The impact of perioperative stroke and delirium on outcomes after surgical aortic valve replacement

OBJECTIVE

The effects of stroke and delirium on postdischarge cognition and patient-centered health outcomes after surgical aortic valve replacement (SAVR) are not well characterized. Here, we assess the impact of postoperative stroke and delirium on these health outcomes in SAVR patients at 90 days.

METHODS

Patients (N = 383) undergoing SAVR (41% received concomitant coronary artery bypass graft) enrolled in a randomized trial of embolic protection devices underwent serial neurologic and delirium evaluations at postoperative days 1, 3, and 7 and magnetic resonance imaging at day 7. Outcomes included 90-day functional status, neurocognitive decline from presurgical baseline, and quality of life.

RESULTS

By postoperative day 7, 25 (6.6%) patients experienced clinical stroke and 103 (28.5%) manifested delirium. During index hospitalization, time to discharge was longer in patients experiencing stroke (hazard ratio, 0.62; 95% confidence interval [CI], 0.42-0.94; P = .02) and patients experiencing delirium (hazard ratio, 0.68; 95% CI, 0.54-0.86; P = .001). At day 90, patients experiencing stroke were more likely to have a modified Rankin score >2 (odds ratio [OR], 5.9; 95% CI, 1.7-20.1; P = .01), depression (OR, 5.3; 95% CI, 1.6-17.3; P = .006), a lower 12-Item Short Form Survey physical health score (adjusted mean difference -3.3 ± 1.9; P = .08), and neurocognitive decline (OR, 7.8; 95% CI, 2.3-26.4; P = .001). Delirium was associated with depression (OR, 2.2; 95% CI, 0.9-5.3; P = .08), lower 12-Item Short Form Survey physical health (adjusted mean difference -2.3 ± 1.1; P = .03), and neurocognitive decline (OR, 2.2; 95% CI, 1.2-4.0; P = .01).

CONCLUSIONS

Stroke and delirium occur more frequently after SAVR than is commonly recognized, and these events are associated with disability, depression, cognitive decline, and poorer quality of life at 90 days postoperatively. These findings support the need for new interventions to reduce these events and improve patient-centered outcomes.

Factors influencing the detection rate of fumarate peak in 1H MR spectroscopy of fumarate hydratase-deficient renal cell carcinoma at 3 T MRI

AIM

To identify factors that may be associated with fumarate detection rate in 1H-magnetic resonance spectroscopy (MRS) in fumarate hydratase-deficient renal cell carcinoma (FH-RCC).

MATERIALS AND MEHODS

Between February 2018 and March 2022, 16 FH-RCC patients with 30 lesions underwent 1H-MRS. Detection results were classified as having a detected fumarate peak (n=12), undetected peak (n=10), or technical failure (n=8). Factors including tumour size, tumour location, treatment history, and metastasis status were collected and analysed. A Bayesian logistic regression model was applied to evaluate the association between these factors and the detection result.

RESULTS

Bayesian analysis demonstrated significant associations between fumarate detection results and the following factors: long-axis diameter (odds ratio [OR] of 1.64; 95% confidence interval [CI] of 1.07-2.53), short-axis diameter (OR of 1.90; 95% CI of 1.19-3.06), voxel size (OR of 2.85; 95% CI of 1.70-4.75), treatment history (OR of 0.35; 95% CI of 0.21-0.58), non-metastatic state (OR of 2.45; 95% CI of 1.48-4.06), and lymph node metastasis (OR of 0.35; 95% CI of 0.21-0.58). Technical failure results were associated with factors such as treatment history (OR of 2.59; 95% CI of 1.37-4.66), non-metastatic state (OR of 0.36; 95% CI of 0.19-0.66), and lymph node metastasis (OR of 2.61; 95% CI of 1.39-4.74).

CONCLUSION

Tumour size, treatment history, and metastasis character were associated with the detection of abnormal fumarate accumulation. This finding will serve as a reference for interpreting 1H-MRS results and for selecting suitable scenarios to evaluate FH-RCC.

Evaluation of Radiotherapy Dose and Survival Outcomes for Teenagers, and Young Adults with Nasopharyngeal Carcinoma in UK and Ireland

PURPOSE/OBJECTIVE(S)

Nasopharyngeal carcinoma (NPC) follows a bimodal distribution with a smaller incidence peak in teenagers and young adults (TYAs). In TYAs, an over-whelming proportion are associated with Epstein-Barr virus (EBV). We have evaluated the variation in TYA NPC practice patterns across the UK and Ireland, along with survival outcomes.

MATERIALS/METHODS

We performed a multicenter, observational cohort study, of patients aged 13-25 years, with histologically confirmed NPC, treated between the years 2002-2022. An initial expression of interest was sent to selected centers treating H&N patients in the UK and Ireland. For analysis, patients were assessed based on total prescribed dose, with a cut off for low dose (LD) (≤61.2Gy) versus a high dose (HD)(>61.2Gy).

RESULTS

Ninety-five patients, from 9 centers, were eligible for inclusion. Patient demographics are shown in table1. At a median follow up of 45 months (IQR 23-111), 3-year overall survival (OS) was 98% (95% CI 93%-100%) with LD versus 91% (95% CI 83%-99%) with HD (Hazard ratio (HR) = 3.0; 95% CI 0.3-27, p = 0.3). 3-year progression free survival (PFS) was 84% (95% CI 71%-97%) with LD versus 83% (95% CI 72%-94%) with HD (HR 1.3; 95% CI 0.4-4.0, p = 0.6), and 5-year PFS was 84% (95% CI 71%-97%) with LD versus 83% (95% CI 72%-94%) with HD (HR 1.3; 95% CI 0.4-4.0, p = 0.6). Incidence of distant metastasis (DM) was 9.9%. 2 patients (6%) with T3-T4 tumors, treated with LD, had locoregional failure (LRF) compared to 1 patient (3%) treated with HD.

CONCLUSION

We have demonstrated excellent survival outcomes for the UK & Ireland TYA NPC patients. As the majority of cases in this age group have EBV+ NPC, with survival similar between LD and HD protocols, we propose that pediatric protocols, with lower radiotherapy doses should be considered for all TYA NPC, with the aim of reducing late effects. Additional analysis to better understand the impact of heterogeneity between both groups, including choice of protocol, induction and adjuvant treatment will follow this study. Prospective evaluation, as part of an international collaboration, is required to optimize the management strategy for this rare cohort of patients.

Rapid Unpaired CBCT-Based Synthetic CT for CBCT-Guided Adaptive Radiotherapy

PURPOSE/OBJECTIVE(S)

Quantitative cone beam CT (CBCT) is the foundation for image-guided radiation therapy, improving treatment setup, tumor delineation and dose calculation. However, CBCT images suffer from severe artifacts, limiting clinical utility. Deep learning can overcome these limitations, boosting radiographic and dosimetric quality critical for online adaptive radiotherapy (ART). We hypothesize adapted contrastive unpaired translation (CUT), a recent method for image-to-image translation of photographic images, can improve CBCT quality while reducing compute time, demonstrating utility for ART.

