducted and involved semi-structured phone interviews with 40 Australian adults aged 55 years and over. A Constructivist Grounded Theory approach was taken, and Social Practice Theory guided the thematic analysis of the data.

Results

Two major themes were generated from the data. The first theme demonstrated that gambling was often embedded within older adults' social practices. For example, older adults would attend gambling venues with their social networks and engage in gambling as a way of building their social connection. Sometimes gambling occurred to try to meet the expectations of the wider social group, potentially increasing the risk of harm. Second, it was evident that gambling had become part a routine activity for older adults' everyday life.

Conclusions

Older adults social practices related to gambling were linked with the accessibility and availability of gambling products in community environments. Interventions aimed at preventing and reducing gambling harm in older adults need to shift away from the individual and instead focus on disrupting social practices, including the routines associated with gambling.

Key messages

Gambling was used by older adults to consolidate social connections and strengthen their sense of belonging within social groups and often involved routines around gambling. To prevent further harm from gambling to older adults, strategies should focus on the social context of older adults gambling rather than the individual characteristics of gamblers.

Early laser surgery is not associated with very preterm delivery or reduced neonatal survival in TTTS

OBJECTIVE

To evaluate the association of laser photocoagulation of placental anastomoses (LPA) prior to 18 weeks' gestation (early LPA) with very preterm delivery and neonatal survival in pregnancies with twin-twin transfusion syndrome (TTTS).

METHODS

This was a retrospective cohort study of monochorionic diamniotic twin pregnancies with TTTS undergoing LPA between 2002 and 2018 at two institutions. The rates of delivery < 28, < 30 and < 32 weeks' gestation, preterm prelabor rupture of membranes (PPROM) and 30-day survival of one or both infants were compared between pregnancies undergoing early LPA and those undergoing LPA ≥ 18 weeks' gestation. Regression analysis was performed to determine the association of early LPA with very preterm delivery and 30-day survival, adjusted for Quintero stage, study phase, selective fetal growth restriction, gestational age at delivery, maternal age ≥ 35 years, body mass index > 35 kg/m² , placental location, use of Seldinger method to place the operative trocar, size of the trocar, participating center, use of Solomon technique, cerclage and PPROM. Survival analysis using the Cox proportional hazard model was applied to examine the LPA-to-delivery interval according to the timing of surgery, adjusted for confounding variables.

RESULTS

A total of 414 TTTS pregnancies were included in the study, of which 68 (16.4%) underwent early LPA. In the total cohort, the incidence of delivery at < 28, < 30 and < 32 weeks' gestation was 22.7%, 39.6% and 53.4%, respectively. Survival of both twins and survival of at least one twin at 30 days were 67.5% and 90.8%, respectively. No significant difference was noted between pregnancies that underwent early LPA and those that had LPA ≥ 18 weeks in the rate of delivery < 28 weeks (19.1% vs 23.4%; P = 0.4), < 30 weeks (38.2% vs 39.9%; P = 0.8) and < 32 weeks (44.1% vs 55.2%; P = 0.1) and PPROM (29.0% vs 24.1%; P = 0.4), or in the incidence of double-twin survival (63.9% vs 68.1%; P = 0.5) and survival of at least one infant (91.8% vs 90.6%; P = 0.7) at 30 days. Early LPA was not associated with very preterm delivery or neonatal survival in the regression analyses. Early LPA was associated with a longer LPA-to-delivery interval compared with LPA performed ≥ 18 weeks (median, 106.9 days (range, 2-164 days) vs median, 69.3 days (range, 0-146 days); P < 0.001) when adjusted for confounding variables (hazard ratio, 2.56 (95% CI, 1.76-3.73); P < 0.001).

