Reducing Salivary Toxicity with Adaptive Radiotherapy (ReSTART): A Randomized Controlled Trial Comparing Conventional IMRT to Adaptive IMRT in Head and Neck Squamous Cell Carcinomas

BACKGROUND

The utility of Adaptive Radiotherapy (ART) in Head and Neck Squamous Cell Carcinoma (HNSCC) remains to be ascertained. While multiple retrospective and single-arm prospective studies have demonstrated its efficacy in decreasing parotid doses and reducing xerostomia, adequate randomized evidence is lacking.

METHODS AND ANALYSIS

ReSTART (Reducing Salivary Toxicity with Adaptive Radiotherapy) is an ongoing phase III randomized trial of patients with previously untreated, locally advanced HNSCC of the oropharynx, larynx, and hypopharynx. Patients are randomized in a 1:1 ratio to the standard Intensity Modulated Radiotherapy (IMRT) arm {Planning Target Volume (PTV) margin 5 mm} vs. Adaptive Radiotherapy arm (standard IMRT with a PTV margin 3 mm, two planned adaptive planning at 10th and 20th fractions). The stratification factors include the primary site and nodal stage. The RT dose prescribed is 66Gy in 30 fractions for high-risk PTV and 54Gy in 30 fractions for low-risk PTV over six weeks, along with concurrent chemotherapy. The primary endpoint is to compare salivary toxicity between arms using salivary scintigraphy 12 months' post-radiation. To detect a 25% improvement in the primary endpoint at 12 months in the ART arm with a two-sided 5% alpha value and a power of 80% (and 10% attrition ratio), a sample size of 130 patients is required (65 patients in each arm). The secondary endpoints include acute and late toxicities, locoregional control, disease-free survival, overall survival, quality of life, and xerostomia scores between the two arms.

DISCUSSION

The ReSTART trial aims to answer an important question in Radiation Therapy for HNSCC, particularly in a resource-limited setting. The uniqueness of this trial, compared to other ongoing randomized trials, includes the PTV margins and the xerostomia assessment by scintigraphy at 12 months as the primary endpoint.

Dectin-1 stimulation promotes a distinct inflammatory signature in the setting of HIV-infection and aging

Dectin-1 is an innate immune receptor that recognizes and binds β-1, 3/1, 6 glucans on fungi. We evaluated Dectin-1 function in myeloid cells in a cohort of HIV-positive and HIV-negative young and older adults. Stimulation of monocytes with β-D-glucans induced a pro-inflammatory phenotype in monocytes of HIV-infected individuals that was characterized by increased levels of IL-12, TNF-α, and IL-6, with some age-associated cytokine increases also noted. Dendritic cells showed a striking HIV-associated increase in IFN-α production. These increases in cytokine production paralleled increases in Dectin-1 surface expression in both monocytes and dendritic cells that were noted with both HIV and aging. Differential gene expression analysis showed that HIV-positive older adults had a distinct gene signature compared to other cohorts characterized by a robust TNF-α and coagulation response (increased at baseline), a persistent IFN-α and IFN-γ response, and an activated dendritic cell signature/M1 macrophage signature upon Dectin-1 stimulation. Dectin-1 stimulation induced a strong upregulation of MTORC1 signaling in all cohorts, although increased in the HIV-Older cohort (stimulation and baseline). Overall, our study demonstrates that the HIV Aging population has a distinct immune signature in response to Dectin-1 stimulation. This signature may contribute to the pro-inflammatory environment that is associated with HIV and aging.

Increasing sensitivity of antibody-antigen interactions using photo-cross-linking

Understanding antibody-antigen interactions in a polyclonal immune response in humans and animal models is critical for rational vaccine design. Current approaches typically characterize antibodies that are functionally relevant or highly abundant. Here, we use photo-cross-linking and single-particle electron microscopy to increase antibody detection and unveil epitopes of low-affinity and low-abundance antibodies, leading to a broader structural characterization of polyclonal immune responses. We employed this approach across three different viral glycoproteins and showed increased sensitivity of detection relative to currently used methods. Results were most noticeable in early and late time points of a polyclonal immune response. Additionally, the use of photo-cross-linking revealed intermediate antibody binding states and demonstrated a distinctive way to study antibody binding mechanisms. This technique can be used to structurally characterize the landscape of a polyclonal immune response of patients in vaccination or post-infection studies at early time points, allowing for rapid iterative design of vaccine immunogens.

High-throughput single-cell profiling of B cell responses following inactivated influenza vaccination in young and older adults

Seasonal influenza contributes to a substantial disease burden, resulting in approximately 10 million hospital visits and 50 thousand deaths in a typical year in the United States. 70 - 85% of the mortality occurs in people over the age of 65. Influenza vaccination is the best protection against the virus, but it is less effective for the elderly, which may be in part due to differences in the quantity or type of B cells induced by vaccination. To investigate this possibility, we sorted pre- and post-vaccination peripheral blood B cells from three young and three older adults with strong antibody responses to the inactivated influenza vaccine and employed single-cell technology to simultaneously profile the gene expression and the B cell receptor (BCR) of the B cells. Prior to vaccination, we observed a higher somatic hypermutation frequency and a higher abundance of activated B cells in older adults than in young adults. Following vaccination, young adults mounted a more clonal response than older adults. The expanded clones included a mix of plasmablasts, activated B cells, and resting memory B cells in both age groups, with a decreased proportion of plasmablasts in older adults. Differential abundance analysis identified additional vaccine-responsive cells that were not part of expanded clones, especially in older adults. We observed broadly consistent gene expression changes in vaccine-responsive plasmablasts and greater heterogeneity among activated B cells between age groups. These quantitative and qualitative differences in the B cells provide insights into age-related changes in influenza vaccination response.

Biomedical waste plastic: bacteria, disinfection and recycling technologies-a comprehensive review

Plastic recycling reduces the wastage of potentially useful materials as well as the consumption of virgin materials, thereby lowering the energy consumption, air pollution by incineration, soil and water pollution by landfilling. Plastics used in the biomedical sector have played a significant role. Reducing the transmission of the virus while protecting the human life in particular the frontline workers. Enormous volumes of plastics in biomedical waste have been observed during the outbreak of the pandemic COVID-19. This has resulted from the extensive use of personal protective equipment such as masks, gloves, face shields, bottles, sanitizers, gowns, and other medical plastics which has created challenges to the existing waste management system in the developing countries. The current review focuses on the biomedical waste and its classification, disinfection, and recycling technology of different types of plastics waste generated in the sector and their corresponding approaches toward end-of-life option and value addition. This review provides a broader overview of the process to reduce the volume of plastics from biomedical waste directly entering the landfill while providing a knowledge step toward the conversion of "waste" to "wealth." An average of 25% of the recyclable plastics are present in biomedical waste. All the processes discussed in this article accounts for cleaner techniques and a sustainable approach to the treatment of biomedical waste.

Graphical abstract

The Plasma Cell Infiltrate Populating the Muscle Tissue of Patients with Inclusion Body Myositis Features Distinct B Cell Receptor Repertoire Properties

Inclusion body myositis (IBM) is an autoimmune and degenerative disorder of skeletal muscle. The B cell infiltrates in IBM muscle tissue are predominantly fully differentiated Ab-secreting plasma cells, with scarce naive or memory B cells. The role of this infiltrate in the disease pathology is not well understood. To better define the humoral response in IBM, we used adaptive immune receptor repertoire sequencing, of human-derived specimens, to generate large BCR repertoire libraries from IBM muscle biopsies and compared them to those generated from dermatomyositis, polymyositis, and circulating CD27+ memory B cells, derived from healthy controls and Ab-secreting cells collected following vaccination. The repertoire properties of the IBM infiltrate included the following: clones that equaled or exceeded the highly clonal vaccine-associated Ab-secreting cell repertoire in size; reduced somatic mutation selection pressure in the CDRs and framework regions; and usage of class-switched IgG and IgA isotypes, with a minor population of IgM-expressing cells. The IBM IgM-expressing population revealed unique features, including an elevated somatic mutation frequency and distinct CDR3 physicochemical properties. These findings demonstrate that some of IBM muscle BCR repertoire characteristics are distinct from dermatomyositis and polymyositis and circulating Ag-experienced subsets, suggesting that it may form through selection by disease-specific Ags.