MATERIALS/METHODS

Same-day CBCT and quality assurance CT (QACT) images acquired from 79 patients receiving proton therapy for prostate cancer between 2019 and 2020 at a single institution were retrospectively collected. QACT images were acquired for quality assurance in accordance with institutional policy. Seventy-nine patients yielded 102 non-contrast CBCT-QACT image sets. Each QACT image was rigidly registered to the corresponding CBCT and resampled to 1 × 1 × 2 mm to establish uniform voxel size and spacing. CBCT images were randomly shuffled prior to input to the CUT model for unsupervised training and QACT-quality synthetic CT images were generated as outputs. We compared mean absolute error (MAE), structural similarity index measure (SSIM), and Fréchet inception distance (FID) against same-day QACT.

RESULTS

MAE, SSIM, and FID were compared for the CycleGAN and CUT data relative to input QACT and are reported as the mean across five-fold cross-validation ± standard error. CUT achieved superior performance in MAE (19.5 ± 3.9 HU vs. cycleGAN 47.1 ± 25.4) and FID (31.5 ± 6.6 vs cycleGAN 75.9 ± 41.3). MAE indicates pixel-level correspondence to QACT HU intensity values, making the synthetic outputs of CUT useful for dose calculations during ART. FID further demonstrates perceptual visual similarity. SSIM for CycleGAN (0.7 ± 0.2) and CUT (0.8 ± 0.0) were similar, indicating acceptable reproducibility of global structure. CUT was faster and lighter than CycleGAN. CycleGAN contained a total of 28,286,000 parameters; CUT contained 14,703,000, approximately half that of CycleGAN. As a result, CycleGAN computes on a single CT image slice over 0.33s while CUT requires just 0.18s.

CONCLUSION

The contrastive method investigated here was demonstrated to be faster and more accurate than CycleGAN, requiring fewer networks and parameters to achieve superior performance. We demonstrated anatomic boundary preservation and HU fidelity superior to cycleGAN while significantly reducing compute time. We plan to investigate the use of these synthetic CT images in automated segmentation prior to exploration of CUT in a prospective setting.

Equity of Access to Proton Beam Therapy in England: A National NHS analysis

PURPOSE/OBJECTIVE(S)

Policies to improve population health have often focused on equitable access to health services. While new technologies have an enormous potential in improving health outcomes, they may not always be equally accessible across diverse geographical areas and socio-economic backgrounds. Between 2008 and 2018, 1352 patients with eligible indications for Proton Beam Therapy (PBT) were treated overseas within the NHS Proton Overseas Programme (POP) and 947 patients have been treated at the Christie since the National NHS PBT service started in December 2018. The 8 most common PBT cancer indications cover more than 80% of the referrals and referral rates depend on several factors. Aim of this study is to evaluate equity of access to PBT throughout the country and how this has changed since the national PBT service inception.

MATERIALS/METHODS

Incidence data were available for 7/8 of the most common PBT cancer indications. These data were provided by the National Disease Registration Service (NDRS) by diagnosis, age group and by the 7 NHS regions in England. The incidence data referred to the time period 2013-2019. The first national NHS PBT center started accepting referrals in October 2018, therefore this time period was split in pre-NHS PBT (1/1/13-30/9/18) and post-NHS PBT (1/10/18-31/12/19). Demographics and clinical characteristics of patients referred for PBT were extracted from the national NHS PBT registry for matching clinical diagnoses and time period. The ratio between the referred (observed) and newly diagnosed (expected) patients is the Proton Utilization Proportion (PUP), which tracks the proportion of eligible patients using the technology.

RESULTS

For the 7 common PBT indications examined, the total number of newly diagnosed patients was 2134 in the pre-NHS PBT period and 461 in the post-NHS PBT period. The (accepted) referrals were 587 and 300 in the pre-and post-NHS PBT period, respectively. An increase in the PUP between the pre-NHS PBT and the post-NHS PBT is noted for any diagnostic category, age group and NHS region. The most noticeable increase is noticed for Medulloblastoma, which became a commissioned indication for PBT only in 2016.The PUP in England increased post-NHS PBT by 137% overall. Of note, post-NHS PBT, 99% of the patients aged 0-15 with these 7 common indications for PBT were referred and treated with PBT.

CONCLUSION

Promoting equality of access to cutting-edge radiotherapy technologies is at the heart of NHS England's values. Throughout the development of the policies and processes related to PBT access in the UK, the NHS has given regard to the need to reduce geographical variation which may contribute to health inequalities. The PUP has increased since the opening of a National PBT service in England, which uses a central web-based Proton Referral Pathway managed by a National Proton Office. Further analysis will follow to examine whether socio-economic or geographical barriers exist within each region.

Proton Beam Therapy in the Reirradiation Setting of Brain and Base of Skull Tumour Recurrences

The therapeutic management of local tumour recurrence after a first course of radical radiotherapy is always complex. Surgery and reirradiation carry increased morbidity due to radiation-induced tissue changes. Proton beam therapy (PBT) might be advantageous in the reirradiation setting, thanks to its distinct physical characteristics. Here we systematically reviewed the use of PBT in the management of recurrent central nervous system (CNS) and base of skull (BoS) tumours, as published in the literature. The research question was framed following the Population, Intervention, Comparison and Outcomes (PICO) criteria: the population of the study was cancer patients with local disease recurrence in the CNS or BoS; the intervention was radiation treatment with PBT; the outcomes of the study focused on the clinical outcomes of PBT in the reirradiation setting of local tumour recurrences of the CNS or BoS. The identification stage resulted in 222 records in Embase and 79 in Medline as of March 2023. Sixty-eight duplicates were excluded at this stage and 56 were excluded after screening as not relevant, not in English or not full-text articles. Twelve full-text articles were included in the review and are presented according to the site of disease, namely BoS, brain or both brain and BoS. This review showed that reirradiation of brain/BoS tumour recurrences with PBT can provide good local control with acceptable toxicity rates. However, reirradiation of tumour recurrences in the CNS or BoS setting needs to consider several factors that can increase the risk of toxicities. Therefore, patient selection is crucial. Randomised evidence is needed to select the best radiation modality in this group of patients.

Dose Volume Thresholds Associated with Acute Skin Toxicities in Proton Beam Therapy

PURPOSE/OBJECTIVE(S)

The depth-dose characteristics of proton beam therapy (PBT) mean that the skin-sparing effect is reduced with PBT, potentially leading to an increased incidence and severity of acute radiotherapy induced skin toxicities (RIST). Predictive factors of acute RIST in patients treated with PBT remain largely undefined. In this study, we retrospectively reviewed the acute RIST of patients treated with pencil beam scanning (PBS) PBT to identify dose-volume thresholds which are predictive of acute RIST.

