Design and Implementation of a Learner-Centered Self-Paced Peritoneal Oncology Education Program

BACKGROUND

Current educational programs for peritoneal surface malignancies (PSM) are unstructured and often target advanced learners. The authors describe the design and implementation of a structured, self-paced course at a high-volume PSM center.

METHODS

In 2020, a learner-centered course was designed using the Canvas educational platform in consultation with the Center for Teaching at the University of Chicago. The course consisted of disease-site-specific modules, perioperative care pathways, in-built voluntary quizzes, and multimedia supplements for advanced learners. Trainees were provided access during the PSM service rotation, and engagement was compared across training levels by measuring the time spent online.

RESULTS

Course design and management required 71 h between 2020 and 2022, with the majority of time spent in the design phase. During 3 years, 62 personnel (21 [34%] medical students, 28 [45%] residents, 8 [13%] staff, and 5 [8%] fellows) were assigned the course. The overall engagement rate was 83.9% (86% of medical students, 75% of residents, 100% of staff and fellows), and the median time spent online was 12.4 min/week (interquartile range [IQR], 2.1-53.0 min/week). Fourth-year medical students and clinical fellows spent more time online than other learners (73 min/week [IQR, 24.5-100 min/week] vs 13.3 min/week [IQR, 7.3-26.5 min/week]) (p = 0.001).

CONCLUSIONS

The design and implementation of a PSM-specific course was feasible and sustainable using an online learning platform. Higher engagement was noted among invested learners. Non-technical factors for reduced engagement need to be ascertained further to improve the next iteration of this course.

Gender gap in study inclusion: Insights from the STAR-FIB cohort study

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Swiss National Science Foundation Swiss Heart Foundation

Background

The underrepresentation of women in cardiovascular clinical trials is well described but cannot be fully explained by sex-specific differences in the prevalence of cardiovascular diseases. Data on potential sex- and gender-related differences in study exclusion reasons are scarce.

The STAR-FIB cohort study aimed to estimate the age and sex-specific prevalence of screening-detected atrial fibrillation (AF) in 800 hospitalized patients aged 65-84 years using serial seven-day ECGs. Recruitment for study inclusion was stratified by sex (female/male, as stated in the patient’s records) and age (four age bands, ≥65 to <70, ≥70 to <75, ≥75 to <80, and ≥80 to <85 years), and was truncated for each subgroup after the inclusion of 100 participants.

Purpose

To assess sex and gender differences in patient recruitment for inclusion in the STAR-FIB cohort study.

Methods

A screening log containing sex-category, age, and reasons for exclusion was maintained. Exclusion criteria are shown in the figure. For the purpose of the present study, an explorative analysis of all exclusion criteria with respect to sex category was done.

Results

Overall, 11’470 patients were identified for eligibility, 795 patients (49% women; mean age 75 years) were enrolled, and 10’675 patients (52% women vs. 48% men, p =0.13) were not enrolled. The two major exclusion reasons were unwillingness to participate, which was more frequent in women (27.9% of women vs. 18.4% of men, p < 0.01), and the presence of clinical AF, which was more prevalent in men (27.1% of men vs. 20.5 % of women, p < 0.01). A detailed analysis of all exclusion criteria analysed by sex category is provided in the figure.

Conclusions

Clinical AF was more frequent in men, in accordance with the well described sex-driven (biological) higher prevalence of AF in men. In contrast, we found a higher percentage of women unwilling to participate in this study, which may represent a more gender-based (sociocultural) phenomenon. A further exploration of these findings should be performed and may help to identify and potentially overcome modifiable obstacles for study participation.

Incidental arrhythmias during atrial fibrillation screening in a hospital-based patient population

Funding Acknowledgements

Type of funding sources: None.

Introduction

Screening for atrial fibrillation may reveal other, incidental arrhythmias of relevance. We sought to describe such incidental arrhythmias in the prospective STARFIB cohort study, which screened for silent atrial fibrillation in hospitalized patients aged 65-84 years.

Method

Patients included in the STARFIB cohort study had up to three 7-day Holter ECGs, performed in two-month intervals. We analysed all the 7-day Holter ECGs of study participants for the presence of one of the following incidental arrhythmias: 1) sick-sinus-syndrome (SSS), defined as sinus arrest of ≥3 seconds duration; 2) second or higher degree atrioventricular block (AVB); 3) sustained atrial tachycardia of ≥30 seconds duration (AT); and 4) sustained ventricular tachycardia of ≥30 seconds duration (VT).

