A37 EFFICACY AND SAFETY OF RISANKIZUMAB AS MAINTENANCE THERAPY IN PATIENTS WITH CROHN’S DISEASE: 52 WEEK RESULTS FROM THE PHASE 3 FORTIFY STUDY

Background

Risankizumab (RZB), an anti-IL-23 p19 inhibitor, was well-tolerated and superior to placebo (PBO) in inducing clinical remission and endoscopic response in patients (pts) with moderate-to-severe Crohn’s disease (CD) in two phase 3 studies at 12 weeks.

Aims

FORTIFY (NCT03105102), was a 52-week (wk) phase 3 double-blind, re-randomized responder withdrawal study that evaluated the efficacy and safety of continuing RZB as subcutaneous (SC) maintenance therapy versus withdrawal to placebo in pts achieving induction response to RZB

Methods

Week 12 IV RZB responders were re-randomized 1:1:1 to: RZB SC 360mg (N=141), RZB 180mg (N=157), or PBO (withdrawal from IV RZB; N=164) every 8wks for 52wks. Co-primary endpoints were clinical remission (per CD Activity Index [CDAI] (US); or stool frequency/abdominal pain score [SF/APS] (OUS) and endoscopic response at wk52. Other clinical and endoscopic endpoints, inflammatory biomarkers, RZB serum levels, and safety were assessed over time.

Results

Rates of clinical remission (CDAI, SF/APS) and clinical response were similar for RZB and PBO groups through wk24, with rates lower for PBO thereafter. At wk52, clinical remission (CDAI, SF/APS) and endoscopic response rates were significantly higher with RZB 360mg than PBO ( P<0.01); RZB 180mg was superior to PBO for clinical remission per CDAI and endoscopic response ( P<0.01). Endoscopic remission and deep remission rates increased over time with 360mg, remained steady with 180mg, and decreased with PBO. Mean fecal calprotectin (FCP) and C-reactive protein (CRP) levels decreased with SC RZB, but increased with PBO, over 52wks. Exposure-adjusted event rates (per 100 pts-years) of serious adverse event (AE) were generally similar among groups (360mg, 21.0 E/100PY and 180mg, 19.5 E/100PY vs PBO, 19.3 E/100PY), as were AEs leading to drug discontinuation (4.8 E/100PY and 2.4 E/100PY vs 3.7 E/100PY), and serious infections (6.0 E/100PY and 3.0 E/100PY vs 5.0 E/100PY).

Conclusions

In pts with moderate-to-severe CD, a robust pharmacodynamic effect on the IL-23 pathway after 12wks RZB IV induction was maintained with RZB SC maintenance therapy. The durability of RZB was demonstrated with high rates of efficacy over the 52-wk study. RZB was superior to PBO for achieving clinical remission and endoscopic response at wk52. Results for the more stringent endpoints (endoscopic remission\deep remission) and persistent improvements in inflammatory biomarkers are consistent with a dose response relationship. Continued RZB SC maintenance treatment was generally safe and well-tolerated.

Funding Agencies

AbbVie

Severe multisystem inflammatory syndrome (MIS-C/A) after confirmed SARS-CoV-2 infection: a report of four adult cases

BACKGROUND

Multisystem inflammatory syndrome (MIS) triggered by a recent SARS-Cov-2 infection has been recognised worldwide. Although predominantly affecting children (MIS-C), similar presentations have been reported among adults (MIS-A).

METHOD

A retrospective case series describing four critically ill patients with MIS-C/A diagnosed between January and April 2021 at Sahlgrenska University Hospital, Gothenburg, Sweden. Clinical presentation, laboratory and radiological findings, treatment and outcome are reported.

RESULTS

Cases occurred in previously healthy patients with a history of laboratory-confirmed mild SARS-CoV-2 infection four to seven weeks earlier. The median age was 24 years (range 19-43) and 3/4 were male. All fulfilled suggested MIS-C/A criteria according to the US Centre for Disease Control and all required care at an intensive care unit. Treatment was initiated with intravenous immunoglobulin, interleukin-1-receptor antagonists, and pulse steroids in 3/4 cases which resulted in rapid clinical improvement. No severe complications were noticed in any case during a three-month follow-up period.

CONCLUSION

MIS-C/A should be considered, irrespective of age, in patients with fever, hyperinflammation and multiple organ system involvements emerging weeks after COVID-19. Previously suggested treatment regimens for MIS-C seem to be applicable also for MIS-A.

Universal description of wetting on multiscale surfaces using integral geometry

HYPOTHESIS

Emerging energy-related technologies deal with multiscale hierarchical structures, intricate surface morphology, non-axisymmetric interfaces, and complex contact lines where wetting is difficult to quantify with classical methods. We hypothesise that a universal description of wetting on multiscale surfaces can be developed by using integral geometry coupled to thermodynamic laws. The proposed approach separates the different hierarchy levels of physical description from the thermodynamic description, allowing for a universal description of wetting on multiscale surfaces.