Platelet response to influenza vaccination reflects effects of aging

Platelets are uniquely positioned as mediators of not only hemostasis but also innate immunity. However, how age and geriatric conditions such as frailty influence platelet function during an immune response remains unclear. We assessed the platelet transcriptome at baseline and following influenza vaccination in Younger (age 21-35) and Older (age ≥65) adults (including community-dwelling individuals who were largely non-frail and skilled nursing facility (SNF)-resident adults who nearly all met criteria for frailty). Prior to vaccination, we observed an age-associated increase in the expression of platelet activation and mitochondrial RNAs and decrease in RNAs encoding proteins mediating translation. Age-associated differences were also identified in post-vaccination response trajectories over 28 days. Using tensor decomposition analysis, we found increasing RNA expression of genes in platelet activation pathways in young participants, but decreasing levels in (SNF)-resident adults. Translation RNA trajectories were inversely correlated with these activation pathways. Enhanced platelet activation was found in community-dwelling older adults at the protein level, compared to young individuals both prior to and post-vaccination; whereas SNF residents showed decreased platelet activation compared to community-dwelling older adults that could reflect the influence of decreased translation RNA expression. Our results reveal alterations in the platelet transcriptome and activation responses that may contribute to age-associated chronic inflammation and the increased incidence of thrombotic and pro-inflammatory diseases in older adults.

PD-1highCXCR5-CD4+ peripheral helper T cells promote CXCR3+ plasmablasts in human acute viral infection

T cell-B cell interaction is the key immune response to protect the host from severe viral infection. However, how T cells support B cells to exert protective humoral immunity in humans is not well understood. Here, we use COVID-19 as a model of acute viral infections and analyze CD4+ T cell subsets associated with plasmablast expansion and clinical outcome. Peripheral helper T cells (Tph cells; denoted as PD-1highCXCR5-CD4+ T cells) are significantly increased, as are plasmablasts. Tph cells exhibit "B cell help" signatures and induce plasmablast differentiation in vitro. Interestingly, expanded plasmablasts show increased CXCR3 expression, which is positively correlated with higher frequency of activated Tph cells and better clinical outcome. Mechanistically, Tph cells help B cell differentiation and produce more interferon γ (IFNγ), which induces CXCR3 expression on plasmablasts. These results elucidate a role for Tph cells in regulating protective B cell response during acute viral infection.

Function Preservation With Brachytherapy: Reviving the Art. Improving Quality of Life With Brachytherapy for Urological Malignancies

Brachytherapy for localised prostate, muscle-invasive bladder and penile cancer is well established, providing high tumour dose delivery and minimising normal tissue doses compared with external beam techniques. In prostate cancer, the main impact on quality of life relates to diminished sexual function and irritative or obstructive urinary symptoms, which are seen up to 15 years after treatment. Significant changes in bowel function are rare. Compared with radical prostatectomy or external beam radiotherapy, irritative or obstructive urinary symptoms are more prominent, whereas incontinence is less than after radical prostatectomy and bowel changes are less than after external beam radiotherapy. For muscle-invasive bladder cancer, when compared with radical cystectomy, although no difference is seen for urinary symptoms or fatigue, role and social functioning scores are higher and there is better post-treatment sexual function in both men and women. Compared with surgical treatment for penile cancer, brachytherapy results in better erectile function scores than after glansectomy and partial penectomy and high quality of life scores, with good satisfaction ratings for cosmetic appearance.

492. Dectin-1 Stimulation Promotes a Distinct Inflammatory Signature in the Setting of Aging and HIV-infection

Background

Dectin-1 is an innate immune pattern recognition receptor that recognizes and binds b-1,3/1,6 glucans on fungal pathogens.

Methods

We evaluated Dectin-1 function in innate immune cells (Monocytes and Dendritic cells) in a cohort of HIV-positive and HIV-negative young and older adults (n= 81). PBMCs were stimulated with whole glucan particles (1,3/1,6-b-glucan, WGP), a specific Dectin-1 agonist and analyzed via intracellular cytokine staining (ICS) and multicolor flow cytometry of monocytes and dendritic cells. Sorted CD14+ CD16+ monocytes stimulated with WGP and subjected to RNA-seq analysis.

Results

Stimulation of monocytes with β-D-glucans induced a pro-inflammatory phenotype in monocytes of HIV-infected individuals that was characterized by increased levels of IL-12, TNF-a, and IL-6, with some age-associated cytokine increases also noted. Dendritic cells showed a striking HIV-associated increase in IFN-a production. This increase in cytokine production paralleled increases in Dectin-1 surface expression in both monocytes and dendritic cells that were noted with both HIV and aging. Differential gene expression analysis showed that HIV-positive older adults had a distinct gene signature compared to other cohorts characterized by a robust TNF-a and coagulation response that was already increased at baseline, and a persistent IFN-α and IFN-γ response. HIV-older adults also demonstrated an activated dendritic cell signature and M1 macrophage signature upon stimulation that was not seen in young individuals. Pathways upregulated in all cohorts were the signaling pathways MTORC-1, hypoxia pathway (pathways involved in trained immunity) and the unfolded protein response. Of note MTORC-1 signaling was upregulated at baseline in HIV-Older adults.

Conclusion

Overall, our study demonstrates that increased age and HIV-infection can affect the function of Dectin-1 and lead to a distinct inflammatory signature. Dectin-1 stimulation in HIV-Older adults led to a more pro-inflammatory phenotype that was demonstrated through both protein and gene expression. Dectin-1 induced inflammation in HIV-infected individuals may be contributing to the pro-inflammatory environment that is seen in the setting of both aging and HIV-infection.

Disclosures

All Authors: No reported disclosures.

Metabolomic and transcriptomic signatures of influenza vaccine response in healthy young and older adults

Seasonal influenza causes mild to severe respiratory infections and significant morbidity, especially in older adults. Transcriptomic analysis in populations across multiple flu seasons has provided insights into the molecular determinants of vaccine response. Still, the metabolic changes that underlie the immune response to influenza vaccination remain poorly characterized. We performed untargeted metabolomics to analyze plasma metabolites in a cohort of younger and older subjects before and after influenza vaccination to identify vaccine-induced molecular signatures. Metabolomic and transcriptomic data were combined to define networks of gene and metabolic signatures indicative of high and low antibody response in these individuals. We observed age-related differences in metabolic baselines and signatures of antibody response to influenza vaccination and the abundance of α-linolenic and linoleic acids, sterol esters, fatty-acylcarnitines, and triacylglycerol metabolism. We identified a metabolomic signature associated with age-dependent vaccine response, finding increased tryptophan and decreased polyunsaturated fatty acids (PUFAs) in young high responders (HRs), while fatty acid synthesis and cholesteryl esters accumulated in older HRs. Integrated metabolomic and transcriptomic analysis shows that depletion of PUFAs, which are building blocks for prostaglandins and other lipid immunomodulators, in young HR subjects at Day 28 is related to a robust immune response to influenza vaccination. Increased glycerophospholipid levels were associated with an inflammatory response in older HRs to flu vaccination. This multi-omics approach uncovered age-related molecular markers associated with influenza vaccine response and provides insight into vaccine-induced metabolic responses that may help guide development of more effective influenza vaccines.

Phenotypes of disease severity in a cohort of hospitalized COVID-19 patients: Results from the IMPACC study

BACKGROUND

Better understanding of the association between characteristics of patients hospitalized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management.

METHODS

Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1164 patients from 20 hospitals across the United States. Disease severity was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multivariable logistic regression was performed.

FINDINGS

The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsupervised clustering of ordinal score over time revealed distinct disease course trajectories. Risk factors associated with prolonged hospitalization or death by day 28 included age ≥ 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) having at least one symptom consistent with PASC, most commonly dyspnea (56% among symptomatic patients). Female sex was the only associated risk factor for PASC.

INTERPRETATION

Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19.

FUNDING

NIH.