MATERIALS/METHODS

All patients treated with PBS-PBT at a single institution between December 2018-October 2022 were included in this study. Acute RIST were recorded as per RTOG grading scale and dichotomized to Grade (G) <2 vs ≥2. Anonymized demographics, clinical and dosimetric data were extracted from electronic patient records and a treatment planning system. Skin structure is defined as 5mm rind grown as an inner margin from the patient contour. The following skin dose-volume statistics were collected: Dmax (maximum dose to any pixel inside the skin contour) and dose to skin volumes in 5Gy increments (V5Gy, V10Gy etc.). Preliminary analyses of dosimetric data of patients with G0, G1 vs ≥G2 acute RIST are presented, with significance assessed at the 5% level using t-tests and univariate logistic regression models, and risk thresholds determined using receiver operating characteristic (ROC) curves.

RESULTS

We report the data for 582 patients with extracted dosimetric data. The pediatric, teenage and young adult (TYA) and adult populations were 38%, 19% and 43% respectively. The three most common indications for PBT were head and neck cancers (HNC) (23%), sarcoma (21%), and chordoma (15%). Increasing age, HNC and sarcoma were associated with an increased risk of grade 2+ acute RIST. For patients who developed acute RIST of G2+, the median volume receiving 10Gy, 20Gy, 30Gy, 40Gy and 50Gy were significantly higher (P<0.0001) than patients with G0 and G1. The dose volume effect of acute RIST is greater at 30Gy and above. Similarly, median Dmax was significantly higher in the G2+ acute RIST group compared to G0 and G1 (P<0.0001) for all age groups. Using the ROC curve, we observed threshold volumes (in cm3) for V10Gy, V20Gy, V30Gy, V40Gy and V50Gy (Table 1).

CONCLUSION

The volume of irradiated skin and Dmax are associated with the risk of developing acute RIST in patients treated with PBS PBT. Further work is being done to develop a model predictive of acute RIST in clinical setting.

Assessing Equity of Access to Proton Beam Therapy: A Literature Review

Proton beam therapy (PBT) is one of the most advanced radiotherapy technologies, with growing evidence to support its use in specific clinical scenarios and exponential growth of demand and capacity worldwide over the past few decades. However, geographical inequalities persist in the distribution of PBT centres, which translate into variations in access and use of this technology. The aim of this work was to look at the factors that contribute to these inequalities, to help raise awareness among stakeholders, governments and policy makers. A literature search was conducted using the Population, Intervention, Comparison, Outcomes (PICO) criteria. The same search strategy was run in Embase and Medline and identified 242 records, which were screened for manual review. Of these, 24 were deemed relevant and were included in this analysis. Most of the 24 publications included in this review originated from the USA (22/24) and involved paediatric patients, teenagers and young adults (61% for children and/or teenagers and young adults versus 39% for adults). The most reported indicator of disparity was socioeconomic status (16/24), followed by geographical location (13/24). All the studies evaluated in this review showed disparities in the access to PBT. As paediatric patients make up a significant proportion of the PBT-eligible patients, equity of access to PBT also raises ethical considerations. Therefore, further research is needed into the equity of access to PBT to reduce the care gap.

Characterizing longitudinal change in accelerometry-based moderate-to-vigorous physical activity in the Hispanic Community Health Study/Study of Latinos and the Framingham Heart Study

BACKGROUND

Physical activity promotes health and is particularly important during middle and older age for decreasing morbidity and mortality. We assessed the correlates of changes over time in moderate-to-vigorous physical activity (MVPA) in Hispanic/Latino adults from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL: mean [SD] age 49.2 y [11.5]) and compared them to a cohort of primarily White adults from the Framingham Heart Study (FHS: mean [SD] 46.9 y [9.2]).

METHODS

Between 2008 and 2019, we assessed accelerometry-based MVPA at two time points with an average follow-up of: 7.6 y, SD 1.3 for HCHS/SOL, and 7.8 y, SD 0.7 for FHS. We used multinomial logistic regression to relate socio-demographic and health behaviors with changes in compliance with 2018 US recommendations for MVPA from time 1 to time 2 (remained active or inactive; became active or inactive) across the two cohorts.

RESULTS

In HCHS/SOL mean MVPA was 22.6 (SD, 23.8) minutes at time 1 and dropped to 16.7 (19.0) minutes at time 2. In FHS Mean MVPA was 21.7 min (SD, 17.7) at time 1 and dropped to 21.3 min (SD, 19.2) at time 2. Across both cohorts, odds of meeting MVPA guidelines over time were about 6% lower in individuals who had lower quality diets vs. higher, about half in older vs. younger adults, about three times lower in women vs. men, and 9% lower in individuals who had a higher vs. lower BMI at baseline. Cohorts differed in how age, gender, income, education, depressive symptoms, marital status and perception of general health and pain associated with changes in physical activity. High income older Hispanics/Latino adults were more likely to become inactive at the follow-up visit as were HCHS/SOL women who were retired and FHS participants who had lower levels of education and income. Higher depressive symptomology was associated with becoming active only in HCHS/SOL women. Being male and married was associated with becoming inactive in both cohorts. Higher perception of general health and lower perception of pain were associated with remaining active only in FHS adults.

CONCLUSIONS

These findings highlight potentially high-risk groups for targeted MVPA intervention.

An investigation of the PM2.5 concentrations and cumulative inhaled dose during subway commutes in Changchun, China

Air quality in subway systems is crucial as it affects the health of passengers and staff. Although most tests of PM2.5 concentrations in subway stations have taken place in public areas, PM2.5 is less understood in workplaces. Few studies have estimated the cumulative inhaled dose of passengers based on real-time changes in PM2.5 concentrations as they commute. To clarify the above issues, this study first measured PM2.5 concentrations in four subway stations in Changchun, China, where measuring points included five workrooms. Then, passengers' exposure to PM2.5 during the whole subway commute (20-30 min) was measured and segmented inhalation was calculated. The results showed that PM2.5 concentration in public places ranged from 50 to 180 μg/m3, and was strongly correlated with outdoors. While the PM2.5 average concentration in workplaces was 60 µg/m3, and it was less affected by outdoor PM2.5 concentration. Passenger's cumulative inhalations in single commuting were about 42 μg and 100 μg when the outdoor PM2.5 concentrations were 20-30 μg/m3 and 120-180 μg/m3, respectively. The PM2.5 inhalation in carriages accounted for the largest proportion of the entire commuting, about 25-40%, because of the longer exposure time and higher PM2.5 concentrations. It is recommended to improve the tightness of the carriage and filter the fresh air to improve the air quality inside. The average daily PM2.5 inhaled by staff was 513.53 μg, which was 5-12 times higher than that of passengers. Installing air purification devices in workplaces and reminding staff to take personal protection can positively protect their health.