CONCLUSION

Laser surgery before 18 weeks is not associated with an increased rate of very preterm delivery and PPROM or with reduced neonatal survival when compared with LPA after 18 weeks. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Clinician and staff perspectives on potential disparities introduced by the rapid implementation of telehealth services during COVID-19: a mixed-methods analysis

The COVID-19 pandemic has rapidly altered ambulatory health care delivery and may have worsened disparities in health care access. To assess the telehealth implementation experiences of ambulatory personnel in different disciplines and their perspectives on potential telehealth disparities, and to make recommendations for more equitable telehealth delivery. We used a convergent parallel mixed-methods design. Clinic managers from geriatric medicine, internal medicine, and psychiatry e-mailed a survey to clinicians and staff regarding experiences with telehealth care delivery. Quantitative survey responses were analyzed with Fisher's Exact tests. Qualitative responses were coded thematically. Recommendations were categorized by type of implementation strategy. Quantitative and qualitative findings on telehealth disparities were merged in a joint data display. Respondents (n = 147, 57% response rate) were distributed across three specialties: 66% internal medicine, 19% psychiatry, and 14% geriatric medicine. Prior to 2020, 77% of clinicians had never delivered telehealth services. By Spring 2020, 78% reported conducting more than half of clinic visits by telehealth. Among clinicians, 52% agreed/strongly agreed that rapid telehealth implementation exacerbated access to care disparities to: older adult patients, those with limited internet access, and those needing interpretation services. Staff expressed similar difficulties with telehealth set-up especially for these patients. To improve telehealth equity, clinicians recommended to: (i) change infrastructure; (ii) train and educate stakeholders; and (iii) support clinicians. Clinicians and staff reported specific subpopulations had challenges in accessing telehealth visits. To avoid perpetuating telehealth access disparities, further co-discovery of equitable implementation strategies with patients and clinics are urgently needed.

International audit of simulation use in pre-registration medical radiation science training

INTRODUCTION

Simulation-based education (SBE) can replicate the challenging aspects of real-world clinical environments, while providing a safe and less intimidating setting. Literature supports its use within medical radiation science (MRS) training for safe practice of psychomotor skills, development of problem solving, team working, interpersonal and decision-making skills and embedding awareness of patient safety. This project aimed to quantify usage of SBE resources and activities internationally and to evaluate how this changed during COVID-19 restrictions.

METHODS

An anonymous online survey tool gathered data relating to programme demographics, simulation resources, simulation activities and future plans. A link to the survey was distributed to programme leads via social media, professional bodies and national networks.

RESULTS

A total of 72 responses were received from a range of countries and representing a range of programme structures. Most respondents reported up to 100 h of SBE per student per year with low fidelity resources and image viewing software featuring most prominently. There was low reported engagement of service users within simulation activities. Respondents also indicated that COVID-19 had been a trigger for rapid uptake of simulation resources.

CONCLUSION

SBE forms an important aspect of MRS training internationally with low-fidelity resources being widely deployed. Where available, high fidelity virtual reality and specialised profession-specific resources were used heavily. There was a low level of reported engagement with service users or expert patients in simulation activities. Future research will identify whether the rapid uptake of SBE during COVID-19 continues and clarify the role of service users in SBE provision.

IMPLICATIONS FOR PRACTICE

Increased collaboration between MRS education providers may help to improve parity of SBE provision and identify additional opportunities to engage service users within SBE.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Durable benefit of rituximab maintenance post-autograft in patients with relapsed follicular lymphoma: 12-year follow-up of the EBMT lymphoma working party Lym1 trial

We report the 12-year follow-up of the prospective randomized EBMT LYM1 trial to determine whether the benefit of brief duration rituximab maintenance (RM) on progression-free survival (PFS) in patients with relapsed follicular lymphoma (FL) receiving an autologous stem cell transplant (ASCT) is sustained. One hundred and thirty-eight patients received RM with or without purging. The median follow-up after random assignment is 12 years (range 10-13) for the whole series. The 10-year PFS after ASCT is 47% (95% CI 40-54) with only 4 patients relapsing after 7.5 years. RM continues to significantly improve 10-year PFS after ASCT in comparison with NM [P = 0.002; HR 0.548 (95% CI 0.38-0.80)]. Ten-year non-relapse mortality (NRM) was not significantly different between treatment groups (7% overall). 10-year overall survival (OS) after ASCT was 75% (69-81) for the whole series, with no significant differences according to treatment sub-groups. 10-year OS for patients who progressed within 24 months (POD24T) was 60%, in comparison with 85% for patients without progression. Thus the benefit of rituximab maintenance after ASCT on relapse prevention is sustained at 12 years, suggesting that RM adds to ASCT-mediated disease eradication and may enhance the curative potential of ASCT.