THEORY AND SIMULATIONS

The theoretical framework is presented followed by application to limiting cases of wetting on multiscale surfaces. Limiting cases include those considered in the Wenzel, Cassie-Baxter, and wicking state models. Wetting characterisation of multiscale surfaces is explored by conducting simulations of a fluid droplet on a structurally rough surface and a chemically heterogeneous surface.

FINDINGS

The underlying origin of the classical wetting models is shown to be rooted within the proposed theoretical framework. Integral geometry provides a topological-based wetting metric that is not contingent on any type of wetting state. The wetting metric is demonstrated to account for multiscale features along the common line in a scale consistent way; providing a universal description of wetting for multiscale surfaces.

Thermodynamics of fluctuations based on time-and-space averages

We develop nonequilibrium theory by using averages in time and space as a generalized way to upscale thermodynamics in nonergodic systems. The approach offers a classical perspective on the energy dynamics in fluctuating systems. The rate of entropy production is shown to be explicitly scale dependent when considered in this context. We show that while any stationary process can be represented as having zero entropy production, second law constraints due to the Clausius theorem are preserved due to the fact that heat and work are related based on conservation of energy. As a demonstration, we consider the energy dynamics for the Carnot cycle and for Maxwell's demon. We then consider nonstationary processes, applying time-and-space averages to characterize nonergodic effects in heterogeneous systems where energy barriers such as compositional gradients are present. We show that the derived theory can be used to understand the origins of anomalous diffusion phenomena in systems where Fick's law applies at small length scales, but not at large length scales. We further characterize fluctuations in capillary-dominated systems, which are nonstationary due to the irreversibility of cooperative events.

Discriminatory accuracy of the SOFA score for determining clinical decompensation in patients presenting with COVID-19

Introduction

While the global dissemination of vaccines targeting the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in a decline in the incidence of infections, the case fatality rates have remained relative stable. A major objective of managing hospitalized patients with documented or suspected COVID-19 infection is the rapid identification of features associated with severe illness using readily available laboratory tests and clinical tools. The sequential organ failure assessment (SOFA) score is a validated tool to facilitate the identification of patients at risk of dying from sepsis.

Purpose

The aim of this study was to assess the discriminatory accuracy of the SOFA score in predicting clinical decompensation in patients hospitalized with COVID-19 infection.

Methods

We conducted a retrospective analysis at a three-hospital health system, comprised of one tertiary and two community hospitals, located in the Chicago metropolitan area. All patients had positive SARS-CoV-2 testing and were hospitalized for COVID-19 infection. The primary outcome was clinical decompensation, defined as the composite endpoint of death, ICU admission, or need for intubation. We utilized the most abnormal laboratory values observed during the admission to calculate the SOFA score. Receiver Operating Curves (ROC) were then constructed to determine the sensitivity and specificity of SOFA scores.

Results

Between March 1st and May 31st 2020, 1029 patients were included in our analysis with 367 patients meeting the study endpoint. The median SOFA score was 2.0 IQR (Q1, Q3 1,4) for the entire cohort. Patients who had in-hospital mortality had a median SOFA score of 4.0 (Q1,Q3 3,7). In patients that met the primary composite endpoint, the median SOFA score was 3.0, IQR (Q1, Q3 2,6). The ROC was 0.776 (95% CI 0.746–0.806, p<0.01).

Conclusion

The SOFA score demonstrates strong discriminatory accuracy for prediction of clinical decompensation in patients presenting with COVID-19 at our urban hospital system.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Loyola University Medical Center

Predictors of clinical decompensation in patients presenting with COVID-19 in an urban hospital health system

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in a pandemic which has infected more than 128 million people and led to over 2.8 million deaths worldwide. Although the introduction of efficacious vaccines has led to overall declines in the incidence of SARS-CoV-2 infection, there has been a recent increase in infections once more due to the appearance of mutant strains with higher virulence. It therefore remains vital to identify predictors of poor outcomes in this patient population.

Purpose

The objective of our study was to identify predictors of prolonged hospitalization, intensive care unit (ICU) admission, intubation, and death in patients infected with SARS-CoV-2.

Methods

We conducted a retrospective analysis of all patients hospitalized with SARS-CoV-2 at our health system that includes one tertiary care center and two community hospitals located in the Chicago metropolitan area. The main outcome was a composite endpoint of hospitalization >28 days, ICU admission, intubation, and death.

Explanatory variables associated with the primary outcome in the bivariate analysis (p<0.05) were included in the multivariable logistic regression model. Statistical analysis was performed using IBM SPSS 25.0.

Results

Between March 1, 2020 and May 31, 2020, 1029 patients hospitalized with SARS-CoV-2 were included in our analysis. Of these patients, 379 met the composite endpoint. Baseline demographics are described in Table 1. Of note, our cohort consisted of a predominantly minority patient population including 47% Hispanic, 17% African American, 16% Caucasian, and 16% other.

In bivariate analysis, age, hypertension, tobacco and alcohol abuse, obesity, coronary artery disease, arrhythmias, valvular heart disease, dyslipidemia, hypertension, stroke, diabetes, documented thrombosis, troponin, CRP, ESR, ferritin, LDH, BNP, D-dimer >5x the upper limit of normal, lactate, and right ventricular outflow tract velocity time integral <9.5 were significant.