A Salivary Gland Resident Macrophage Subset Regulating Radiation Responses

Radiotherapy of head and neck cancers frequently leads to irreversible hypofunction of salivary glands, which severely compromises the quality of life and is extremely difficult to treat. We found recently that salivary gland resident macrophages are sensitive to radiation and interact with epithelial progenitors and endothelial cells through homeostatic paracrine factors. Heterogeneous subpopulations of resident macrophages are present in other organs with distinct functions, whereas subpopulations of salivary gland resident macrophages with distinct functions or transcriptional profiles have not been reported yet. Using single-cell RNA sequencing, we found that mouse submandibular glands (SMGs) contain 2 distinct self-renewing resident macrophage subsets, an MHC-II^hi subset present in many other organs and an uncommon Csf2r⁺ subset. The main source of Csf2 in SMGs are innate lymphoid cells (ILCs) that rely on IL15 for maintenance, while the main source of IL15 protein is Csf2r⁺ resident macrophages, indicating a homeostatic paracrine interaction between these cells. Csf2r⁺ resident macrophages are the major source of hepatocyte growth factor (Hgf) that regulates homeostasis of SMG epithelial progenitors. Meanwhile, Csf2r⁺ resident macrophages are responsive to Hedgehog signaling that can rescue salivary function impaired by radiation. Consistently, irradiation persistently decreased numbers of ILCs and levels of IL15 and Csf2 in SMGs, which were all recovered by transient activation of Hedgehog signaling after radiation. Csf2r⁺ resident macrophages and MHC-II^hi resident macrophages share transcriptome profiles of perivascular macrophages and macrophages associated with nerves and/or epithelial cells in other organs, respectively, and such niche preferences were supported by lineage tracing and immunofluorescent staining. These findings reveal an uncommon resident macrophage subset that regulates the homeostasis of the salivary gland and is promising as the target to restore salivary gland function impaired by radiation.

Chimeric Antigen Receptor-Natural Killer Cells: A New Breakthrough in the Treatment of Solid Tumours

Natural killer (NK) cells can quickly and directly eradicate tumour cells without recognising tumour-specific antigens. NK cells also participate in immune surveillance, which arouses great interest in the development of novel cancer therapies. The chimeric antigen receptor (CAR) family is composed of receptor proteins that give immune cells extra capabilities to target specific antigen proteins or enhance their killing effects. CAR-T cell therapy has achieved initial success in haematological tumours, but is prone to adverse reactions, especially with cytokine release syndrome in clinical applications. Currently, CAR-NK cell therapy has been shown to successfully kill haematological tumour cells with allogeneic NK cells in clinical trials without adverse reactions, proving its potential to become an off-the-shelf product with broad clinical application prospects. Meanwhile, clinical trials of CAR-NK cells for solid tumours are currently underway. Here we will focus on the latest advances in CAR-NK cells, including preclinical and clinical trials in solid tumours, the advantages and challenges of CAR-NK cell therapy and new strategies to improve the safety and efficacy of CAR-NK cell therapy.

Neonatal and paediatric point-of-care ultrasound review

Purpose

Point-of-care ultrasound (POCUS) examinations for children and newborns are different from POCUS exams for adults due to dissimilarities in size and body composition, as well as distinct surgical procedures and pathologies in the paediatric patient. This review describes the major paediatric POCUS exams and how to perform them and summarizes the current evidence-based perioperative applications of POCUS in paediatric and neonatal patients.

Method

Literature searches using PubMed and Google Scholar databases for the period from January 2000 to November 2021 that included MeSH headings of [ultrasonography] and [point of care systems] and keywords including "ultrasound" for studies involving children aged 0 to 18 years.

Results

Paediatric and neonatal POCUS exams can evaluate airway, gastric, pulmonary, cardiac, abdominal, vascular, and cerebral systems.

Discussion

POCUS is rapidly expanding in its utility and presence in the perioperative care of paediatric and neonatal patients as their anatomy and pathophysiology are uniquely suited for ultrasound imaging applications that extend beyond the standard adult POCUS exams.

Conclusions

Paediatric POCUS is a powerful adjunct that complements and augments clinical diagnostic evaluation and treatment.

Improving Postpartum Attendance among Women with Gestational Diabetes Using the Medical Home Model of Care

OBJECTIVE

Poor attendance at the 6-week postpartum (PP) visit has been well reported. Attendance at this visit is crucial to identify women who have persistent diabetes mellitus (DM) following pregnancies affected by gestational DM (GDM). The medical home model has eliminated barriers to care in various other settings. This study sought to improve PP attendance among women with GDM by jointly scheduling PP visits and the 2-month well infant visits.

STUDY DESIGN

All patients with a diagnosis of GDM who received care at a New York City-based publicly insured hospital clinic and delivered between October 2017 and June 2019 were eligible. Data were obtained via chart review. The primary outcome was attendance at the PP visit compared with previously published historical controls. Secondary outcomes were rates of PP glucose screening and well infant attendance.

RESULTS

Of the 74 patients enrolled, 41.9% were Hispanic and 17.6% were Black, mean age was 31.6 years, and 58.1% delivered vaginally. Attendance at the 6-week PP visit was 68.9%, and attendance at the infant visit was 55.1%. PP glucose testing was ordered for 76.5% of attendees at the PP visit, and of those ordered, 43.6% of attendees completed testing. All patients had joint visits requested, though only 70.3% of visits were scheduled jointly. Among those who were jointly scheduled, 71.2% of women attended, 57.7% of infants attended, and 7.7% of pairs attended on the same day. The PP visit attendance rate was not significantly different than the prior attendance rate (p = 0.84).

CONCLUSION

This study was unable to improve PP visit attendance among women with GDM by jointly scheduling the 6-week PP visit and the 2-month well-infant visit. Future research could be directed toward a shared space where both women and children can be seen to attempt to increase PP visit attendance and monitoring for women with GDM.

KEY POINTS

· Attendance at the PP visit is poor, and without a visit, women with pregnancies affected by gestational diabetes remain unscreened for PP dysglycemia.. · Jointly scheduling women and their infants to eliminate barriers to care studied by this group, however, were unable to improve attendance.. · Innovative strategies are needed to improve PP attendance among women with pregnancies affected by GDM..

Transcriptome analysis of the binucleate ciliate Tetrahymena thermophila with asynchronous nuclear cell cycles

Tetrahymena thermophila harbors two functionally and physically distinct nuclei within a shared cytoplasm. During vegetative growth, the "cell cycles" of the diploid micronucleus and polyploid macronucleus are offset. Micronuclear S phase initiates just before cytokinesis and is completed in daughter cells before onset of macronuclear DNA replication. Mitotic micronuclear division occurs mid-cell cycle, while macronuclear amitosis is coupled to cell division. Here we report the first RNA-seq cell cycle analysis of a binucleated ciliated protozoan. RNA was isolated across 1.5 vegetative cell cycles, starting with a macronuclear G1 population synchronized by centrifugal elutriation. Using MetaCycle, 3244 of the 26,000+ predicted genes were shown to be cell cycle regulated. Proteins present in both nuclei exhibit a single mRNA peak that always precedes their macronuclear function. Nucleus-limited genes, including nucleoporins and importins, are expressed before their respective nucleus-specific role. Cyclin D and A/B gene family members exhibit different expression patterns that suggest nucleus-restricted roles. Periodically expressed genes cluster into seven cyclic patterns. Four clusters have known PANTHER gene ontology terms associated with G1/S and G2/M phase. We propose that these clusters encode known and novel factors that coordinate micro- and macronuclear-specific events such as mitosis, amitosis, DNA replication, and cell division.