P-795 Comparison of intra-ovarian platelet rich plasma versus autologous bone marrow derived stem cell instillation in women with diminished ovarian reserve for ovarian rejuvenation

Study question

To compare role of intra-ovarian platelet rich plasma (PRP) versus marrow derived stem cell (SC) instillation for improvement in ovarian reserve (AFC, AMH and FSH)

Summary answer

Both PRP and SC therapy improves the ovarian reserve however, response to PRP is superior to SC post intervention

What is known already

With increasing incidence of females with diminished ovarian reserve (DOR), posing a serious challenge in terms of limited treatment options for these couples. Clinicians are trying to find effective strategies besides oocyte donation or adoption Of late, novel ovarian rejuvenation approaches has been investigated which are currently available for research purposes only. Multiple studies are evaluating effect of intra-ovarian PRP or autologous SC instillation, the results are encouraging as they are showing improvement in ovarian reserve thus bringing a paradigm shift in treatment options. None of the published studies so far have compared PRP versus SC in DOR population.

Study design, size, duration

A prospective comparative study was conducted at Division of Reproductive Medicine of a tertiary care institute. 72 infertile females (20-39 years) with poor ovarian reserve (AMH <1.2 ng /ml; AFC<5) were enrolled in the study between January 2020 to December 2021. The two comparative groups underwent either intra-ovarian PRP instillation (n = 42) or autologous SC transplantation (n = 30).

Participants/materials, setting, methods

After the two groups were matched (PRP vs SC) for baseline characteristics (Age, AMH, AFC, FSH, Estradiol), 30 subjects in each group were compared for change in serum FSH/AMH/Estradiol levels, AFC, right and left ovarian volume at 1st month and 3rd month post intervention from the baseline. This was also compared between the two groups using Student t-test. The cost and procedural pain measured using Visual analog scale (VAS) were also compared between the groups.

Main results and the role of chance

After matching for baseline characteristics, significant ∼ 1.8/2 and ∼1.5/1.6 fold increase in AFC at 1st/3rd month post intervention (p<0.001) was observed after PRP instillation and SC transplantation respectively. This significant improvement was observed more in PRP group than SC group at 3rd month post intervention (7.07 vs 5.60, p=0.02), while no significant difference existed at 1st month of follow up. However, there was no significant improvement in serum FSH, AMH and Estradiol levels (p0.05) from the baseline at 1st and 3rd month post intervention in both the groups. Similarly, there was no significant difference between the two groups in serum FSH level (7.98 IU/ml vs 9.62 IU/ml, p=0.062; 8.26 IU/ml vs 9.50 IU/ml, p=0.15), AMH level (1.62 ng/ml vs 1.02 ng/ml, p=0.27; 1.35 ng/ml vs 0.95 ng/ml, p=0.24), Estradiol level (49.12 pg/ml vs 56.48 pg/ml p=0.443; 54.7 pg/ml vs 61.12 pg/ml, p=0.44), right ovarian volume (3.13 cm3 vs 2.49 cm3, p=0.06; 3.37 cm3 vs 2.74 cm3,p=0.063) and left ovarian volume (2.98 cm3 vs 2.47 cm3, p=0.102; 2.87 cm3 vs 2.34 cm3,p=0.103) at 1st and 3rd month post intervention respectively. PRP was more cost-effective and associated with less pain (32.5 mm vs 28.13 mm, p=0.02), and better patient compliance.

Limitations, reasons for caution

This was a comparative study and the participants were not randomized but were matched for the baseline characteristics. Also due to impact of Covid-19 causing intermittent pause in nonessential facilities like IVF services, a smaller sample size could be enrolled and also clinical outcomes could not be evaluated

Wider implications of the findings

This study, although comparative, for the first time highlights the beneficial role of PRP over SC, thus can establish superiority of PRP as minimally invasive, economical, patient friendly and a recommended therapy for ovarian rejuvenation and folliculogenesis, providing the DOR females an opportunity to produce their own offspring.

Trial registration number

CTRI/2020/01/022726

P94 LOWER RATE OF MAJOR BLEEDING IN HIGH–RISK PATIENTS UNDERGOING LEFT ATRIAL APPENDAGE OCCLUSION: A PROPENSITY MATCHED COMPARISON WITH DIRECT ORAL ANTICOAGULATION

Background

Stroke prophylaxis in very high risk (CHA2DS2–VASc ≥ 5) patients with atrial fibrillation (AF) is one of the major challenges faced by physicians. Specifically, initiating direct oral anticoagulants (DOACs) in these patients poses a therapeutic conundrum due to the concomitant high risk of bleeding. Left atrial appendage occlusion (LAAO) might be a potential alternative for thromboembolic (TE) prevention; however, there are no studies comparing these two strategies in very high–risk patients.

Objective

To evaluate the efficacy of LAAO versus DOACs in AF patients at very high TE risk.

Methods

Data were extracted from two prospective databases including 1053 Watchman and 1328 DOAC patients. Watchman patients with a CHA2DS2–VASc ≥ 5 accounted for 26.3% (n = 277). In order to attenuate the imbalance in covariates, a 1:1 propensity score matching technique was used (co–variates: age, sex, CHA2DS2–VASc and HAS–BLED scores). This method resulted in 554 matched patients (277 patients per group; mean age: 79±7y; 57.4% F; CHA2DS2–VASc: 5.8±0.9). The primary endpoint was a composite of cardiovascular (CV) death, TE events (Stroke/TIA/peripheral embolism) and clinically significant bleeding. The annual TE and major bleeding risks were estimated based on the CHA2DS2–VASc score and compared with the annualized observed risk.

Results

After a mean follow–up of 26±7 months, total events were 55 (9.4 event rates per 100 patient–years) in LAAO group vs. 78 (14.9 event rates per 100 patient–years) in DOAC group. DOACs had a significantly higher risk of the primary endpoint (hazard ratio [HR]: 1.30; 95% confidence interval [CI]: 1.08 to 1.56; p = 0.03). TE events (HR: 1.15; 95% CI: 0.84 to 1.57; p = 0.63) and CV death (HR: 1.13; 95% CI: 0.84 to 1.54; p = 0.63) did not differ between groups. Major bleeding events were significantly lower in LAAO patients (HR: 0.75; 95% CI: 0.51 to 0.82; p = 0.04). The unadjusted estimated risk of TE events was 12.3% with LAAO and 12.4% with DOACs. The annualized incidence of TE was 3.2% with LAAO and 4.1% with DOACs, which led to a risk reduction of 74% and 67%, respectively.

Conclusion

In a large cohort of AF patients at very high TE risk (CHA2DS2–VASc ≥ 5), LAAO showed similar stroke prevention but a significantly lower risk of major bleeding than DOACs during a > 2year follow–up.

C32 TRANSCATHETER LEAK OCCLUSION WITH ENDOVASCULAR COILS FOLLOWING LEFT ATRIAL APPENDAGE CLOSURE: PROCEDURAL SUCCESS AND OUTCOMES BEFORE AND AFTER LEAK CLOSURE

Background

Whether residual peri–device leaks after left atrial appendage occlusion (LAAO) portend a higher risk of thromboembolism (TE), it is still a matter of debate.

Objectives

We report the TE risk in patients with incomplete LAA closure before and after leak closure with endovascular coils.

Methods

One hundred twenty–four Watchman patients with a significant (≥3mm) leak (mean age: 74 ± 9 years; 66.9% males; CHA2DS2–VASc: 4.4 ± 1.7; HAS–BLED: 3.1 ± 1) underwent LAA leak coiling. The expected annual TE risk was estimated based on the patients’ CHA2DS2–VASc and compared with the annualized incidence observed before and after coiling (Fig.1B).