After multivariable adjustment, explanatory variables associated with the composite endpoint included troponin (OR 2.36; 95% CI 1.08–5.17, p 0.03), D-dimer (OR 1.5; 95% CI 1.23–1.98, p<0.01, lactate (OR 1.58; 95% CI 1.28–1.95, p<0.01), and documented thrombosis (OR 3.56; 95% CI 1.30–8.70, p<.05). Race was not a predictor of poor outcomes in the bivariate or multivariate analysis (Table 2).

Conclusions

In a large urban cohort with a predominantly minority population, we identified several clinical predictors of poor outcomes. Of note, race was not a predictor of the primary endpoint in this study. While recent literature has demonstrated worse outcomes among racial minorities infected with SARS-CoV-2, our data suggests these variations are related to social determinants of health rather than biologic causes.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Loyola University Medical Center

Microbiological colonization of peripheral venous catheters: a prospective observational study in a Swedish county hospital

Background

Most peripheral venous catheters (PVCs) used in Scandinavia are fitted with an injection port, creating an open PVC system. This port is difficult to disinfect, which may lead to the introduction of micro-organisms upon use.

Aim

To investigate the prevalence of microbiological colonization of the injection port and internal lumen of ported PVCs with a minimum dwell time of 48 h at sample collection.

Methods

Adult patients admitted to different medical and surgical departments and the intensive care unit were invited to participate in this prospective observational study. With the PVC in situ, the injection port and internal lumen were swabbed and cultured separately. Demographic and clinical data were collected to compare patients with colonized and non-colonized PVCs.

Findings

In total, 300 PVCs from 300 patients were analysed. Of these, 33 patients (11.0%) had at least one positive culture. The colonization locations were as follows: port only, 26 (8.7%); internal lumen only, 5 (1.7%); and port and internal lumen, 2 (0.7%). The colonization rate was significantly higher in the injection port than in the internal lumen (P<0.0001). A ported PVC inserted in the hand incurred a significant risk of colonization (P=0.03). The odds ratio for colonization among patients in the infectious diseases department was 0.1 (95% confidence interval 0.1–1; P<0.06) compared with patients in the medical department.

Conclusion

This study showed that 11% of ported PVCs were colonized by micro-organisms, with the vast majority (8.7%) of colonization occurring in the injection port.

Clinical trial registration

ClinicalTrials.gov; ID NCT03351725.

Association of clinical factors and recent anticancer therapy with COVID-19 severity among patients with cancer: a report from the COVID-19 and Cancer Consortium

BACKGROUND

Patients with cancer may be at high risk of adverse outcomes from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed a cohort of patients with cancer and coronavirus 2019 (COVID-19) reported to the COVID-19 and Cancer Consortium (CCC19) to identify prognostic clinical factors, including laboratory measurements and anticancer therapies.

PATIENTS AND METHODS

Patients with active or historical cancer and a laboratory-confirmed SARS-CoV-2 diagnosis recorded between 17 March and 18 November 2020 were included. The primary outcome was COVID-19 severity measured on an ordinal scale (uncomplicated, hospitalized, admitted to intensive care unit, mechanically ventilated, died within 30 days). Multivariable regression models included demographics, cancer status, anticancer therapy and timing, COVID-19-directed therapies, and laboratory measurements (among hospitalized patients).

RESULTS

A total of 4966 patients were included (median age 66 years, 51% female, 50% non-Hispanic white); 2872 (58%) were hospitalized and 695 (14%) died; 61% had cancer that was present, diagnosed, or treated within the year prior to COVID-19 diagnosis. Older age, male sex, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes mellitus, non-Hispanic black race, Hispanic ethnicity, worse Eastern Cooperative Oncology Group performance status, recent cytotoxic chemotherapy, and hematologic malignancy were associated with higher COVID-19 severity. Among hospitalized patients, low or high absolute lymphocyte count; high absolute neutrophil count; low platelet count; abnormal creatinine; troponin; lactate dehydrogenase; and C-reactive protein were associated with higher COVID-19 severity. Patients diagnosed early in the COVID-19 pandemic (January-April 2020) had worse outcomes than those diagnosed later. Specific anticancer therapies (e.g. R-CHOP, platinum combined with etoposide, and DNA methyltransferase inhibitors) were associated with high 30-day all-cause mortality.

CONCLUSIONS

Clinical factors (e.g. older age, hematological malignancy, recent chemotherapy) and laboratory measurements were associated with poor outcomes among patients with cancer and COVID-19. Although further studies are needed, caution may be required in utilizing particular anticancer therapies.

CLINICAL TRIAL IDENTIFIER

NCT04354701.

Transthyretin amyloid deposits in lumbar spinal stenosis and assessment of signs of systemic amyloidosis

BACKGROUND

Wild-type transthyretin (ATTRwt) amyloidosis is the most common systemic amyloidosis in Western countries and manifests mainly as progressive restrictive cardiomyopathy.

OBJECTIVE

To study the prevalence of ATTR deposits in ligament tissue in patients undergoing surgery for lumbar spinal stenosis and to assess whether these deposits are associated with cardiac amyloidosis.