PLASMA PROTEOMIC SIGNATURE OF DECLINE IN GAIT SPEED AND GRIP STRENGTH

Physical function predicts health-related quality of life. The biological mechanisms underlying declines in physical function with age remain unclear. We examined the plasma proteomic profile associated with longitudinal changes of physical functions measured by gait speed and grip strength in community-dwelling adults. We applied aptamer-based platform to assay 1,161 plasma proteins on 2,871 participants (60% women, aged 76 years) in Cardiovascular Health Study (CHS) in 1992/1993 and 1,550 participants (55% women, aged 54 years) in Framingham Offspring Study (FOS) in 1991-1995. Gait speed and grip strength were measured annually for 6 years in CHS and at cycles 7 (1998-2001) and 8 (2005-2008) in FOS. The associations of individual protein levels (log-transformed and standardized) with longitudinal changes of gait speed and grip strength in two populations were examined separately by linear mixed effect models. Meta-analyses were implemented using random effect models with a Bonferroni correction for multiple testing. We found that plasma levels of 18 and 12 proteins were associated with changes in gait speed and grip strength, respectively (Bonferroni-corrected p < .05). The proteins most strongly associated with gait speed decline were growth/differentiation factor 15 (GDF-15) (uncorrected Meta-analytic p = 1.60E-15), pleiotrophin (PTN) (1.29E-08), and metalloproteinase inhibitor 1 (TIMP-1) (2.02E-08). For grip strength decline, the strongest associations were for GDF-15 (1.39E-07), carbonic anhydrase III (6.60E-07), and TIMP-1 (3.21E-06). Several statistically significant proteins are involved in the alternative complement pathway, extracellular matrix remodeling or immune function. These novel proteomic biomarkers may inform our understanding of the pathophysiology of functional decline.

Plasma proteomic signature of decline in gait speed and grip strength

The biological mechanisms underlying decline in physical function with age remain unclear. We examined the plasma proteomic profile associated with longitudinal changes in physical function measured by gait speed and grip strength in community-dwelling adults. We applied an aptamer-based platform to assay 1154 plasma proteins on 2854 participants (60% women, aged 76 years) in the Cardiovascular Health Study (CHS) in 1992-1993 and 1130 participants (55% women, aged 54 years) in the Framingham Offspring Study (FOS) in 1991-1995. Gait speed and grip strength were measured annually for 7 years in CHS and at cycles 7 (1998-2001) and 8 (2005-2008) in FOS. The associations of individual protein levels (log-transformed and standardized) with longitudinal changes in gait speed and grip strength in two populations were examined separately by linear mixed-effects models. Meta-analyses were implemented using random-effects models and corrected for multiple testing. We found that plasma levels of 14 and 18 proteins were associated with changes in gait speed and grip strength, respectively (corrected p < 0.05). The proteins most strongly associated with gait speed decline were GDF-15 (Meta-analytic p = 1.58 × 10^-15 ), pleiotrophin (1.23 × 10^-9 ), and TIMP-1 (5.97 × 10^-8 ). For grip strength decline, the strongest associations were for carbonic anhydrase III (1.09 × 10^-7 ), CDON (2.38 × 10^-7 ), and SMOC1 (7.47 × 10^-7 ). Several statistically significant proteins are involved in the inflammatory responses or antagonism of activin by follistatin pathway. These novel proteomic biomarkers and pathways should be further explored as future mechanisms and targets for age-related functional decline.

Survival and renal outcomes of direct heart transplant from veno-arterial extracorporeal membrane oxygenation support

Backgrounds

Patients on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support are given the highest priority for cardiac transplantation (OHT) in the new UNOS heart allocation policy adopted in October 2018. Although patients may receive an organ quicker there may not be enough time to recover end-organ function. To date, little is known about survival and renal outcomes of direct OHT in patients that have been supported with VA-ECMO as a bridge to transplant due to limited experience in most transplant centers.

Purpose

The aim of this study was to investigate survival and renal outcomes of direct OHT in patients supported with VA-ECMO prior to transplant.

Methods

From January 2010 to February 2022, 23 patients who received single organ OHT alone directly from VA-ECMO support were retrospectively analyzed (16 patients after the new allocation policy). Kaplan-Meier analysis was used to estimate event-free survival.

Results

The median age of recipients was 48 years. The median length of pre-transplant VA-ECMO support was 5 days. Additional pre-transplant support with intra-aortic balloon pump or Impella was utilized in 15 patients (65.2%) and 2 patients (9%) respectively. There was a trend toward improvement of serum creatinine after initiation of VA-ECMO support (Pre-ECMO: 1.66±1.22 mg/dl vs. Pre-OHT: 1.20±0.74 mg/dl, P=0.084). Four patients required preoperative renal replacement therapy (RRT); three were on RRT at the time of OHT. The median ischemic time of donor hearts was 168 minutes. VA-ECMO support was continued in 10 patients (43.5%) after OHT.

Hospital mortality was 8.7% (2 patients). Post-transplant RRT was required in 9 patients (39.1%), and, of these, 5 patients were transitioned to permanent dialysis. Among the 14 patients who did not require post-transplant RRT, none required RRT during the follow-up period (median, 21.5 months). Kaplan-Meier survival analysis showed that estimated survival at 1 year and 3 years were 86.1%, and 77.5%, respectively (Figure 1A). The freedom from dialysis rate was 82.4% at 1 year, and 74.9% at 3 years (Figure 2A). Both survival (100% vs. 66.7%, P=0.008, Fig.1B) and dialysis free rate (100% vs. 55.6%, P=0.002, Figure 2B) at one-year were significantly worse in patients who required postoperative RRT.

Conclusions

To our knowledge this is the largest single center study of OHT in patients that were supported with VA-ECMO. VA-ECMO as a bridge to end-organ recovery and OHT resulted in excellent outcomes. Patients who required post-transplant RRT more likely to require long-term dialysis, while those that did not receive RRT showed favorable outcomes. Overall survival in this patient population is comparable to patients that were not on VA-ECMO prior to transplant.

Funding Acknowledgement

Type of funding sources: None.

P01.07.A Neurocognitive outcomes after proton beam therapy for skull base tumours

Background

Evidence suggests that Proton Beam Therapy (PBT) may lessen the risk of neurocognitive decline (NCD) by reducing the dose to the normal brain as compared to conventional photon radiotherapy (XRT). We report the incidence of moderate-severe (Grade ≥3) NCD in adults treated for skull base chordomas and chondrosarcomas within the United Kingdom’s Proton Overseas Programme (POP).

Material and Methods

Baseline (pre-PBT) and follow-up clinical outcomes data were prospectively collected as part of a national PBT-outcomes registry, which started in 2008 . This registry is curated by a dedicated Proton Clinical Outcomes Unit. Specifically, late toxicities ≥G3 as per CTCAE (Common Terminology Criteria for Adverse Events) v4.0 definition, occurring later than 90 days after treatment completion, were recorded. This study focuses on the incidence of memory impairment (MI) in the adult (≥25 y) cohort.