Morton's neuroma: review of anatomy, pathomechanism, and imaging

Morton's neuroma is a commonly encountered cause of forefoot pain, which may limit weight-bearing activities and footwear choices. Although the aetiology and pathomechanism of this condition is controversial, the histological endpoint is well established as benign perineural fibrosis of a common plantar digital nerve, typically within the third intermetatarsal space. The diagnosis of Morton's neuroma is mainly based on characteristic symptoms and clinical findings, but may be confirmed by ultrasonography. Although ultrasound is a highly accurate diagnostic tool for Morton's neuroma, it is subject to interoperator variability due to differences in technique and level of experience. In this paper, the authors review the anatomy of the common plantar digital nerves and surrounding structures in the forefoot, which are deemed relevant to the understanding of Morton's neuroma, especially from a sonographic point of view. Several theories of the pathomechanism of Morton's neuroma are briefly discussed. The main purpose of this article is to illustrate the ultrasound techniques for evaluating Morton's neuroma and performing ultrasound-guided corticosteroid injections.

Fight Against COVID-19: ARCI's Technologies for Disinfection

COVID-19 (SARS-CoV-2) is causing a huge concern to the global population due to its highly contagious properties. The SARS-CoV-2 is a new variant in the coronavirus family. The world is focussing on several methods to battle against this novel corona virus, including control of its spread. In this context, ARCI has quickly made efforts to develop disinfection systems including a UVC-based disinfection trolley, honeycomb air heater and a fogging chamber using UVC germicidal lamps, dry heat sterilization and HOCl-based chemical disinfectant to provide rapid and effective inactivation of microorganisms causing the pandemic. These systems have been successfully deployed at different hospitals for their validation.

Impact of the size of the lesion in prenatal neural tube defect repair on imaging, neurosurgical and motor outcomes: a retrospective cohort study

OBJECTIVES

(1) To compare brain findings between large and non-large neural tube defect (NTD); (2) to evaluate the impact of large lesion on the surgical parameters; (3) to study any associations between the size of the lesions and brain findings 6 weeks postoperatively and neurological short-term outcomes.

DESIGN

Retrospective cohort study.

SETTING

Texas Children's Hospital, between 2011 and 2018.

POPULATION

Patients who underwent prenatal NTD repair.

METHODS

Large lesion was defined when the lesion's surface was >75th centile of our cohorts' lesions.

MAIN OUTCOME MEASURES

Time of referral: ventriculomegaly and anatomical level of the lesion; surgery: duration and need for relaxing incisions. 6 weeks postoperative: hindbrain herniation (HBH) and ventriculomegaly. After delivery: dehiscence, need for hydrocephalus treatment and motor function.

RESULTS

A total of 99 patients were included, 25 of whom presented with large lesions. Type of lesion and ventriculomegaly were comparable between individuals with large and non-large lesions. Individuals with large lesions were associated with increased need for relaxing incisions by 5.4 times (95% CI 1.3-23.2, P = 0.02). Six weeks postoperatively, having a large lesion decreased by ten times the likelihood of having a postoperative reversal of HBH (odds ratio = 0.1, 95% CI 0.1-0.4, P < 0.01). At birth, larger lesions increased the risk for repair dehiscence by 6.1 times (95% CI 1.6-22.5, P < 0.01) and the risk of dehiscence or leakage of cerebrospinal fluid at birth by 5.5 times (95% CI 1.6-18.9, P < 0.01).

CONCLUSION

Prenatal repair of patients with large NTD presents a lower proportion of HBH reversal 6 weeks after the surgery, a higher risk of dehiscence and a higher need for postnatal repair.

TWEETABLE ABSTRACT

Evaluation of the size of fetal NTD can predict adverse neurological outcomes after prenatal NTD repair.