MATERIALS AND METHODS

A total of 250 patients, aged 50-89 (57% women), none with known cardiovascular disease, were included. Ligaments were investigated microscopically for amyloid. ATTR type was determined by immunohistochemistry and fibril type by Western blot. The amount of amyloid was graded 0-4. All patients with grade 3-4 ATTR deposits were offered cardiac investigation including ECG, cardiac ultrasound, plasma NT-proBNP and cardiac magnetic resonance (CMR), including modern tissue characterization.

RESULTS

Amyloid was identified in 221 of the samples (88.4%). ATTR appeared in 93 samples (37%) of whom 42 (17 women and 25 men) were graded 3-4; all had fibril type A (mixture of full-length TTR and fragmented TTR). Twenty-nine of 42 patients with grade 3-4 ATTR deposits accepted cardiovascular investigations; none of them had definite signs of cardiac amyloidosis, but five men had a history of carpal tunnel syndrome.

CONCLUSIONS

The prevalence of ATTR deposits in ligamentum flavum in patients with lumbar spinal stenosis was high but not associated with manifest ATTR cardiac amyloidosis. However, the findings of fibril type A, the prevalence of previous carpal tunnel syndrome and ATTR amyloid in surrounding adipose and vascular tissue indicate that amyloid deposits in ligamentum flavum may be an early manifestation of systemic ATTR disease.

Characterization of wetting using topological principles

HYPOTHESIS

Understanding wetting behavior is of great importance for natural systems and technological applications. The traditional concept of contact angle, a purely geometrical measure related to curvature, is often used for characterizing the wetting state of a system. It can be determined from Young's equation by applying equilibrium thermodynamics. However, whether contact angle is a representative measure of wetting for systems with significant complexity is unclear. Herein, we hypothesize that topological principles based on the Gauss-Bonnet theorem could yield a robust measure to characterize wetting.

THEORY AND EXPERIMENTS

We introduce a macroscopic contact angle based on the deficit curvature of the fluid interfaces that are imposed by contacts with other immiscible phases. We perform sessile droplet simulations followed by multiphase experiments for porous sintered glass and Bentheimer sandstone to assess the sensitivity and robustness of the topological approach and compare the results to other traditional approaches.

FINDINGS

We show that the presented topological principle is consistent with thermodynamics under the simplest conditions through a variational analysis. Furthermore, we elucidate that at sufficiently high image resolution the proposed topological approach and local contact angle measurements are comparable. While at lower resolutions, the proposed approach provides more accurate results being robust to resolution-based effects. Overall, the presented concepts open new pathways to characterize the wetting state of complex systems and theoretical developments to study multiphase systems.

Signature of elastic turbulence of viscoelastic fluid flow in a single pore throat

When a viscoelastic fluid, such as an aqueous polymer solution, flows through a porous medium, the fluid undergoes a repetitive expansion and contraction as it passes from one pore to the next. Above a critical flow rate, the interaction between the viscoelastic nature of the polymer and the pore configuration results in spatial and temporal flow instabilities reminiscent of turbulentlike behavior, even though the Reynolds number Re≪1. To investigate whether this is caused by many repeated pore body-pore throat sequences, or simply a consequence of the converging (diverging) nature present in a single pore throat, we performed experiments using anionic hydrolyzed polyacrylamide (HPAM) in a microfluidic flow geometry representing a single pore throat. This allows the viscoelastic fluid to be characterized at increasing flow rates using microparticle image velocimetry in combination with pressure drop measurements. The key finding is that the effect, popularly known as "elastic turbulence," occurs already in a single pore throat geometry. The critical Deborah number at which the transition in rheological flow behavior from pseudoplastic (shear thinning) to dilatant (shear thickening) strongly depends on the ionic strength, the type of cation in the anionic HPAM solution, and the nature of pore configuration. The transition towards the elastic turbulence regime was found to directly correlate with an increase in normal stresses. The topology parameter, Q_{f}, computed from the velocity distribution, suggests that the "shear thickening" regime, where much of the elastic turbulence occurs in a single pore throat, is a consequence of viscoelastic normal stresses that cause a complex flow field. This flow field consists of extensional, shear, and rotational features around the constriction, as well as upstream and downstream of the constriction. Furthermore, this elastic turbulence regime, has high-pressure fluctuations, with a power-law decay exponent of up to |-2.1| which is higher than the Kolmogorov value for turbulence of |-5/3|.

Correction to: Development of a new reproductive tissue cryopreservation clinical service for children: the Oxford programme

In the published version, the Acknowledgements section was missing a funding note of co-author Dr C Verrill. The corrected version should read as follows.

Linking continuum-scale state of wetting to pore-scale contact angles in porous media

HYPOTHESIS

Wetting phenomena play a key role in flows through porous media. Relative permeability and capillary pressure-saturation functions show a high sensitivity to wettability, which has different definitions at the continuum- and pore-scale. We hypothesize that the wetting state of a porous medium can be described in terms of topological arguments that constrain the morphological state of immiscible fluids, which provides a direct link between the continuum-scale metrics of wettability and pore-scale contact angles.