Results

Between 2008-2018, 141 adult patients were treated for skull base chordomas (77 patients, 54.6%) and chondrosarcomas (64 patients, 45.4%) via the POP (the majority -62.8%- treated at the University of Florida PBT Institute). Median age at treatment was 51 years (range 26-77). Median prescription dose was 73.8 GyRBE (70-75.6), with a median dose per fraction of 1.8 Gy (1.2-2.1). Of note, the median dose for chondrosarcomas was 70.2 GyRBE (70-75.6), whereas the median dose for chordomas was 73.8 GyRBE (72-75.6). Median follow up was 39 months (0-138). On clinical assessment, 4 patients (2 chordomas, 2 chondrosarcomas) were reported with G3 MI after a median time of 43 months (27-49). None of them had impaired memory at baseline, nor relevant neurological comorbidities. Median age of those who developed G3 MI was 63 y (39-70). Median prescription dose was 72.9 GyRBE (70-73.8). Plans were available for 3 of these 4 patients. Relevant dose statistics to hippocampi and temporal lobes were extracted. Dmean to the omo- and contralateral hippocampi in these 3 patient plans were: patient 1) 33.7 and 11.6 GyRBE; patient 2) 28.1 and 24.4 Gy; patient 3) 8.7 and 8.2 GyRBE, respectively. V20 to the omo- and contralateral temporal lobes in the same patients were: patient 1) 47% and 10%; patient 2) 29% and 28.7%; patient 3) 30% and 28%, respectively. Suggested constraints for these structures are: Dmean &lt; 20 Gy to the hippocampi and V20Gy &lt;10% to the temporal lobes.

Conclusion

Our results indicate that adult patients undergoing high dose radiation for radioresistant tumours may experience detrimental effects on memory. Neurocognitive baseline and follow-up assessment is not routinely performed in this age group but might be appropriate to explore which domains of cognitive function are mainly affected. Larger cohorts are warranted to establish predictive factors and better understand dose volume effect of brain structures and neurocognitive sequelae.

Sexual Harassment Prevalence Among OBGYN Trainees and Cultural Climate of their Training Programs: Result From a Nationwide Survey

OBJECTIVE

Sexual harassment has many short- and long-term consequences and greatly impacts the clinical work environment, job satisfaction, job performance, and mental wellbeing of the individual. Data on prevalence of sexual harassment in a women-majority field such as Obstetrics and Gynecology (OBGYN) are limited. This national cross-sectional study sought to determine the prevalence of sexual harassment among OBGYN trainees in the United States (U.S.) and assess the associated departmental cultural climate.

DESIGN, SETTING, PARTICIPANTS

This study was a cross-sectional, anonymous, voluntary, national survey of OBGYN residents and fellows in the U.S. conducted from May 1, 2019 to June 30, 2019. The validated Sexual Experience Questionnaire was administered via an online survey. Trainees were also queried regarding wellbeing, work satisfaction, and departmental/institutional reporting structure. Demographic data were also gathered. The main outcome was prevalence of sexual harassment among U.S. OBGYN trainees.

RESULTS

An email including the survey link was distributed to 1473 OBGYN trainees from 60 programs; 366 completed it (24.8% response rate). The mean age of survey respondents was 30.5 (SD 2.9) years. The majority of respondents were women (86%), White (64.1%), and residents (PGY 1-4, 80.2%). The prevalence of sexual harassment among respondents was 69.1% (69.6% of men and 68.7% of women). The prevalence of sexual harassment by race/ethnicity was: Hispanic/Latina 75.0%, White 68.7%, Asian 68.6%, and Black 47.4% trainees. The majority of respondents' program directors were women (66.4%, 227/342) and the majority of department chairs were men (68.9%, 235/341). The prevalence of sexual harassment did not differ based on the gender of the respondents' program directors and chairs (p-value 0.93).

CONCLUSIONS

There is a high prevalence of sexual harassment among U.S. OBGYN trainees. Action is required to improve institutional and departmental cultures.

Multi-system trajectories and the incidence of heart failure in the Framingham Offspring Study

BACKGROUND

Heart failure is a multi-system disease, with non-cardiac systems playing a key role in disease pathogenesis.

OBJECTIVE

Investigate whether longitudinal multi-system trajectories incrementally predict heart failure risk compared to single-occasion traits.

METHODS

We evaluated 3,412 participants from the Framingham Heart Study Offspring cohort, free of heart failure, who attended examination cycle 5 and at least one examination between 1995-2008 (mean age 67 years, 54% women). We related trajectories for the following organ systems and metabolic functions to heart failure risk using Cox regression: kidney (estimated glomerular filtration rate), lung (forced vital capacity and the ratio of forced expiratory volume in one second/forced vital capacity), neuromotor (gait time), muscular (grip strength), cardiac (left ventricular mass index and heart rate), vascular function (pulse pressure), cholesterol (ratio of total/high-density lipoprotein), adiposity (body mass index), inflammation (C-reactive protein) and glucose homeostasis (hemoglobin A1c). Using traits selected via forward selection, we derived a trajectory risk score and related it to heart failure risk.

RESULTS

We observed 276 heart failure events during a median follow up of 10 years. Participants with the 'worst' multi-system trajectory profile had the highest heart failure risk. A one-unit increase in the trajectory risk score was associated with a 2.72-fold increase in heart failure risk (95% CI 2.21-3.34; p<0.001). The mean c-statistics for models including the trajectory risk score and single-occasion traits were 0.87 (95% CI 0.83-0.91) and 0.83 (95% CI 0.80-0.86), respectively.

CONCLUSION

Incorporating multi-system trajectories reflective of the aging process may add incremental information to heart failure risk assessment when compared to using single-occasion traits.

Arterial Stiffness and Long-Term Risk of Health Outcomes: The Framingham Heart Study

BACKGROUND

Arterial stiffness increases with age and is associated with an increased risk of adverse outcomes on short-term follow-up (typically <10 years). Data regarding associations of arterial stiffness with health outcomes on longer-term follow-up are lacking.

METHODS

We evaluated 7283 Framingham Study participants (mean age 50 years, 53% women) who underwent assessment of carotid-femoral pulse wave velocity (a marker of arterial stiffness) via applanation tonometry at one or more routine examinations. We used time-dependent Cox proportional hazards regression models to relate carotid-femoral pulse wave velocity to the incidence of health outcomes (updating carotid-femoral pulse wave velocity and all covariates at serial examinations).

RESULTS

On long-term follow-up (median 15 years; minimum-maximum, 0-20), participants developed cardiometabolic disease (hypertension [1255 events]; diabetes [381 events]), chronic kidney disease (529 events), dementia (235 events), cardiovascular disease (684 events) and its components (coronary heart disease [314 events], heart failure [191 events], transient ischemic attacks or stroke [250 events]), and death (1086 events). In multivariable-adjusted models, each SD increment in carotid-femoral pulse wave velocity was associated with increased risk of hypertension (hazard ratio [HR], 1.32 [95% CI, 1.21-1.44]), diabetes (HR, 1.32 [95% CI, 1.11-1.58]), chronic kidney disease (1.19 [95% CI, 1.05-1.34]), dementia (HR 1.27 [95% CI, 1.06-1.53]), cardiovascular disease (HR, 1.20 [95% CI, 1.06-1.36]) and its components (coronary heart disease, HR 1.37 [95% CI, 1.13-1.65]; transient ischemic attack/stroke, HR, 1.24 [95% CI, 1.00-1.53]), and death (HR, 1.29 [95% CI, 1.17-1.43]). The association with heart failure was borderline nonsignificant (HR, 1.21 [95% CI, 0.98-1.51], P=0.08).