THU0408 EFFECT OF NEW-ONSET GOUT ON KIDNEY TRANSPLANT OUTCOMES: A RETROSPECTIVE COHORT ANALYSIS OF THE UNITED STATES RENAL DATA SYSTEM

Background:

Gout is a frequent comorbidity in kidney transplant (KT) recipients. However, assessing the independent effect of gout on KT outcomes is difficult because of multiple confounders (e.g., temporal changes in estimated glomerular filtration rate [eGFR], cyclosporine or tacrolimus dose, urate-lowering medication use) that obscure a clear picture of gout’s potential impact.

Objectives:

This investigation assessed if the development of new-onset gout after KT was an independent risk factor for loss of graft function, as assessed by the need for maintenance hemodialysis following KT.

Methods:

This retrospective cohort study analyzed data on patients in the United States Renal Data System (USRDS) who received a primary KT between 1/1/2008 and 12/31/2015. The date of transplantation was the ‘index’ date. Eligible patients were required to have ≥24 months of Medicare coverage and no prior history of gout, defined as ≥1 claim with a gout diagnosis code in the 24 months prior to the index date. All patients were also required to have ≥12 months of coverage post index. Patients who died, experienced graft failure, or returned to dialysis <12 months post index were excluded. Because the first year following transplant is associated with the highest frequency of rejections, we evaluated subjects beginning 1 year after transplant. The exposure of interest was new-onset gout, defined as the presence of ≥2 claims for gout post index, and the primary endpoint was return to dialysis >12 months post index. Baseline time-invariant confounders included recipient and donor demographics and clinical characteristics at index. Time-varying confounders included body mass index (BMI) adjusted tacrolimus and cyclosporine dose, eGFR, and urate-lowering medication use post index. Patients who died or lost Medicare coverage >12 months post index were censored; all patients remaining at the end of the study period (12/31/2016) were also censored. A marginal structural model (MSM) was fitted to determine the relative risk of new-onset gout on return to dialysis, while controlling for both time-invariant and time-varying confounders.

Results:

18,525 of 466,589 KT recipients in the USRDS met study eligibility. Within the observation period, 1,399 (7.6%) developed new-onset gout and 1,420 (7.7%) returned to dialysis >12 months post index. Median time from index to new-onset gout and from index to return to dialysis was 16.2 months (IQR: 33.4) and 32.8 months (IQR: 28.4), respectively. Adjusting for baseline time-invariant and time-varying confounders via the MSM showed new-onset gout was associated with a 51% increased risk of return to dialysis >12 months post index (RR: 1.51, 95% CI: 1.03, 2.20).

Conclusion:

New-onset gout was independently associated with a 51% increased risk of return to dialysis >12 months after primary KT compared to a control cohort without gout. To our knowledge, this is the first observation of this outcome in an appropriately controlled cohort study of KT recipients with gout. Results from this analysis may have important implications for the monitoring and management of new-onset gout in the kidney transplant population.

References:

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[12]Kim DG, et al.PloS One2018;13:e0209156.

Disclosure of Interests: :

Justin Li: None declared, David Yin: None declared, Zheng Wang: None declared, Mark Brigham: None declared, Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Jeffrey Kent Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Megan Francis-Sedlak Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Richard Johnson Shareholder of: Colorado Research Partners LLC, XORTX Therapeutics, Consultant of: Horizon Therapeutics, Eli Lilly, Speakers bureau: Horizon Therapeutics, Nandini Hadker: None declared, Kevin Francis: None declared, Herman Sanchez: None declared, Gavin Miyasato: None declared

Comparative dynamic aerosol efficiencies of three emergent coronaviruses and the unusual persistence of SARS-CoV-2 in aerosol suspensions

The emergent coronavirus, designated severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is a zoonotic pathogen that has demonstrated remarkable transmissibility in the human population and is the etiological agent of a current global pandemic called COVID-191. We measured the dynamic (short-term) aerosol efficiencies of SARS-CoV-2 and compared the efficiencies with two other emerging coronaviruses, SARS-CoV (emerged in 2002) and Middle Eastern respiratory syndrome CoV (MERS-CoV; emerged starting in 2012). We also quantified the long-term persistence of SARS-CoV-2 and its ability to maintain infectivity when suspended in aerosols for up to 16 hours.