Results

The time between LAAO and leak coiling was 8±6 months [83 patients–year (PY)]; before leak closure, 6 (4.8%) patients had a TE event (annualized rate: 7.2%). Coil deployment was successful in all cases [median n. of coils deployed: 5 (IQR: 2–10)]. Procedure time was 79 ± 40 min; the mean volume of iodinated contrast medium used was 80 ± 43mL. The overall complication rate was 2.4% (1 pericardial tamponade, 2 pericardial effusion). Follow–up TEE after 61±14 days revealed complete LAA sealing or a negligible leak in 117 cases (94.4%); the remaining 7 patients had a moderate leak. During 14±6 months post–coiling (145 PY), 1 (0.8%) patient suffered from stroke. The incidence of TE events was significantly lower after leak closure than before coiling (0.8% vs 4.8%; log–rank p = 0.02; Fig.1A). The annualized TE rates were 7.2% before and 0.7% after leak closure (Fig. 1A). According to the expected rate estimated from the patients’ CHA2DS2–VASc (9.8%), LAAO with and without significant leaks yielded to a risk reduction of 26.5% and 92.9% (Fig. 1B).

Conclusions

Transcatheter leak occlusion via endovascular coils was safe. LAA closure led to a significant reduction in TE events.

P4 LEFT ATRIAL APPENDAGE ANATOMICAL CHANGES FOLLOWING RADIOFREQUENCY–BASED OSTIAL ISOLATION

Background

Left atrial appendage (LAA) electrical isolation (ei) may be achieved via radiofrequency (RF) energy applications at the level of the appendage ostium targeting the sites of earliest activation recorded by a mapping catheter. Notably, RF has long been used in vascular, orthopedic, and aesthetic surgery to promote thermal–induced collagen matrix contraction, fibrosis, and tissue retraction. LAA anatomical changes associated to RF–induced tissue retraction have never been reported.

Objective

To quantify the anatomical changes of the LAA ostium following RF–based LAAei.

Methods

Thirty–four consecutive patients requiring AF ablation with LAAei underwent transesophageal echocardiography (TEE) within 7 days before (baseline TEE) and >6 months after (follow–up TEE) ablation. The diameter of LAA orifice and landing zone were measured at 4 different views (0°, 45°, 90°, 135°). Measurements were performed by two independent reviewers blinded to the patient’s identity.

Results

Among 34 AF patients (68±7yrs, 73.5% males), the LAA morphology was classified as chicken wing in 15 (44%) patients, windsock in 10 (29%), cactus in 6 (18%), and cauliflower in 3 (9%). At baseline TEE, the mean maximum and mean minimum ostial diameters were 25±4mm and 22±4mm, respectively. The mean maximum and mean minimum diameters of the landing zone were 26±4mm and 23±3mm, respectively. On average, LAAei was achieved after 16±7 minutes of RF at a power of 45–47W. Follow–up TEE was performed 257±148 days after LAAei. The median LAA contraction velocity was 0.1 m/s (IQR: 0.04–0.18) and was significantly impaired in all patients. At follow–up TEE, the mean maximum and mean minimum ostial diameters were 19±4mm and 17±3mm, respectively. The mean maximum and mean minimum diameters of the landing zone were 20±4mm and 18±4mm, respectively. The mean relative reduction of the ostium and the landing zone were –24.4% and –22.5%, respectively. Box–Whisker plots of the maximum and minimum ostial diameters before and after LAAei are reported in Fig. 1.

Conclusion

RF led to a > 20% reduction of the diameters of the ostium and the landing zone. These changes may have important implications for a successful percutaneous occlusion procedure and justify a staged approach of isolation and occlusion.

No evidence of fetal defects or anti-syncytin-1 antibody induction following COVID-19 mRNA vaccination

The impact of Coronavirus Disease 2019 (COVID-19) mRNA vaccination on pregnancy and fertility has become a major topic of public interest. We investigated 2 of the most widely propagated claims to determine (1) whether COVID-19 mRNA vaccination of mice during early pregnancy is associated with an increased incidence of birth defects or growth abnormalities; and (2) whether COVID-19 mRNA-vaccinated human volunteers exhibit elevated levels of antibodies to the human placental protein syncytin-1. Using a mouse model, we found that intramuscular COVID-19 mRNA vaccination during early pregnancy at gestational age E7.5 did not lead to differences in fetal size by crown-rump length or weight at term, nor did we observe any gross birth defects. In contrast, injection of the TLR3 agonist and double-stranded RNA mimic polyinosinic-polycytidylic acid, or poly(I:C), impacted growth in utero leading to reduced fetal size. No overt maternal illness following either vaccination or poly(I:C) exposure was observed. We also found that term fetuses from these murine pregnancies vaccinated prior to the formation of the definitive placenta exhibit high circulating levels of anti-spike and anti-receptor-binding domain (anti-RBD) antibodies to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) consistent with maternal antibody status, indicating transplacental transfer in the later stages of pregnancy after early immunization. Finally, we did not detect increased levels of circulating anti-syncytin-1 antibodies in a cohort of COVID-19 vaccinated adults compared to unvaccinated adults by ELISA. Our findings contradict popular claims associating COVID-19 mRNA vaccination with infertility and adverse neonatal outcomes.

COMPARATIVE STUDY OF CONCURRENT CHEMORADIATION USING PACLITAXEL IN TWO HISTOPATHOLOGICAL SUBTYPES (SQUAMOUS CELL CARCINOMA/ADENOCARCINOMA) OF UNRESECTABLE NON-SMALL CELL LUNG CANCER

Background. Lung cancer is still a global burden and with rising population and increasing life expectancy the incidence of lung cancer is still on the rise. Objective. To compare the treatment response and toxicity of weekly paclitaxel in locally advanced unresectable non-small cell lung cancer (NSCLC), when administered concurrently with external beam radiation to the chest in two different histopathological types – adenocarcinoma and squamous cell carcinoma. Methods. A prospective randomised control trial was conducted in 60 NSCLC patients who were divided into two arms; adenocarcinoma and squamous cell carcinoma arm. All patients were treated with chemoradiation with concurrent paclitaxel 60 mg/m2. Data were evaluated with SPSS version 21.0 for windows with p-value <0.05. Results. Haematological toxicity was the most common side effects evident from the third week of chemotherapy. At the end of 1 month of treatment, two (6.7%) patients had complete response in Arm A and one (3.3%) patient had complete response in Arm B. One (3.3%) patient had disease progression in Arm A and two patients progressed in Arm B. At 7 months post treatment three (10%) patients had complete response in both Arm A and Arm B. Four (13.3%) patients had disease progression in Arm A and ten (33.4%) patients progressed in Arm B. Conclusions. Paclitaxel can be used as an alternative chemotherapeutic agent to the standard cisplatin. However, further studies with larger sample size are required to confirm the findings.

Combining Cellular Immunology With RNAseq to Identify Novel Chlamydia T-Cell Subset Signatures

Chlamydia trachomatis serovars A-L cause important diseases of the eyes and reproductive tract by infecting epithelium lining those organs. A major hurdle for vaccine trials is finding a surrogate biomarker for protective immunity. Investigational data argues for T-cell biomarker(s) reflecting mucosal adaption, cytokine polarization, B-cell help, antibacterial effector mechanisms, or some combination thereof. A human investigation and 2 mouse studies link IL-13 to protection from infection/immunopathology. We performed RNAseq on T cells resident in spleens and genital tracts of naturally immune mice. CD4 signatures were consistent with helper function that differed by site including a genital tract-specific Fgl2 signal. The genital tract CD8 signature featured IL-10 and promotion of healing/scarring with a unique transcription of granzyme A. The RNAseq data was used to refine previously published CD4γ13 and CD8γ13 transcriptomes derived from protective T-cell clones, potentially identifying practicable T-cell subset signatures for assessing Chlamydia vaccine candidates.

Single-cell multi-omics reveals dyssynchrony of the innate and adaptive immune system in progressive COVID-19

Dysregulated immune responses against the SARS-CoV-2 virus are instrumental in severe COVID-19. However, the immune signatures associated with immunopathology are poorly understood. Here we use multi-omics single-cell analysis to probe the dynamic immune responses in hospitalized patients with stable or progressive course of COVID-19, explore V(D)J repertoires, and assess the cellular effects of tocilizumab. Coordinated profiling of gene expression and cell lineage protein markers shows that S100Ahi/HLA-DRlo classical monocytes and activated LAG-3hi T cells are hallmarks of progressive disease and highlights the abnormal MHC-II/LAG-3 interaction on myeloid and T cells, respectively. We also find skewed T cell receptor repertories in expanded effector CD8+ clones, unmutated IGHG+ B cell clones, and mutated B cell clones with stable somatic hypermutation frequency over time. In conclusion, our in-depth immune profiling reveals dyssynchrony of the innate and adaptive immune interaction in progressive COVID-19.