Results

A total of 2’077 Holter ECGs were performed in 794 patients (mean age 74.7 years; 49% females), resulting in a mean cumulative duration of an analyzable ECG signal of 414±136 hours per patient. We found incidental arrhythmias in 94 patients (11.8%). Among these were SSS in 14 patients (1.8%), AVB in 41 (5.2%), AT in 41 (5.2%), and VT in two (0.3%). The median pause duration in SSS was 4 seconds and SSS resulted in pacemaker implantation in one patient with a pause of 9 seconds duration. The most severe type of AVB found per patient was second degree AVB type Wenkebach in 23 patients (2.9%), second degree AVB type Mobitz or 2:1 AV conduction in 10 patients (1.3%) and complete AVB in 8 (1%; maximum pause 18 seconds). AVB led to pacemaker implantation in 9 patients (1.1%). The median duration and heart rate of AT was 2.2 minutes and 144 bpm, respectively. Initiation of betablocker therapy was recommended in 3 patients (0.4%) due to symptomatic AT. The duration and heart rate of VT was 3 minutes at 216 bpm in one patient and 38 seconds at 150 bpm in another. The former patient with VT experienced syncope and an ICD was implanted, whereas in the latter the betablocker dose was increased. One patient died from a non-cardiac cause during a Holter ECG, which showed progressive bradycardia and finally asystole.

Conclusion

Incidental arrhythmias were frequently discovered during screening for atrial fibrillation and resulted in device therapy in 1.4% of our cohort patients.

Trauma-informed Approaches to Substance Use Interventions with Indigenous Peoples: A Scoping Review

Indigenous Peoples experience disproportionately higher rates of problematic substance use. These problems are situated in a context of individual and intergenerational trauma from colonization, residential schools, and racist and discriminatory practices, policies, and services. Therefore, substance use interventions need to adopt a trauma-informed approach. We aimed to synthesize and report the current literature exploring the intersection of trauma and substance use interventions for Indigenous Peoples. Fourteen databases were searched using keywords for Indigenous Peoples, trauma, and substance use. Of the 1373 sources identified, 117 met inclusion criteria. Literature on trauma and substance use with Indigenous Peoples has increased in the last 5 years (2012-2016, n = 29; 2017-2021, n = 48), with most literature coming from the United States and Canada and focusing on historical or intergenerational trauma. Few articles focused on intersectional identities such as 2SLGBTQIA+ (n = 4), and none focused on veterans. There were limited sources (n = 25) that reported specific interventions at the intersection of trauma and substance use. These sources advocate for multi-faceted, trauma-informed, and culturally safe interventions for use with Indigenous Peoples. This scoping review illuminates gaps in the literature and highlights a need for research reporting on trauma-informed interventions for substance use with Indigenous Peoples.

Impact of clinical risk factor profile vs. atrial fibrillation phenotype on outcome after pulmonary vein isolation

Aims

Catheter ablation for atrial fibrillation (AF) is increasingly performed. Both clinical risk factors as well as the AF phenotype have been shown to influence ablation outcomes. The inter-relationship of the two however is incompletely understood.

Methods

In a retrospective analysis of a prospective registry of patients undergoing a first pulmonary vein isolation, the association of 8 predefined clinical risk factors (age >70 years, female gender, hypertension, BMI >30 kg/m2, coronary artery disease, heart failure, chronic kidney disease (CKD; eGFR<60ml/min/1.73m2) and diabetes mellitus) and the AF phenotype (paroxysmal vs. persistent AF) were assessed as well as their impact on AF recurrence during follow-up.

Results

Overall, 715 patients were enrolled (median age 63 years, 27% females, 69% paroxysmal AF). The prevalence of obesity, hypertension, heart failure and CKD was significantly higher in persistent AF, while female gender was more prevalent in paroxysmal AF. After 2 years of follow-up, overall freedom from recurrence was 46%, and was higher in paroxysmal AF compared to persistent AF (54.1% vs. 29.1%, p<0.001). Of the clinical risk factors, obesity (p=0.02), CKD (p=0.01) and heart failure (p=0.01) were significantly associated with lower arrhythmia-free survival, and there was a trend for hypertension and coronary artery disease (both p<0.2). A risk score composed of those 5 factors was associated with recurrences in patients with paroxysmal AF (p=0.04, Figure 1), but not in those with persistent AF (p=0.85, Figure 2).