Combustion Method for Determination of Crude Protein in Meat and Meat Products: Collaborative Study

Twelve laboratories participated in a collaborative study to compare a combustion method with the AOAC mercury catalyst Kjeldahl method (928.08) for the determination of crude protein in meat and meat products. Three different combustion instruments were used; consequently, the combustion method for this study is written in generic terms describing the principle, the apparatus specifications, and the performance requirements needed. Fifteen sample pairs were used for the study; each pair consisted of the same commercial meat product from each of 2 different manufacturers. Protein content of all samples ranged from about 10 to 20%. In addition, nicotinic acid and lysine monohydrochloride were used as standards to assess combustion equipment performance. All laboratories and all instruments performed the combustion method satisfactorily on the basis of results for the standards. For the meat samples, repeatability standard deviations (sr) ranged from 0.11 to 0.40 for the Kjeldahl method and from 0.12 to 0.41 for the combustion method; the repeatability relative standard deviations (RSDr) ranged from 0.82 to 2.41% and from 0.60 to 2.23% for the Kjeldahl and combustion methods, respectively. Reproducibility standard deviations (SR) ranged from 0.20 to 0.49 for the Kjeldahl method and from 0.18 to 0.46 for the combustion method, whereas the reproducibility relative standard deviations (RSDR) ranged from 1.59 to 2.84% for the Kjeldahl method and from 1.32 to 3.35% for the combustion method. Overall grand means were 15.59% protein for the Kjeldahl method and 15.75% protein for the combustion method. The combustion method was adopted first action by AOAC International.

Engaging patients and families to transform heart failure care

For patients with advanced heart failure involvement as a member of the healthcare team is critical to safe, high-quality and goal-directed care. While recognized as an important aspect of care, patient engagement is not yet a standard practice. This presents an opportunity for professional education and development in team-based care. This short report describes the development of a Community and Patient Advisory Team (CPAT) formed to support patient involvement in interprofessional collaborative practice. The CPAT, composed of patient and family advisors, researchers, care team members, and grant operations staff, served as a core team within the structure of a project to shape a new vision of care delivery. This was accomplished through participation in quarterly leadership workshops and facilitation of team training focused on patient-provider communication strategies to improve patient safety. The advisory team led the co-development of patient materials to support patient engagement during the new implementation of structured interprofessional bedside rounds. Involving community members as partners helped shape our work to more effectively and directly address gaps in current patient care.

Soft-sheath, stiff-core microfiber hydrogel for coating vascular implants

Vascular implants remain clinically challenged due to often-occurring thrombosis and stenosis. Critical to addressing these complications is the design of implant material surfaces to inhibit the activities of platelets, smooth muscle cells (SMCs) and inflammatory cells. Recent mechanobiology studies accentuate the significance of material elasticity to cells and tissues. We thus developed and characterized an implant coating composed of hybrid, viscoelastic microfibers with coaxial core-sheath nanostructure. The coating over metallic stent material was formed by first depositing coaxially-electrospun fibers of poly(L-lactic acid) core and polyethylene glycol dimethacrylate sheath, and then polymerizing fibers with various UV times. Material characterizations were performed to evaluate the coating structure, mechanical property and biocompatibility. Results showed that coaxial microfibers exhibited arterial-like mechanics. The soft surface, high water content and swelling ratio of the coaxial fibers resemble hydrogels, while they are mechanically strong with an elastic modulus of 172-729 kPa. The coating strength and surface elasticity were tunable with the photopolymerization time. Further, the elastic fibers, as conformal coating on stent metal, strongly reduced SMC overgrowth and discouraged platelet adhesion and activation, compared to bare metals. Importantly, after 7-day subcutaneous implantation, coaxial fiber-coated implants showed more favorable in vivo responses with reduced tissue encapsulation, compared to bare stent metals or those coated with a two-layered fiber mixture composed of fibers from individual polymers. The excellent biocompatibility aroused from nanostructural interfaces of hybrid fibers offering hydrated, soft, nonfouling microenvironments. Such integrated fiber system may allow creation of advanced vascular implants that possess physico-mechanical properties of native arteries.