Measurement of Differential Branching Fractions of Inclusive B→X_{u}ℓ^{+}ν_{ℓ} Decays

The first measurements of differential branching fractions of inclusive semileptonic B→X_{u}ℓ^{+}ν_{ℓ} decays are performed using the full Belle data set of 711  fb^{-1} of integrated luminosity at the ϒ(4S) resonance and for ℓ=e, μ. With the availability of these measurements, new avenues for future shape-function model-independent determinations of the Cabibbo-Kobayashi-Maskawa matrix element |V_{ub}| can be pursued to gain new insights in the existing tension with respect to exclusive determinations. The differential branching fractions are reported as a function of the lepton energy, the four-momentum-transfer squared, light-cone momenta, the hadronic mass, and the hadronic mass squared. They are obtained by subtracting the backgrounds from semileptonic B→X_{c}ℓ^{+}ν_{ℓ} decays and other processes, and corrected for resolution and acceptance effects.

Impact of circulating SARS-CoV-2 variants on mRNA vaccine-induced immunity

The emergence of SARS-CoV-2 variants with mutations in major neutralizing antibody-binding sites can affect humoral immunity induced by infection or vaccination1-6. Here we analysed the development of anti-SARS-CoV-2 antibody and T cell responses in individuals who were previously infected (recovered) or uninfected (naive) and received mRNA vaccines to SARS-CoV-2. While individuals who were previously infected sustained higher antibody titres than individuals who were uninfected post-vaccination, the latter reached comparable levels of neutralization responses to the ancestral strain after the second vaccine dose. T cell activation markers measured upon spike or nucleocapsid peptide in vitro stimulation showed a progressive increase after vaccination. Comprehensive analysis of plasma neutralization using 16 authentic isolates of distinct locally circulating SARS-CoV-2 variants revealed a range of reduction in the neutralization capacity associated with specific mutations in the spike gene: lineages with E484K and N501Y/T (for example, B.1.351 and P.1) had the greatest reduction, followed by lineages with L452R (for example, B.1.617.2). While both groups retained neutralization capacity against all variants, plasma from individuals who were previously infected and vaccinated displayed overall better neutralization capacity than plasma from individuals who were uninfected and also received two vaccine doses, pointing to vaccine boosters as a relevant future strategy to alleviate the effect of emerging variants on antibody neutralizing activity.

Optimal ablation targets during second catheter ablation in patients with persistent AF

Introduction

Pulmonary vein isolation (PVI) is the cornerstone of ablative therapy in atrial fibrillation (AF). However, the one-year success rate after single ablation procedure is known to be up to 60%, necessitating repeat procedures in many.

Purpose

We evaluated the impact of different ablation strategies on procedural success at the second ablation in patients with persistent AF (PerAF).

Methods

Consecutive PerAF patients scheduled to undergo their second ablation were screened and only those that have received PVI plus isolation of left atrial posterior wall (PWI) and superior vena cava (SVC) at the first procedure (n=1390), were included in the analysis. At the second ablation, all reconnected structures were ablated. Additionally, based on operators' decision, non-PV triggers were targeted for ablation.

Patients were classified into two groups based on the ablation strategy: group 1: Re-isolation of reconnected PVs, PW, SVC and group 2: additional ablation of non-PV triggers (from inter-atrial septum, coronary sinus (CS), left atrial appendage (LAA) and crista terminalis). Arrhythmia-monitoring was performed quarterly for 1 year and biannually afterwards. Ablation success was assessed off-antiarrhythmic drugs (AAD).

Results

Of the 1390 patients included in the analysis, 698 were in group 1 and 692 were in group 2.

In group 1, reconnected PV, PW and SVC were re-isolated in 98 (14%), 311 (44.5%) and 173 (24.8%) respectively. In 131 (18.7%) patients, in the absence of any reconnection, CS was empirically isolated.

In group 2, PV, PW and SVC were re-isolated in 83 (12%), 270 (39%) and 113 (16.3%) patients respectively. Additionally, non-PV triggers were ablated in 505 (73%) and empirical isolation of LAA and CS in the absence of detectable triggers and PV reconnection was performed in 187 (27%).

At 2 years of follow-up, 425 (61%) and 602 (87%) from group 1 and 2 were arrhythmia-free off-AAD (p&lt;0.001).

Conclusion

Including non-PV triggers as targets for ablation at the repeat procedure was associated with significantly higher success rate in persistent AF.

Funding Acknowledgement

Type of funding sources: None.

Long-term outcome of endocardial-only versus combined endocardial-epicardial homogenization of the scar for treatment of ventricular tachycardia in patients with ischemic cardiomyopathy

Introduction

We investigated the ablation success of scar homogenization with combined (epicardial + endocardial) versus endocardial-only approach for ventricular tachycardia (VT) in patients with ischemic cardiomyopathy (ICM) at 5 years of follow-up.

Method

Consecutive ICM patients undergoing VT ablation at our center were classified into group 1: endocardial scar homogenization and group 2: endocardial +epicardial scar homogenization. Patients with previous open heart surgery were excluded.

All patients underwent bipolar substrate mapping with standard scar settings defined as normal tissue &gt;1.5 mV and severe scar &lt;0.5 mV. Non-inducibility of monomorphic VT was the procedural endpoint in both groups. Patients were followed up twice a year for 5 years with implantable device interrogations.

Results

A total of 361 (Group 1: 291 and group 2: 70) patients were included in the study (mean age: 67 years, male: 88.4%).

At 5 years, significantly higher number of patients from group 2 remained arrhythmia-free (figure 1). Of those patients, 87 (45%) and 51 (89%) from group 1 and 2 respectively were off-anti-arrhythmic drugs (AAD) (p&lt;0.001). After adjusting for age, gender, hypertension, diabetes, and obstructive sleep apnea, scar homogenization using endo-epicardial approach was associated with 51% less recurrence compared to the endocardial ablation strategy (Hazard Ratio: 0.49, 95% CI: 0.27–0.89, p: 0.02).

Conclusion

In this series of patients with ischemic cardiomyopathy and VT, endo-epicardial scar homogenization was associated with a lower need for AAD and a significantly lower recurrence rate at 5-years of follow-up compared to the endocardial ablation alone.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Linear increase in the number of non-pulmonary vein triggers from paroxysmal to persistent and long-standing persistent AF in patients undergoing repeat procedure after successful isolation of pulmona

Introduction

This study evaluated the prevalent triggers responsible for recurrence following successful PVI in different types of atrial fibrillation (AF).

Methods

Consecutive AF patients undergoing repeat catheter ablation with permanently isolated PV were included in the analysis. High-dose isoproterenol challenge (20- 30μg/min for 15–20min) was used to confirm PV reconnection and identify non-PV triggers.

Circular mapping catheter (CMC) was used to map the site of origin of significant ectopic activity by comparing the activation sequence of the sinus beat with that of the ectopic beat. For the coronary sinus (CS), ablation catheter was positioned at the level of the mitral valve annulus, parallel to the one positioned in the CS. Left atrial appendage (LAA) firing was detected by placing the CMC in the left superior PV and thus recording far-field potentials from the LAA.

Results

This prospective study included 1850 AF patients undergoing repeat AF ablation (Table 1), of which 573 (31%) had received one and the remaining 1277 patients had received 2 earlier ablations. Permanent PVI was confirmed with isoproterenol challenge.

Table 1 shows the distribution of non-PV triggers. A linear increase in the number of non-PV triggers was observed from PAF to PerAF to LSPAF. Significantly higher number of LSPAF patients had detectable non-PV triggers compared to PerAF and PAF cases.