CONCLUSIONS

Our prospective observations of a large community-based sample establish the long-term prognostic importance of arterial stiffness for multiple health outcomes.

Clinical correlates of plasma insulin levels over the life course and association with incident type 2 diabetes: the Framingham Heart Study

INTRODUCTION

Insulin is a glucose-lowering hormone that affects carbohydrate, lipid, and protein metabolism. Limited data exist on the correlates of insulin levels over the life course in healthy community-dwelling individuals.

RESEARCH DESIGN AND METHODS

Using multilevel modeling of multiple serial observations over 21 years, we assessed the longitudinal correlates of fasting insulin and the cross-sectional correlates of fasting and 2-hour (2h, post 75 g glucose challenge) plasma insulin concentrations in 2140 relatively healthy Framingham Heart Study participants without diabetes (61% women; mean age, 42 years). We used multivariable-adjusted Cox regression to relate glycemic markers (fasting and 2h-insulin, fasting glucose, 2h-glucose, and hemoglobin A_1C) to the risk of type 2 diabetes during follow-up.

RESULTS

Over the life course, fasting insulin concentrations were inversely associated with age, male sex, and physical activity, whereas waist circumference, the total/high-density lipoprotein (HDL) cholesterol ratio, and blood triglycerides were positively associated with insulin levels (p<0.005 for all). Male sex (inversely related) and the total/HDL cholesterol ratio (positively related) emerged as the most important cross-sectional correlates of 2h-insulin (p<0.005 for all). All markers were associated with higher risk of type 2 diabetes (352 cases, median follow-up 18 years, p<0.001 for all).

CONCLUSIONS

We observed common and distinct correlates of fasting and 2h-insulin levels. Our findings highlight a potential role of insulin in lipid and lipoprotein metabolism. Furthermore, fasting and 2h-insulin are critical markers of future diabetes risk. Further studies are needed to confirm our findings.

Association of orthostatic blood pressure response with incident heart failure: The Framingham Heart Study

IMPORTANCE

Orthostatic hypotension (OH) and hypertension (OHT) are aberrant blood pressure (BP) regulation conditions associated with higher cardiovascular disease risk. The relations of OH and OHT with heart failure (HF) risk in the community are unclear and there remains a paucity of data on the relations with HF subtypes [HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF)].

OBJECTIVE

Relate OH and OHT with HF risk and its subtypes.

DESIGN

Prospective observational cohort.

SETTING

Community-based individuals in the Framingham Heart Study Original Cohort.

PARTICIPANTS

1,914 participants (mean age 72 years; 1159 women) attending examination cycle 17 (1981-1984) followed until December 31, 2017 for incident HF or death.

EXPOSURES

OH or OHT, defined as a decrease or increase, respectively, of ≥20/10 mmHg in systolic/diastolic BP upon standing from supine position.

OUTCOMES AND MEASURES

At baseline, 1,241 participants had a normal BP response (749 women), 274 had OH (181 women), and 399 had OHT (229 women). Using Cox proportional hazards regression models, we related OH and OHT to risk of HF, HFrEF, and HFpEF compared to the absence of OH and OHT (reference), adjusting for age, sex, body mass index, systolic and diastolic BP, hypertension treatment, smoking, diabetes, and total cholesterol/high-density lipoprotein.

RESULTS

On follow-up (median 13 years) we observed 492 HF events (292 in women; 134 HFrEF, 116 HFpEF, 242 HF indeterminate EF). Compared to the referent, participants with OH [n = 84/274 (31%) HF events] had a higher HF risk (Hazards Ratio [HR] 1.47, 95% CI 1.13-1.91). Moreover, OH was associated with a higher HFrEF risk (HR 2.21, 95% CI 1.34-3.67). OHT was not associated with HF risk.

CONCLUSIONS AND RELEVANCE

Orthostatic BP response may serve as an early marker of HF risk. Findings suggest shared pathophysiology of BP regulation and HF, including HFrEF.

[Value of purple sign for predicting rebleeding events in cirrhotic patients following endoscopic selective varices devascularization]

OBJECTIVE

To assess the value of the purple sign for predicting long-term rebleeding events in cirrhotic patients following endoscopic selective varices devascularization.

METHODS

We retrospectively analyzed the clinical data of 97 patients with liver cirrhosis, who had a history of gastroesophageal variceal bleeding and underwent endoscopic selective varices devascularization. Thirty-two of the patients showed purple sign after endoscopic treatment. We used propensity score matching (PSM) to minimize the selection bias of the patients (purple sign vs no purple sign) and reduce the intergroup differences of clinical characteristics. The primary outcome measure of this study was cumulative rebleeding events after endoscopic selective varices devascularization.

RESULTS

The 1-year rebleeding rate (27.0% vs 36.7%) or 6-month rebleeding rate (10.9% vs 26.9%) following endoscopic treatment was not significantly different between the purple sign group and no purple sign group before PSM (P=0.2385). But after PSM, the 1-year rebleeding rate (28.2% vs 56.4%) and 6-month rebleeding rate (5.0% vs 37.0%) were significantly lower in the purple sign group than in the no purple sign group (P=0.0304).

CONCLUSIONS

The presence of purple sign indicates a lower risk of rebleeding after endoscopic treatment of cirrhotic gastroesophageal varices and a potentially favorable treatment response after endoscopic therapy, thus providing a clinical indicator for stratification of the patients for sequential endoscopic sessions.

Arteriosclerosis, Atherosclerosis, and Cardiovascular Health: Joint Relations to the Incidence of Cardiovascular Disease

[Figure: see text].

Rate of Post-Fertilization Mitotic Activity Predicts Embryonic Competence via Next Generation Sequencing: An Analysis of 39,301 Cleavage Stage Embryos

Objective

To investigate the association between cleavage stage development, embryonic competence, and euploidy in patients undergoing in vitro fertilization (IVF) with subsequent next generation sequencing.

Methods

The retrospective cohort study included patients at an academic fertility center who underwent IVF with at least one cleavage stage embryo from 2016 to 2019. Embryos were analyzed as slow (<6 cells), intermediate (6-8 cells), or fast (>8 cells); day 3 cell count was also analyzed as a continuous variable. Primary outcomes were blastulation rate, biopsied blastocyst rate, and euploid rate. Odds of blastulation, biopsy, and euploidy were also calculated. Additionally, we modeled the predicted probability of an embryo reaching blastulation, biopsy, and euploidy based on cleavage stage development.