Examining Differences in Recovery Outcomes between Male and Female Hip Fracture Patients: Design and Baseline Results of a Prospective Cohort Study from the Baltimore Hip Studies

BACKGROUND

Incidence of hip fractures in men is expected to increase, yet little is known about consequences of hip fracture in men compared to women. It is important to investigate differences at time of fracture using the newest technologies and methodology regarding metabolic, physiologic, neuromuscular, functional, and clinical outcomes, with attention to design issues for recruiting frail older adults across numerous settings.

OBJECTIVES

To determine whether at least moderately-sized sex differences exist across several key outcomes after a hip fracture.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study (Baltimore Hip Studies 7th cohort [BHS-7]) was designed to include equal numbers of male and female hip fracture patients to assess sex differences across various outcomes post-hip fracture. Participants were recruited from eight hospitals in the Baltimore metropolitan area within 15 days of admission and were assessed at baseline, 2, 6 and 12 months post-admission.

MEASUREMENTS

Assessments included questionnaire, functional performance evaluation, cognitive testing, measures of body composition, and phlebotomy.

RESULTS

Of 1709 hip fracture patients screened from May 2006 through June 2011, 917 (54%) were eligible and 39% (n=362) provided informed consent. The final analytic sample was 339 (168 men and 171 women). At time of fracture, men were sicker (mean Charlson score= 2.4 vs. 1.6; p<0.001) and had worse cognition (3MS score= 82.3 vs. 86.2; p<0.05), and prior to fracture were less likely to be on bisphosphonates (8% vs. 39%; p<0.001) and less physically active (2426 kilocalories/week vs. 3625; p<0.001).

CONCLUSIONS

This paper provides the study design and methodology for recruiting and assessing hip fracture patients and evidence of baseline and pre-injury sex differences which may affect eventual recovery one year later.

95 N-Acetyl cysteine as a potential treatment for equine persistent breeding-induced endometritis

Persistent breeding-induced endometritis (PBIE) is a major cause of infertility in mares. Transient uterine inflammation is a normal response to breeding; however, PBIE-susceptible mares do not clear this inflammation in a timely fashion. Uterine inflammation at the time of embryonic descent from the oviducts ultimately results in early embryonic death and is seen clinically as infertility. Several risk factors for PBIE have been identified and include age, parity, anatomical conformation, such as poor perineal conformation and cervical fibrosis, as well as other reproductive tract abnormalities. N-Acetyl cysteine (NAC), a mucolytic used to treat endometritis in mares, has anti-inflammatory properties, affects inflammatory cytokines, and is a mild inhibitor of nitric oxide synthase. Increased nitric oxide, causing smooth muscle relaxation and alterations in inflammatory cytokines, has been documented in PBIE mares. The objective of our study was to determine if NAC treatment would lower nitric oxide and inflammatory cytokine levels, thereby resolving PBIE. A randomised, blinded, crossover design clinical trial was performed utilising PBIE-susceptible mares (n=10). Mares were screened for bacterial endometritis before enrolment in the study and only mares that had negative bacterial cultures were used. No other treatments were given to mares while they were enrolled in the study. Intrauterine infusion of 180mL of 3.3% NAC was performed 12h before insemination, when a follicle &gt;35mm was present. Mares were sampled for endometrial cytology and endometrial fluid to determine inflammatory cytokine (ELISA) and nitric oxide (colourimetric assay) levels at 12 and 72h post-insemination. Endometrial biopsies were taken at the same time points post-insemination to determine gene expression of inflammatory cytokines by qPCR. Clinical signs of endometrial oedema and intrauterine fluid volumes were assessed at 12 and then every 24h post-breeding. Statistical assessment of the data was performed using a repeated-measures ANOVA. Uterine inflammation, as determined by percent number of neutrophils on endometrial cytology (P=0.0006), and interleukin 6 gene expression (P=0.003) were highest at 12h. Uterine oedema was greatest at 12 and 24h (P=0.02) and uterine fluid volumes were highest at 24h (P=0.02). Interestingly, interleukin-6 protein levels were not in accordance with gene expression, and were highest at 72h. In this clinical trial, pre-breeding intrauterine treatment with NAC did not affect nitric oxide levels, cytokine gene expression, or clinical signs of PBIE. However, the pattern of inflammation noted in this study is consistent with that described in PBIE mares. Nevertheless, the assessment of inflammatory cytokines, both at the gene and protein level at different time points post-AI, in combination with clinical signs will add to the understanding of the alterations in inflammatory cytokine levels in mares susceptible to PBIE.