EXPERIMENTS

We perform primary drainage and imbibition experiments on Bentheimer sandstone using air and brine. Topological properties, such as Euler characteristic and interfacial curvature are measured utilizing X-ray micro-computed tomography at irreducible air saturation. We also present measurements for the United States Bureau of Mines (USBM) index, capillary pressure and pore-scale contact angles. Additional studies are performed using two-phase Lattice Boltzmann simulations to test a wider range of wetting conditions.

FINDINGS

We demonstrate that contact angle distributions for a porous multiphase system can be predicted within a few percent difference of directly measured pore-scale contact angles using the presented method. This provides a general framework on how continuum-scale data can be used to describe the geometrical state of fluids within porous media.

Liquid Chromatographic Determination of Ochratoxin A in Barley, Wheat Bran, and Rye by the AOAC/IUPAC/NMKL Method: NMKL Collaborative Study1

In an inter laboratory study of the AOAC/lnternational Union of Pure and Applied Chemistry (IUPAC)/ Nordic Committee on Food Analysis (NMKL) liquid chromatographic method for ochratoxin A (OTA), 3 spiked samples each of wheat bran and rye and 3 naturally contaminated barley samples with expected OTA contents between 2 and 9 μg/kg were analyzed by 12 European laboratories. Mean recoveries ranged from 64 to 72%. Within-laboratory standard deviations were 21,17, and 12% for wheat bran, rye, and barley, respectively. Corresponding between-laboratory standard deviations were 23-28,20-28, and 18-31%. Horwitz ratio values ranged from 0.50 to 0.77. The method was accepted as an official NMKL method for determining OTA at ≥2 μg/kg in cereals and cereal products.

Penile Paget's Disease: A Case Report and Review of the Literature

Extramammary Paget's Disease (EMPD) is a rare cutaneous, slow growing, intraepithelial adenocarcinoma that can be either primary (intraepithelial arising within the epidermis) or secondary (intraepithelial spread of a visceral carcinoma). Here we present the case of a 63-year-old male with EMPD of the glans penis stemming from underlying urothelial carcinoma. Our treatment decision elected for management with chemotherapy and local treatment with radiation therapy. Subsequent, review of the literature demonstrated a rare disease with a variety of underlying malignancies causing this secondary pathology. Caregivers should be aware of the association of Paget's disease and urothelial cancer and should have a high index of suspicion that erythematous penile lesions may represent Paget's disease and that penile biopsies should be performed early in this setting.

Development of a new reproductive tissue cryopreservation clinical service for children: the Oxford programme

PURPOSE

This article describes the development of a new reproductive tissue cryopreservation clinical service for children at high risk of infertility in the NHS during times of severe financial constraints in the health service.

METHOD

A development plan with two phases was drawn up. Phase 1 restricted the service to childhood cancer patients referred to the Oxford Paediatric Oncology and Haematology Principle Treatment Centre. It was estimated that there would be 10 patients/year and used existing staff and facilities from paediatric oncology, surgery, anaesthetics radiology, pathology, psychology, teenage-young adult gynaecology, and an existing Human Tissue Authority tissue bank with a licence for storage of tissue under a Human Sector Licence. Phase 2 extended the service to include children and young adults across England, Wales and Ireland-patients from Scotland having access to a research programme in Edinburgh. The main challenge in phase 2 being resources and the need for patients to be able to be treated as close to home as safely as possible.

RESULTS

The Oxford team developed information resources and eligibility criteria based on published best practice, referral and treatment pathways, multidisciplinary team meetings, a network of third party sites, and a dedicated case management and database. As the programme expanded, the Oxford team was able to justify to management the need for a dedicated theatre list. Patient feedback through questionnaires, qualitative work conducted as part of a Ph.D. thesis as well as direct patient stories and interviews in TV, and radio features underpins the positive impact the programme has on patients and their families.

CONCLUSION

The Oxford Reproductive Cryopreservation programme delivers fertility preservation treatment to children and young adults at high risk of infertility safely, effectively and as close to home as possible. The onward view is to apply for national funding for this programme for recognition and sustainability.

Activated platelet aggregation is transiently impaired also by a reduced dose of protamine

Objectives: Protamine reduces platelet aggregation after cardiopulmonary bypass (CPB). We studied the inhibitory effect of a reduced protamine dose, the duration of impaired platelet function and the possible correlation to postoperative bleeding. Design: Platelet function was assessed by impedance aggregometry in 30 patients undergoing cardiac surgery with CPB at baseline, before protamine administration, after 70% and 100% of the calculated protamine dose, after 20 minutes and at arrival to the intensive care unit. Adenosine diphosphate (ADP), thrombin receptor activating peptide-6 (TRAP), arachidonic acid (AA) and collagen (COL) were used as activators. Blood loss was measured during operation and three hours after surgery. Results are presented as median (25th-75th percentile). Results: Platelet aggregation decreased markedly after the initial dose of protamine (70%) with all activators; ADP 89 (71-110) to 54 (35-78), TRAP 143 (116-167) to 109 (77-136), both p < .01; AA 25 (16-49) to 17 (12-24) and COL 92 (47-103) to 60 (38-81) U, both p < .05. No further decrease was seen after 100% protamine. The effect was transient and after twenty minutes platelet aggregation had started to recover; ADP 76 (54-106), TRAP 138 (95-158), AA 20 (10-35), COL 70 (51-93) U. Blood loss during operation correlated to aggregometry measured at baseline and after protaminization. Conclusions: Protamine after CPB induces a marked decrease in platelet aggregation already at a protamine-heparin ratio of 0.7:1. The impairment seems to be transient and recovery had started after 20 minutes.