Conclusion

We observed a linear increase in the number of non-PV triggers in PAF to PerAF and LSPAF patients experiencing recurrence with successful isolation of PVs. As non-PV triggers are often not targeted by operators, this could be the underlying mechanism for more frequent recurrences in non-paroxysmal AF.

Funding Acknowledgement

Type of funding sources: None. Table 1

Benefits of early intervention with catheter ablation in patients with atrial fibrillation

Background

Radiofrequency catheter ablation, a widely recognized therapeutic option for atrial fibrillation (AF) has limited success rate as it is influenced by several factors including duration of AF.

Purpose

We evaluated the ablation success in AF patients intervened early versus late in the disease course.

Methods

Consecutive AF patients undergoing their first catheter ablation in 2015–16 at our center were included in the analysis. Patients were classified into two groups based on the time to ablation after AF diagnosis; 1) early: ≤12 months and 2) late: &gt;12 months.

All received PV isolation plus isolation of posterior wall and superior vena cava. Additionally, in non-paroxysmal AF cases, non-PV triggers were identified with isoproterenol-challenge and ablated. Patients were prospectively followed up for 3 years with regular rhythm monitoring.

Results

A total of 752 and 1248 patients were included in the “early” and “late” group respectively. Baseline characteristics of the study population is provided in Table 1 A. At 4 years of follow-up, overall success rate off-antiarrhythmic drugs was significantly higher in the “early” group (65.4% vs 57%, p&lt;0.001). After stratification by AF type, “early” group was still associated with significantly higher success rate compared to the “late” group (Table 1B).

Conclusion

In this large series with standardized ablation strategy, early intervention with catheter ablation was associated with higher success rate in all AF types.

Funding Acknowledgement

Type of funding sources: None. Table 1

Recovery of conduction following high power short duration approach in radiofrequency catheter ablation for atrial fibrillation: a single-center experience

Introduction

High-power short-duration (HPSD) ablation is currently being adopted by many as the preferred procedural technique in atrial fibrillation (AF). However, the optimal duration of energy delivery to successfully create a durable lesion is not clear yet.

Purpose

We evaluated the association of electrical reconnection with lesion-duration in HPSD ablation.

Methods

Consecutive AF patients undergoing repeat procedure after a prior HPSD ablation with or without isolation of left atrial appendage (LAA) and coronary sinus (CS) were included in this analysis. HPSD ablation was defined as ablation with maximum temperature setting at 420C and power delivery at 45 W for 10–15 sec (5 seconds in the CS area and posterior wall near the esophagus). In some patients a mechanical esophageal deviation tool was used to deflect the esophagus away from the ablation site.

Results

A total of 2249 AF patients (with LAA and CS isolation: 1451; without LAA and CS isolation: 798) receiving redo ablation after a prior HPSD procedure were included in the analysis. At the prior procedure with the HPSD approach, mean duration of ablation was significantly shorter in the area facing the esophagus compared to elsewhere (5.2±1.5 vs 12.5±1.7 seconds, p&lt;0.001). Application duration was reduced to &lt;10 sec to avoid overheating and steam pops in 1221 (84%) patients receiving LAA and CS isolation.

At the redo, recovery of conduction was noted in the CS (592, 40.8%), LAA (493, 34%), and PV and left atrial posterior wall (LAPW) (310, 13.8%). Of the 310 patients with LAPW reconnection, 91% (n=282) had the conduction recovered in the area facing the esophagus.

In 73 patients, esophageal displacement device was used during the prior HPSD ablation. Average duration of ablation lesions in LAPW among those 73 patients was 9.2±2 seconds. PV-LAPW reconnection was observed in 3/73 (4.1%) patients.

Conclusion

HPSD ablation with lesion duration of &lt;10 sec was associated with conduction recovery in the LAA, CS and the LAPW area facing esophagus.

Funding Acknowledgement

Type of funding sources: None.

P–796 Trial of Autologous Marrow derived Stem Cell Ovarian Transplantation (TAMSCOT) in young infertile women with diminished ovarian reserve for ovarian rejuvenation – HOPE still persists

Study question

Does autologous bone marrow derived stem cell (BMDSC) ovarian transplantation optimize ovarian reserve parameters in young infertile women with diminished ovarian reserve (DOR) ?

Summary answer

The autologous stem cell ovarian transplantation (ASCOT) improves AFC and AMH by facilitating the recruitment of existing dormant follicles in young women with DOR.

What is known already

Oocyte donation is the practical therapeutic option when patients with premature ovarian ageing desire pregnancy. It involves significant psychological burden in terms of not able to have their own biological child. ASCOT has opened new doors in poor responders and premature ovarian insufficiency through its beneficial effects on ovarian reserve and IVF outcomes. However recent studies have shown contradictory results in terms of its efficacy. No prior study has been contemplated in DOR group

Study design, size, duration

An open label non randomized controlled trial was conducted at Division of Reproductive Medicine in collaboration with stem cell facility at tertiary care institute. Forty two infertile women less than 35 years age with DOR (AFC&lt;5, AMH&lt;1.2ng/ml and /or high FSH&gt;8IU/l) were enrolled in the study during a period from January 2020 to December 2020. 20 women who did not opt for the intervention were treated as control group whereas 22 women received the intervention.

Participants/materials, setting, methods

Baseline hormonal profile ( Day 2 FSH, estradiol, AMH and AFC) was done in all patients. Women with abnormal uterine cavity, endometriosis, prior ovarian surgery, abnormal karyotype were excluded. Bone marrow aspiration followed by mesenchymal stem cells isolation was performed. The stem cells were transplanted in both the ovaries through transvaginal route on the same day. Follow up visits were planned at one and six months to assess ovarian reserve parameters.

Main results and the role of chance

The mean age, BMI and duration of infertility were comparable between the control and study group (29.5±3.34vs29.36±2.95years, 21.51±1.40vs21.87±1.93kg/m2, 6.9±1.94vs7. 04±3.67 years) . The positive response in terms of improved AMH and AFC was seen in 68% (15/22) patients. The mean number of stem cells injected in these women were 77.71±25.33 million. At first follow up, there was no significant difference between mean FSH, estradiol levels and mean right and left ovarian volume (9.23±3.95 vs 9.02±3.92mIU/l, 61.46±29.25 vs 68.12±62.52 pg/ml, 2.82±2.18 vs 2.44±1.25 cc, 2.02±1.54 vs 2.72±1.06 cc, p &lt; 0.05). There was significant increase in AMH and AFC values as compared to baseline (0.79±0.43 vs 1.26±0.82ng/ml, p = 0.03; 3.47±1.30 vs 6.40±2.23, p &lt; 0.001). At second follow up visit, the significant increase in ovarian reserve persisted for AMH and AFC (0.79±0.43 vs 1.22±0.76 ng/ml, p = 0.02; 3.47±1.30 vs 6.93±1.71,p&lt;0.001). There was no significant difference between serum FSH , Estradiol and ovarian volume. None of the patients developed any complication and the improvement in AFC and AMH persisted during 10 month follow up period.

Limitations, reasons for caution

The limitation of present study is small sample size and non randomization. However, time period for which positive effect lasts has not been documented in earlier studies. This study is currently being endeavored, and women with improved ovarian reserve are followed up for any spontaneous conception or following assisted reproduction.

Wider implications of the findings: The present study demonstrates beneficial role of stem cells in improving ovarian reserve parameters in women with DOR with no acquired cause. If supported by future randomized clinical studies, it could represent a paradigm shift for fertility treatment in these women providing an opportunity to have their own biological child.

Trial registration number

CTRI/2020/01/022726

P-796 Trial of Autologous Marrow derived Stem Cell Ovarian Transplantation (TAMSCOT) in young infertile women with diminished ovarian reserve for ovarian rejuvenation – HOPE still persists

Study question

Does autologous bone marrow derived stem cell (BMDSC) ovarian transplantation optimize ovarian reserve parameters in young infertile women with diminished ovarian reserve (DOR) ?

Summary answer

The autologous stem cell ovarian transplantation (ASCOT) improves AFC and AMH by facilitating the recruitment of existing dormant follicles in young women with DOR.