Results

When compared with intermediate and slow cohorts, fast cleaving embryos had significantly higher rates of blastulation (82.70% vs. 75.13 vs. 42.48%), biopsy (55.04% vs. 44.00% vs. 14.98%), and euploidy (50.65% vs. 47.93% vs. 48.05%). After adjustment for covariates, there was a significant association between cleavage stage development and odds of blastulation (OR 1.38, 95% CI 1.29-1.48), biopsy (OR 1.42, 95% CI 1.34-1.51), and euploidy (OR 1.08, 95% CI 1.01-1.17). Finally, we observed significant associations between cleavage stage development and predicted probability of reaching blastulation (OR 1.29, 95% CI 1.27-1.32), biopsy (OR 1.24, 95% CI 1.22-1.26), and euploidy (OR 1.02, 95% CI 1.01-1.04).

Conclusions

Cleavage stage embryos with greater mitotic activity perform as well as or better than intermediate or slower cleaving embryos. Rapidly cleaving embryos have high rates of euploidy and significant clinical potential.

Opioid-Free Postoperative Pain Management After Adenotonsillectomy With Nasal Turbinate Reduction Using Bilateral Suprazygomatic Infratemporal-Pterygopalatine Fossa Injections: A Case Report

Adenotonsillectomies are one of the most common otolaryngologic surgeries performed to alleviate obstructive sleep-disordered breathing and apnea in children. The pain management following adenotonsillectomy continues to be a challenge for both pediatric anesthesiologists and otolaryngologists due to the mortality that stems from the use of opioid pain medications in children who have an increased baseline risk airway obstruction and apnea that is exacerbated by any exposure to opioids. We present a case utilizing bilateral suprazygomatic maxillary nerve (SZMN) blocks or, more accurately, suprazygomatic infratemporal-pterygopalatine fossa injections to achieve opioid-free perioperative analgesia for pediatric adenotonsillectomy with nasal turbinate reduction.

Comparative immunogenicity of outer membrane protein K and whole-cell antigens of Vibrio parahaemolyticus for diagnosis

The immunogenicity of soluble outer membrane protein K (OmpK)- small ubiquitin-like modifier, OmpK inclusion bodies, formalin, and heat-killed Vibrio parahaemolyticus cells were prepared and studied in a mouse model. The results of whole-cell ELISA and Western blot (WB) revealed that the serum against soluble OmpK and OmpK inclusion bodies reacted only with homologous V. parahaemolyticus. Furthermore, recombinant OmpK proteins were not recognized by the serum against whole-cell V. parahaemolyticus antigens. Unexpectedly, the serum against formalin and heat-killed V. parahaemolyticus reacted broadly with homologous (an immunization strain) and heterologous (non-immunization strains) V. parahaemolyticus and Vibrio species. The WB results revealed that the serum against the two V. parahaemolyticus whole-cell antigens primarily reacted with proteins that were approximately 100, 70, 36, 28, and 22 kDa in the cell lysates from different Vibrio strains, rather than the recombinant OmpK. The 70 and 28 kDa proteins exhibited specificity to Vibrio species, while the 22 kDa protein was more specific to V. parahaemolyticus. This study showed the limitation of recombinant OmpK to prepare diagnostic antibodies and revealed several specific Omps of Vibrio sp. and V. parahaemolyticus that were promising in diagnosis and vaccine development.

From Pruritus to Cholestasis: Building a Statistical Model and Online Application to Predict a Diagnosis Prior to Bile Acid Determination

OBJECTIVE

This study aimed to create a statistical model using clinical and laboratory parameters to predict which patients presenting with pruritus in pregnancy will have elevated total bile acids (TBA) and thus, have a high risk of intrahepatic cholestasis of pregnancy (ICP).

STUDY DESIGN

Retrospective cohort study of patients presenting with pruritus in pregnancy and had TBA sent from a single public hospital from January 1, 2017, to December 31, 2017. Primary outcome is TBA ≥ 10 µmol/L. Multivariate logistic regression with stepwise and backward variable selection were used to create predictive models. Four models were compared using Akaike information criterion (AIC), C-statistic, and the DeLong nonparametric approach to test for differences between area under the curve (AUC) of receiver operating characteristic (ROC) curves. Internal validation was performed via fivefold cross-validation technique on the best-fitting, most parsimonious model.

RESULTS

Of the 320 patients with pruritus, 153 (47.8%) had elevated bile acid levels ≥10 µmol/L. Sixty-nine variables were assessed for association with the primary outcome. Five variables were significantly associated with elevated TBA: pruritus of palms and soles (adjusted odds ratio [aOR]: 2.35 [95% confidence interval, CI: 1.22, 4.54]), gestational hypertension (aOR: 0.10 [95% CI: 0.02, 0.60]), log of total bilirubin (aOR: 4.71 [95% CI: 2.28, 9.75]), systolic blood pressure (aOR: 0.97 [95% CI: 0.94, 0.99]), and alanine aminotransferase (aOR: 1.05 [95% CI: 1.02, 1.07]). The final model was chosen for being parsimonious while having the lowest AIC with highest AUC (0.85; 95% CI: 0.81, 0.89). Internal validation using a probability threshold of 50% demonstrated a sensitivity of 65.5%, specificity of 83.5%, and accuracy of 75.1%.

CONCLUSION

We provide a predictive model using five simple variables to determine the probability that a patient presenting with pruritus in pregnancy carries the diagnosis of ICP. This tool, available via a web app, is designed to aid providers and enhance clinical judgment in difficult triage situations.

KEY POINTS

· Currently, no standard method to triage pruritus in pregnancy exists.. · We present a predictive statistical model using five readily available clinical variables.. · Final calculator yields probability of having intrahepatic cholestasis of pregnancy..

The value of the patient global health assessment in polyarticular juvenile idiopathic arthritis: a nested cohort study

Objective

The objectives were: 1) to explore the discordance between the Patient Global Health Assessment (PtGA) scores, the Physician Global Health Assessment (PhGA) scores, and Pain scores; and 2) to explore whether the PtGA during disease remission is associated with future disease flare in pJIA.

Methods

Data from an NIH funded clinical trial (NCT00792233) evaluating flare were used (N = 137). PtGA, PhGA, and Pain scores were assessed. Flare was defined as any active arthritis. Spearman’s correlation coefficients were calculated, and multivariable logistic regression was performed.

Results

122 patients had records of flare status, of which 63 developed flare, and 42 of these patients had a visit immediately prior to flare. For study subjects with a visit immediately prior to flare, the PtGA, pain scores, and PhGA all increased at time of flare. For every unit increase in PtGA and Pain scores, there was a 9% and 23% higher odds of developing flare, respectively (p = 0.76, p = 0.40). For every unit increase in the PhGA score, there was a substantially lower odds of developing flare (p = 0.05).

Conclusion

Our results demonstrate that the PtGA and Pain scores are strongly correlated with each other and increased at the visit prior to flare, while the PhGA scores are not. Further, the PtGA and Pain score have some predictive value for flare, while the PhGA does not. These findings highlight the value of patient input in medical care and decision-making, and support the development and use of more sophisticated PROs in the care of JIA patients.