Evaluation of tetracycline in milk following extra-label administration of topical tetracycline for digital dermatitis in dairy cattle

Digital dermatitis (DD) is a painful infectious foot lesion commonly treated topically with extra-label tetracycline. Our objectives were to determine the concentrations of tetracycline in milk and plasma and to calculate a withdrawal interval following topical application at various doses. Another objective was to evaluate agreement between tests for measuring tetracycline in milk. A randomized block trial was conducted on 2 farms, where 50 cows with active DD lesions on 2 feet were allocated to 1 of 5 treatment groups (n = 10 cows per group). Treatment groups consisted of topical applications of tetracycline hydrochloride, in a paste or as a powdered form under a bandage, at 3 different dosing levels (2, 5, and 25 g) on each of the 2 affected feet. Following enrollment and treatment, samples were collected from milk, teat skin, and blood every 8 to 24 h for up to 7 d postdosing. Concentrations of tetracycline were measured by liquid chromatography-mass spectrometry and milk samples were further tested using the Charm ROSA TET test (Charm Sciences Inc., Lawrence, MA). Tetracycline was present in milk, plasma, and teat skin from all treatment groups. Tetracycline concentrations varied depending on time of sampling, method of application, and dosing level. At 8 h post-treatment, 11% of cows had tetracycline present in milk higher than 100 ng/mL (ppb) but none higher than 300 ng/mL. The 25-g treatment group had the longest estimated withdrawal interval, the highest observed concentrations (210-244 ng/mL) of tetracycline present in milk, and the longest observed consecutive period of tetracycline presence (from 8 to 72 h) among all treatment groups. Compared with liquid chromatography-mass spectrometry, the Charm test had a sensitivity of 77 and 100% for measuring tetracycline in milk at ≥30 and ≥100 ng/mL, respectively. Post-treatment samples of the teat skin were taken from 15 cows on 6 occasions, and every cow had tetracycline present in at least 1 of those 6 samples. This confirms an association between topical DD treatment with tetracycline and contamination of the teat. A total of 22% of blood samples had detectable tetracycline, and the majority (63%) occurred at 8 h post-treatment. At 100 ng/mL, the estimated cow-level milk withdrawal interval ranged from 0 to 70 h. At 300 ng/mL, the estimated cow-level withdrawal interval ranged from 0 to 34 h, and was 0 h at the bulk tank level. We recommend that conservative measures be adopted after extra-label use of topical tetracycline for DD treatment, including using a low dose and strategic post-treatment testing for tetracycline-class drugs in milk.

Chemical interactions between Saturn’s atmosphere and its rings

The Pioneer and Voyager spacecraft made close-up measurements of Saturn’s ionosphere and upper atmosphere in the 1970s and 1980s that suggested a chemical interaction between the rings and atmosphere. Exploring this interaction provides information on ring composition and the influence on Saturn’s atmosphere from infalling material. The Cassini Ion Neutral Mass Spectrometer sampled in situ the region between the D ring and Saturn during the spacecraft’s Grand Finale phase. We used these measurements to characterize the atmospheric structure and material influx from the rings. The atmospheric He/H2 ratio is 10 to 16%. Volatile compounds from the rings (methane; carbon monoxide and/or molecular nitrogen), as well as larger organic-bearing grains, are flowing inward at a rate of 4800 to 45,000 kilograms per second.