Minimal surfaces in porous media: Pore-scale imaging of multiphase flow in an altered-wettability Bentheimer sandstone

High-resolution x-ray imaging was used in combination with differential pressure measurements to measure relative permeability and capillary pressure simultaneously during a steady-state waterflood experiment on a sample of Bentheimer sandstone 51.6 mm long and 6.1 mm in diameter. After prolonged contact with crude oil to alter the surface wettability, a refined oil and formation brine were injected through the sample at a fixed total flow rate but in a sequence of increasing brine fractional flows. When the pressure across the system stabilized, x-ray tomographic images were taken. The images were used to compute saturation, interfacial area, curvature, and contact angle. From this information relative permeability and capillary pressure were determined as functions of saturation. We compare our results with a previously published experiment under water-wet conditions. The oil relative permeability was lower than in the water-wet case, although a smaller residual oil saturation, of approximately 0.11, was obtained, since the oil remained connected in layers in the altered wettability rock. The capillary pressure was slightly negative and 10 times smaller in magnitude than for the water-wet rock, and approximately constant over a wide range of intermediate saturation. The oil-brine interfacial area was also largely constant in this saturation range. The measured static contact angles had an average of 80^{∘} with a standard deviation of 17^{∘}. We observed that the oil-brine interfaces were not flat, as may be expected for a very low mean curvature, but had two approximately equal, but opposite, curvatures in orthogonal directions. These interfaces were approximately minimal surfaces, which implies well-connected phases. Saddle-shaped menisci swept through the pore space at a constant capillary pressure and with an almost fixed area, removing most of the oil.

From uncertainty to gradually managing and awaiting recovery of a periodic condition- a qualitative study of parents´ experiences of PFAPA syndrome

BACKGROUND

The prevalence of periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome is unknown. Although an uncommon condition, it is considered to be the most common autoinflammatory disease among children in many parts of the world. The knowledge of the consequences of the recurrent fever episodes for the child and its family are limited. This study explores the experiences of parents regarding the impact of the disease on the child's general well-being, the family's situation and how the family handles the associated challenges.

METHODS

A qualitative approach was used, applying a modified version of Grounded theory for design, data collection and analysis. Data was collected from two different sources: communication between parents of children with PFAPA in a closed Facebook group and face-to face interviews with one of the parents of children diagnosed with PFAPA (6 mothers and 2 fathers).

RESULTS

Parents described a lengthy process of how everyday life becomes affected by their child's recurrent fever episodes. This process is depicted in the following Grounded Theory core category: From uncertainty to gradually managing and awaiting recovery. The categories Uncertainty, Assurance, Gradually managing and Recovery describe the experienced illness trajectory. The illness representation illustrates the experiences/impacts of the periodic condition in the subcategories: Harmlessness-Severity, Disclosure of diagnosis, Impact on daily life and Regularity-Unpredictability. The children's well-being was highly affected by the symptoms during episodes. Parents experienced increased stress with constant fatigue, social constraints of family life and restricted career opportunities. Nevertheless, hope of recovery was constantly present.

CONCLUSIONS

PFAPA is associated with a considerable burden on the child and the parents in daily life. Obtaining a diagnosis enables parents to move from a state of uncertainty towards a sense of coherence while awaiting recovery. Because of limited general knowledge of the condition and its impact on daily life, health care professionals need to become aware of the parents' efforts to mitigate the consequences of the recurrent episodes for the child and for the family as a whole.

Surfactant Variations in Porous Media Localize Capillary Instabilities during Haines Jumps

We use confocal microscopy to measure velocity and interfacial tension between a trapped wetting phase with a surfactant and a flowing, invading nonwetting phase in a porous medium. We relate interfacial tension variations at the fluid-fluid interface to surfactant concentration and show that these variations localize the destabilization of capillary forces and lead to rapid local invasion of the nonwetting fluid, resulting in a Haines jump. These spatial variations in surfactant concentration are caused by velocity variations at the fluid-fluid interfaces and lead to localization of the Haines jumps even in otherwise very uniform pore structure and pressure conditions. Our results provide new insight into the nature of Haines jumps, one of the most ubiquitous and important instabilities in flow in porous media.