What is known already

Oocyte donation is the practical therapeutic option when patients with premature ovarian ageing desire pregnancy. It involves significant psychological burden in terms of not able to have their own biological child. ASCOT has opened new doors in poor responders and premature ovarian insufficiency through its beneficial effects on ovarian reserve and IVF outcomes. However recent studies have shown contradictory results in terms of its efficacy. No prior study has been contemplated in DOR group

Study design, size, duration

An open label non randomized controlled trial was conducted at Division of Reproductive Medicine in collaboration with stem cell facility at tertiary care institute. Forty two infertile women less than 35 years age with DOR (AFC&lt;5, AMH&lt;1.2ng/ml and /or high FSH&gt;8IU/l) were enrolled in the study during a period from January 2020 to December 2020. 20 women who did not opt for the intervention were treated as control group whereas 22 women received the intervention.

Participants/materials, setting, methods

Baseline hormonal profile ( Day 2 FSH, estradiol, AMH and AFC) was done in all patients. Women with abnormal uterine cavity, endometriosis, prior ovarian surgery, abnormal karyotype were excluded. Bone marrow aspiration followed by mesenchymal stem cells isolation was performed. The stem cells were transplanted in both the ovaries through transvaginal route on the same day. Follow up visits were planned at one and six months to assess ovarian reserve parameters.

Main results and the role of chance

The mean age, BMI and duration of infertility were comparable between the control and study group (29.5±3.34vs 29.36±2.95years, 21.51±1.40vs21.87±1.93kg/m2, 6.9±1.94vs7.04±3.67 years). The positive response in terms of improved AMH and AFC was seen in 68% (15/22) patients. The mean number of stem cells injected in these women were 77.71±25.33 million. At first follow up, there was no significant difference between mean FSH, estradiol levels and mean right and left ovarian volume (9.23±3.95 vs 9.02±3.92mIU/l, 61.46±29.25 vs 68.12±62.52 pg/ml, 2.82±2.18 vs 2.44±1.25 cc, 2.02±1.54 vs 2.72±1.06 cc, p &lt; 0.05). There was significant increase in AMH and AFC values as compared to baseline (0.79±0.43 vs 1.26±0.82ng/ml, p = 0.03; 3.47±1.30 vs 6.40±2.23, p &lt; 0.001). At second follow up visit, the significant increase in ovarian reserve persisted for AMH and AFC (0.79±0.43 vs 1.22±0.76 ng/ml, p = 0.02; 3.47±1.30 vs 6.93±1.71,p&lt;0.001). There was no significant difference between serum FSH, Estradiol and ovarian volume. None of the patients developed any complication and the improvement in AFC and AMH persisted during 10 month follow up period.

Limitations, reasons for caution

The limitation of present study is small sample size and non randomization. However, time period for which positive effect lasts has not been documented in earlier studies. This study is currently being endeavored, and women with improved ovarian reserve are followed up for any spontaneous conception or following assisted reproduction.

Wider implications of the findings

The present study demonstrates beneficial role of stem cells in improving ovarian reserve parameters in women with DOR with no acquired cause. If supported by future randomized clinical studies, it could represent a paradigm shift for fertility treatment in these women providing an opportunity to have their own biological child

Trial registration number

CTRI/2020/01/022726

Role of MR cisternography in the diagnosis of cerebrospinal fluid rhinorrhoea with diagnostic nasal endoscopy and surgical correlation

Objectives : To study the usefulness and accuracy of MR cisternography as noninvasive study in the diagnosis of cerebrospinal fluid (CSF) fistula with diagnostic sinonasal endoscopy and surgical correlation. Material and Methods: Twenty four patients with clinically suspected CSF rhinorrhoea were examined for CSF fistula with MR cisternography. The MR imaging technique included 3mm thin T2 weighted coronal and sagittal sections using Fast spin echo. In addition 1.5mm thin T2 weighted coronal sections were also obtained using CISS (Constructive Interference in Steady State) sequence. MR findings were correlated with diagnostic sinonasal endoscopy and surgical findings. Results : MR cisternography demonstrated the presence of fistula in 17 patients, absence of fistula in seven patients. Out of 17 patients with fistula, the diagnosis could be confirmed in 14 patients by diagnostic sinonasal endoscopy/surgery. Out of the seven patients without fistula, there was positive correlation in six patients when they were followed up clinically and by diagnostic nasal endoscopy. However in one patient, fistula was demonstrated on CT cisternography and was confirmed on sinonasal endoscopic surgery. The accuracy, sensitivity of MR cisternography was 96, 94% respectively. Conclusion : MR cisternography is a useful and accurate noninvasive study in localizing the site and extent of CSF fistula.

Tuning up the photovoltaic performances upon the utility of diketopyrrolopyrrole in PEO-based gel polymer electrolytes

The role of diketopyrrolopyrrole (DPP-H) as an additive on the ionic conductivity of poly(ethylene oxide) (PEO)-based gel polymer electrolytes (GPE) was studied for DSSC applications. The pure PEO/PC/KI/TPAI/I2 GPE was prepared with a mixture of propylene carbonate (PC) as a non-volatile plasticizer and iodide salts, such as potassium iodide (KI), tetrapropylammonium iodide (TPAI) and iodine (I2), together with PEO. The modified GPEs were prepared with different weight percentage (wt%) ratios (0.5%, 0.75%, 1% and 1.25%) of DPP-H using acetonitrile as a solvent. The polymer gel electrolytes were characterized by X-ray diffractometer (XRD) and Fourier transform infrared spectroscopy (FTIR), and the electrochemical properties were analyzed to relate the nature of the polymer and iodine ion conducting properties. The pure PEO/PC/TPAI/KI/I2 electrolyte exhibited an ionic conductivity value of 0.084 mS·cm-1 at room temperature. Upon the optimized addition of DPP-H (0.75 wt%), the ionic conductivity was found to be improved to a maximum value of 0.393 mS·cm-1, and the highest diffusion coefficient of 1.02 × 10-6 cm2 s-1 was observed. The optimized GPEs photovoltaic characterization studies showed higher power conversion efficiency (PCE) of 6.69% for DSSC under light illumination intensity of 100 mW cm-2. The same was compared with pure electrolyte, which delivered PCE of 4.39%. To gain an in-depth understanding of the interfacial resistance of the fabricated devices, the electron lifetime and transient photo response was analyzed. These above studies showed that prepared GPE could be an efficient alternative for traditional DSSCs with liquid electrolyte.

Linear lesions in dermatology: a clinicoaetiopathological study

BACKGROUND

Linear lesions are fairly common in our daily practice. However, the appearance of these lesions can vary, thus complicating the diagnosis.

AIMS

To study the various clinical presentations, the demographic profile of patients and the clinicopathological correlations of dermatoses presenting with a linear distribution.

METHODS

We conducted an institution-based, cross-sectional, descriptive study of 281 consecutive patients with linear lesions attending dermatology clinics. MedCalc software (V11.6) was used for statistical analysis.

RESULTS

Patients were divided into eight groups: lesions along the lines of Blaschko (n = 136), lesions along blood vessels (n = 3), lesions along lymphatics (n = 3), Koebner phenomenon (n = 24), autoinoculation (n = 24), external factors (n = 45), infestations (n = 2) and 'other' (n = 44). The mean age at presentation was 24.50 ± 18.82 years and the male/female ratio was 1.32 : 1. The commonest symptom was itching/burning (56.94% of patients), while the commonest site was the arm (44.48%); followed by the leg (30.60%), trunk and abdomen (22.42%), head and neck (19.20%), and genitalia (0.35%). Apart from the common cases, there was a wide gamut of rare conditions (e.g. angiokeratoma circumscriptum naeviforme, porokeratotic eccrine ostial and dermal duct naevus, Blaschko-linear syringocystadenoma papilliferum, progressive cribriform and zosteriform hyperpigmentation, unilateral naevoid acanthosis nigricans, fixed drug eruption, discoid lupus erythematosus).

CONCLUSION

Linear lesions act as diagnostic clues to many dermatological conditions, therefore, the importance of meticulous examination in clinical dermatology cannot be overemphasized.