Mechanisms of vortices termination in the cardiac muscle

We propose a solution to a long-standing problem: how to terminate multiple vortices in the heart, when the locations of their cores and their critical time windows are unknown. We scan the phases of all pinned vortices in parallel with electric field pulses (E-pulses). We specify a condition on pacing parameters that guarantees termination of one vortex. For more than one vortex with significantly different frequencies, the success of scanning depends on chance, and all vortices are terminated with a success rate of less than one. We found that a similar mechanism terminates also a free (not pinned) vortex. A series of about 500 experiments with termination of ventricular fibrillation by E-pulses in pig isolated hearts is evidence that pinned vortices, hidden from direct observation, are significant in fibrillation. These results form a physical basis needed for the creation of new effective low energy defibrillation methods based on the termination of vortices underlying fibrillation.

Vaccination of calves with Mycobacterium bovis Bacillus Calmette-Guerin reduces the frequency and severity of lesions of bovine tuberculosis under a natural transmission setting in Ethiopia

Bovine tuberculosis (bTB) is highly prevalent in intensive dairy farms of the urban "milk-sheds" in Ethiopia, and vaccination could be a cost-effective disease control strategy. In the present study, the efficacy of Bacillus Calmette-Guerin (BCG) to protect against bTB was assessed in Holstein-Friesian calves in a natural transmission setting. Twenty-three 2-week-old calves were subcutaneously vaccinated with BCG Danish SSI strain 1331, and matched 26 calves were injected with placebo. Six weeks later, calves were introduced into a herd of M. bovis-infected animals (reactors) and kept in contact with them for 1 year. In vitro and in vivo immunological tests were performed to assess immune responses post-vaccination and during exposure. Successful vaccine uptake was confirmed by tuberculin skin test and IFN-γ responses in vaccinated calves. The kinetics of IFN-γ responses to early secretory antigen target 6 and culture filtrate protein 10 (ESAT6 and CFP10, respectively) and tuberculin skin test responses post-exposure suggested that the animals were infected early after being placed in contact with the infected herd as immunological signs of infection were measurable between 2 and 4 months post-initial exposure. Protection was determined by comparing gross and microscopic pathology and bacteriological burden between vaccinated and control calves. BCG vaccination reduced the proportions of tissues with visible pathology in vaccinates compared to control calves by 49% (p < .001) with 56%, 43%, 72%, and 38% reductions in the proportion of lesioned tisues in head, thoracic, abdominal lymph nodes, and lungs, respectively (p-values .029-.0001). In addition, the lesions were less severe grossly and microscopically in vaccinated calves than in non-vaccinated calves (p < .05). The reduction in the overall incidence rates of bTB was 23%, 28%, and 33% on the basis of the absence of gross pathology, M. bovis culture positivity, and histopathology, respectively, in vaccinated animals. In conclusion, BCG vaccination reduced the frequency and severity of the pathology of bTB significantly, which is likely to reduce onwards transmission of the disease.

Primary Porcine Brain Endothelial Cells as In Vitro Model to Study Effects of Ultrasound and Microbubbles on Blood-Brain Barrier Function

Focused ultrasound (FUS) in the presence of microbubbles transiently and reversibly opens the blood-brain barrier (BBB) in rodents and humans, thereby providing a time window for increased drug delivery into brain tissue. To get insight into the underlying mechanisms that govern ultrasound (US)-mediated opening of the BBB, in vitro models are a useful alternative. In this paper, we have utilized an in vitro BBB model that consists of primary porcine brain endothelial cells (PBECs). PBEC monolayers are grown on permeable membranes, which allow assessment of key features of BBB function as well as US treatment. This experimental model is characterized by low permeability for both small molecules and proteins, has a high transendothelial electrical resistance, and expresses tight junctions and efflux pumps. Here, we compare the effects of inertial and stable cavitation in the presence of SonoVue microbubbles on PBEC monolayers' electrical resistance and permeability properties. Our results point out the fragility of PBEC monolayers, which enhances results variability. In particular, we show that handling of the inserts, such as medium change and transfer to the US setup, modifies the cellular response, and immunostaining of the monolayers introduces damage and cell detachment within the US-exposed monolayers. Our results indicate that stable cavitation might have a more pronounced impact on cell permeability as compared with inertial cavitation in vitro. This paper might contribute to further development of experimental setups that are suitable to characterize the impact of FUS and microbubbles on BBB properties in vitro.

Beyond Darcy's law: The role of phase topology and ganglion dynamics for two-fluid flow

In multiphase flow in porous media the consistent pore to Darcy scale description of two-fluid flow processes has been a long-standing challenge. Immiscible displacement processes occur at the scale of individual pores. However, the larger scale behavior is described by phenomenological relationships such as relative permeability, which typically uses only fluid saturation as a state variable. As a consequence pore scale properties such as contact angle cannot be directly related to Darcy scale flow parameters. Advanced imaging and computational technologies are closing the gap between the pore and Darcy scale, supporting the development of new theory. We utilize fast x-ray microtomography to observe pore-scale two-fluid configurations during immiscible flow and initialize lattice Boltzmann simulations that demonstrate that the mobilization of disconnected nonwetting phase clusters can account for a significant fraction of the total flux. We show that fluid topology can undergo substantial changes during flow at constant saturation, which is one of the underlying causes of hysteretic behavior. Traditional assumptions about fluid configurations are therefore an oversimplification. Our results suggest that the role of fluid connectivity cannot be ignored for multiphase flow. On the Darcy scale, fluid topology and phase connectivity are accounted for by interfacial area and Euler characteristic as parameters that are missing from our current models.

Capillary saturation and desaturation

Capillary desaturation experiments produce disconnected (trapped) ganglia of mesoscopic sizes intermediate between pore size and system size. Experimental evidence for interactions between these mesoscale clusters during desaturation is analyzed and discussed within the established microscopic and macroscopic laws of Newton, Young-Laplace, and Darcy. A theoretical expression for capillary number correlations is introduced that seems to have remained unnoticed. It expresses capillary desaturation curves in terms of stationary capillary pressures and relative permeabilities. The theoretical expression shows that the plateau saturation in capillary desaturation curves may in general differ from the residual nonwetting saturation defined through the saturation limit of the main hysteresis loop. Hysteresis effects as well as the difference between wetting and nonwetting fluids are introduced into the analysis of capillary desaturation experiments. The article examines experiments with different desaturation protocols and discusses the existence of a mesoscopic length scale intermediate between pore scale and sample scale. The theoretical expression is derived entirely within the existing traditional theory of two-phase flow in porous media and compared to a recent experiment.

Flexible thin-film battery based on graphene-oxide embedded in solid polymer electrolyte

Enhanced safety of flexible batteries is an imperative objective due to the intimate interaction of such devices with human organs such as flexible batteries that are integrated with touch-screens or embedded in clothing or space suits. In this study, the fabrication and testing of a high performance thin-film Li-ion battery (LIB) is reported that is both flexible and relatively safer compared to the conventional electrolyte based batteries. The concept is facilitated by the use of solid polymer nanocomposite electrolyte, specifically, composed of polyethylene oxide (PEO) matrix and 1 wt% graphene oxide (GO) nanosheets. The flexible LIB exhibits a high maximum operating voltage of 4.9 V, high capacity of 0.13 mA h cm(-2) and an energy density of 4.8 mW h cm(-3). The battery is encapsulated using a simple lamination method that is economical and scalable. The laminated battery shows robust mechanical flexibility over 6000 bending cycles and excellent electrochemical performance in both flat and bent configurations. Finite element analysis (FEA) of the LIB provides critical insights into the evolution of mechanical stresses during lamination and bending.

A new model for the estimation of time of death from vitreous potassium levels corrected for age and temperature

Analysis of potassium concentration in the vitreous fluid of the eye is frequently used by forensic pathologists to estimate the postmortem interval (PMI), particularly when other methods commonly used in the early phase of an investigation can no longer be applied. The postmortem rise in vitreous potassium has been recognized for several decades and is readily explained by a diffusion of potassium from surrounding cells into the vitreous fluid. However, there is no consensus regarding the mathematical equation that best describes this increase. The existing models assume a linear increase, but different slopes and starting points have been proposed. In this study, vitreous potassium levels, and a number of factors that may influence these levels, were examined in 462 cases with known postmortem intervals that ranged from 2h to 17 days. We found that the postmortem rise in potassium followed a non-linear curve and that decedent age and ambient temperature influenced the variability by 16% and 5%, respectively. A long duration of agony and a high alcohol level at the time of death contributed less than 1% variability, and evaluation of additional possible factors revealed no detectable impact on the rise of vitreous potassium. Two equations were subsequently generated, one that represents the best fit of the potassium concentrations alone, and a second that represents potassium concentrations with correction for decedent age and/or ambient temperature. The former was associated with narrow confidence intervals in the early postmortem phase, but the intervals gradually increased with longer PMIs. For the latter equation, the confidence intervals were reduced at all PMIs. Therefore, the model that best describes the observed postmortem rise in vitreous potassium levels includes potassium concentration, decedent age, and ambient temperature. Furthermore, the precision of these equations, particularly for long PMIs, is expected to gradually improve by adjusting the constants as more reference data are added over time. A web application that facilitates this calculation process and allows for such future modifications has been developed.

Behavioural strategy of large perch Perca fluviatilis varies between a mesotrophic and a hypereutrophic lake

Behaviour of large perch Perca fluviatilis was studied in two lakes differing in environmental state i.e. mesotrophic v. hypereutrophic. A total of 20 adult perch P. fluviatilis (29-42 cm total length) in each lake were tagged with radio-transmitters, tracked and located eight times a day during six 24 h tracking periods over a year, enabling detection of differences in diel activity patterns and habitat use during summer and winter under two different environmental regimes. During summer, P. fluviatilis in the mesotrophic lake showed a distinct crepuscular activity pattern and a change from pelagic residency during daytime towards the littoral zone at night. In contrast, P. fluviatilis in the hypereutrophic lake were active during the entire diel cycle and were spread throughout the lake also during dark. During winter, crepuscular patterns of activity were seen in both lakes. Condition factor of large P. fluviatilis did not differ between the two lakes. Thus, it is suggested that P. fluviatilis in the hypereutrophic turbid lake adopted an alternative behaviour for successful foraging, being uniformly active throughout the diel cycle.