Divergent and self-reactive immune responses in the CNS of COVID-19 patients with neurological symptoms

Individuals with coronavirus disease 2019 (COVID-19) frequently develop neurological symptoms, but the biological underpinnings of these phenomena are unknown. Through single-cell RNA sequencing (scRNA-seq) and cytokine analyses of cerebrospinal fluid (CSF) and blood from individuals with COVID-19 with neurological symptoms, we find compartmentalized, CNS-specific T cell activation and B cell responses. All affected individuals had CSF anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies whose target epitopes diverged from serum antibodies. In an animal model, we find that intrathecal SARS-CoV-2 antibodies are present only during brain infection and not elicited by pulmonary infection. We produced CSF-derived monoclonal antibodies from an individual with COVID-19 and found that these monoclonal antibodies (mAbs) target antiviral and antineural antigens, including one mAb that reacted to spike protein and neural tissue. CSF immunoglobulin G (IgG) from 5 of 7 patients showed antineural reactivity. This immune survey reveals evidence of a compartmentalized immune response in the CNS of individuals with COVID-19 and suggests a role of autoimmunity in neurologic sequelae of COVID-19.

Evidence for X(3872)→J/ψπ^{+}π^{-} Produced in Single-Tag Two-Photon Interactions

We report the first evidence for X(3872) production in two-photon interactions by tagging either the electron or the positron in the final state, exploring the highly virtual photon region. The search is performed in e^{+}e^{-}→e^{+}e^{-}J/ψπ^{+}π^{-}, using 825  fb^{-1} of data collected by the Belle detector operated at the KEKB e^{+}e^{-} collider. We observe three X(3872) candidates, where the expected background is 0.11±0.10 events, with a significance of 3.2σ. We obtain an estimated value for Γ[over ˜]_{γγ}B(X(3872)→J/ψπ^{+}π^{-}) assuming the Q^{2} dependence predicted by a cc[over ¯] meson model, where -Q^{2} is the invariant mass squared of the virtual photon. No X(3915)→J/ψπ^{+}π^{-} candidates are found.

Surgical management of the odontogenic keratocyst: A 20-year experience

The objective of this study was to describe the authors' long-term experience with the management of odontogenic keratocysts (OKCs). All OKC cases treated at the study centre between 1999 and 2015, with a minimum of 5 years of follow-up by December 2019, were reviewed retrospectively. Operative procedures including decompression/marsupialization, enucleation (E), E+Carnoy's solution (CS), E+CS+peripheral ostectomy (PO), and resection were assessed for complete resolution, partial resolution, and recurrence rates. In the parakeratinized non-syndromic group, E+CS+PO resulted in the lowest recurrence rate among the minimally invasive procedures (4.3%), while enucleation resulted in the highest rate (60%). Regarding the other modalities, recurrence was 12.5% for decompression, 11.5% for marsupialization, 16.7% for E+CS, 26.7% for E+PO, and 0% for resection. In the syndromic group, marsupialization resulted in a significantly higher recurrence (23.1%), while E+CS+PO cases showed no recurrence. No recurrence was observed in the orthokeratinized group patients treated with marsupialization or with E+CS. Based on clinico-radiographic features and observed results, it is concluded that OKC, although having a high recurrence rate, is a benign lesion and responds well to conservative procedures in most cases. Radical procedures should be reserved for unresponsive lesions and those with extensive tissue destruction.

The transition to Xpert MTB/RIF ultra: diagnostic accuracy for pulmonary tuberculosis in Kampala, Uganda

BACKGROUND

The World Health Organization (WHO) has endorsed the next-generation Xpert MTB/RIF Ultra (Ultra) cartridge, and Uganda is currently transitioning from the older generation Xpert MTB/RIF (Xpert) cartridge to Ultra as the initial diagnostic test for pulmonary tuberculosis (TB). We assessed the diagnostic accuracy of Ultra for pulmonary TB among adults in Kampala, Uganda.

METHODS

We sampled adults referred for Xpert testing at two hospitals and a health center over a 12-month period. We enrolled adults with positive Xpert and a random 1:1 sample with negative Xpert results. Expectorated sputum was collected for Ultra, and for solid and liquid culture testing for Xpert-negative patients. We measured sensitivity and specificity of Ultra overall and by HIV status, prior history of TB, and hospitalization, in reference to Xpert and culture results. We also assessed how classification of results in the new "trace" category affects Ultra accuracy.

RESULTS

Among 698 participants included, 211 (30%) were HIV-positive and 336 (48%) had TB. The sensitivity of Ultra was 90.5% (95% CI 86.8-93.4) and specificity was 98.1% (95% CI 96.1-99.2). There were no significant differences in sensitivity and specificity by HIV status, prior history of TB or hospitalization. Xpert and Ultra results were concordant in 670 (96%) participants, with Ultra having a small reduction in specificity (difference 1.9, 95% CI 0.2 to 3.6, p=0.01). When "trace" results were considered positive for all patients, sensitivity increased by 2.1% (95% CI 0.3 to 3.9, p=0.01) without a significant reduction in specificity (- 0.8, 95% CI - 0.3 to 2.0, p=0.08).

CONCLUSIONS

After 1 year of implementation, Ultra had similar performance to Xpert. Considering "trace" results to be positive in all patients increased case detection without significant loss of specificity. Longitudinal studies are needed to compare the benefit of greater diagnoses to the cost of overtreatment.

Design and implementation of a prospective cohort study of persons living with and without HIV infection who are initiating medication treatment for opioid use disorder

Background

Opioid use disorder (OUD) negatively impacts the HIV continuum of care for persons living with HIV. Medication treatment for OUD (MOUD) may have differential biological effects in individuals with HIV and OUD. To address the question of modulation of immune responses by MOUDs, we describe state of the art systems biology approaches to carry out the first prospective, longitudinal study of persons with and without HIV infection with OUD initiating MOUD.

Methods

A prospective cohort study of persons with DSM-5 diagnosed OUD who are living with and without HIV infection and initiating treatment with methadone or buprenorphine is underway to assess biological effects of these medications on immunobiological outcomes.

Results

We describe the recruitment, laboratory, and statistical methods of this study as well as the protocol details. Of those screened for enrollment into the study, 468 (36%) were eligible and 135 were enrolled thus far. Retention through month 6 has been high at 80%.

Conclusions

This study will use state of the art systems biology approaches to carry out the first prospective, longitudinal studies of persons living with and without HIV with DSM-5 OUD initiating treatment with MOUD.

Risk factors for progression of paroxysmal to persistent atrial fibrillation following successful PV isolation

Background

Progression from paroxysmal (PAF) to persistent atrial fibrillation (PerAF) following effective PV isolation (PVI) has important clinical implications, as it is relevant for subsequent management of the arrhythmia.

Objective

We evaluated risk factors responsible for progression of PAF to PerAF following successful PVI.

Methods

Consecutive AF patients that received their first catheter ablation as well as the first redo at our center were identified (n=1352). Patients were included in group 1 if the diagnosis was PAF at both first and redo procedure (PAF to PAF) and group 2 if PAF at index progressed to PerAF at redo. All patients received PVI plus isolation of LA posterior wall and SVC at the first procedure.

Results

A total of 822 patients remained as PAF at redo, whereas 530 (39%) progressed from PAF to PerAF. Clinical characteristics of the study population are presented in table 1. In multivariate analysis, BMI (OR 1.02, 1.01–1.04, p=0.04), hypertension (1.4, 1.08–1.8, p=0.01), heart failure (1.67, 1.03–2.69, p=0.03), LA size (2.75, 2.29–3.31, p&lt;0.001) were independent predictors of progression of PAF to PerAF. Data on serum-transthyretin level was available for 37 and 48 patients in group 1 and 2 respectively. It was &lt;18 mg/dL (normal) in 33 (68.7%) patients in group 2 vs 6 (16.2%) in group 1 (p&lt;0.001).

Conclusion

In our patients, after successful PVI, progression of PAF to PerAF was mediated by independent risk factors such as high BMI, heart failure, hypertension, larger LA size and lower LVEF.

Funding Acknowledgement

Type of funding source: None