Conclusion

Clinical risk factors predict outcome after pulmonary vein isolation in patients with paroxysmal, but not persistent AF. This is likely due to a strong association of those risk factors with the occurrence of persistent AF.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

P311Hypertrophic cardiomyopathy and other forms of left ventricular hypertrophy. The P wave can make the difference

Background

Structural disarray of hypertrophied myocytes and interstitial fibrosis characterize hypertrophic cardiomyopathy (HCM). These morphological changes also affect atrial myocytes and, together with hemodynamic alterations because of HCM, may lead to atrial cardiomyopathy. 

Purpose

To investigate the incremental value of P-wave parameters to differentiate left ventricular hypertrophy (LVH) because of HCM from LVH in hypertensive heart disease (HHD) and athletes heart. 

Methods

In a prospective study, we compared electrocardiographic (including signal-averaged ECG of the P wave) and echocardiographic data of patients with HCM, HHD and athletes heart. We developed a predictive model with a simple scoring system to identify HCM.

Results

We compared data of 27 patients with HCM (70% males, 49.8 ± 14.5 years), 324 patients with HHD (52% males, 74.8 ± 5.5 years), and 215 subjects with athletes heart (72% males, 42.3 ± 7.5). The table shows the significant differences among the 3 groups. We included the following parameters into a predictive score to differentiate HCM from other forms of LVH: QRS width (>88ms = 1 point), P-wave integral (>688µVs = 1 point) and septum thickness (>12mm = 2 points). A score >2 (Youden index 0.626) correctly classified HCM in 81% of the cases with a sensitivity and specificity of 82% an 81%, respectively. 

Conclusion Differentiation of HCM from other forms of LVH is improved by including atrial parameters. A simple scoring system including septum thickness, QRS width and P wave integral allowed identification of patients with HCM with a sensitivity and specificity of >80%. This score needs to be validated prospectively.

Table 1 HCM HHD Athletes P-value HCM vs HHD* HCM vs Athletes* 95%-CI P-value 95%-CI P-value P-wave duration [ms] 152.7 ± 25.8 143.9 ± 16.5 133.5 ± 14.2 <0.001 -16.9 -24.6 to -9.1 <0.001 -16.3 -22.7 to -9.9 <0.001 P-wave integral [µVs] 850.4 ± 272.4 672.0 ± 235.4 773.1 ± 260.1 <0.001 -198.6 -320.8 to -76.3 0.002 -68.2 -169.7 to 33.2 0.187 QRS [ms] 110.3 ± 27.3 96.9 ± 20.3 95.1 ± 9.8 <0.001 -16.4 -24.7 to -8.1 <0.001 -13.8 -20.8 to -6.9 <0.001 QTc [ms] 447.9 ± 27.2 438.6 ± 24.5 414.0 ± 22.9 <0.001 -21.1 -32.7 to -9.5 <0.001 -30.8 -40.5 to -21.2 <0.001 LVMMI [g/m2] 153.6 ± 55.5 133.5 ± 30.3 98.6 ± 19.7 <0.001 -15.3 -29.7 to -0.9 0.038 -56.1 -67.7 to -44.6 <0.001 IVS [ms] 16.8 ± 4.2 11.8 ± 2.2 10.3 ± 1.5 <0.001 -5.2 -6.3 to -4.1 <0.001 -6.4 -7.3 to -5.6 <0.001 LAVI [ml/m2] 43.2 ± 13.9 30.5 ± 9.7 30.8 ± 9.5 <0.001 -14.6 -20.0 to -9.3 <0.001 -12.2 -16.6 to -7.9 <0.001 The table shows the study result after univariate and multivariate (*; adjusting for age and sex) analysis.

Abstract Figure 1

P1492Comparison of the long-term performance of the quadripolar IS-4 and the bipolar IS-1 left ventricular lead for cardiac resynchronization therapy

BACKGROUND

The implantation of left ventricular (LV) leads for cardiac resynchronization therapy (CRT) and the management of lead-related complications can be challenging. The introduction of the quadripolar IS-4 LV lead may have facilitated the implantation procedure and may have reduced lead-related complications. Data of long-term follow-up (FU) comparing the IS-4 lead with the IS-1 LV lead are rare and conflicting.

PURPOSE

Comparison of lead-related complications and all-cause mortality between CRT patients who received an IS-4 or an IS-1 LV lead in the long-term FU.

METHODS

Adults with an indication for a CRT-Defibrillator or CRT-Pacemaker, a successful endovascular IS-4 or IS-1 LV lead implantation, and a minimal FU of three years were included in this retrospective study. The combined primary endpoint was freedom from lead-related complications defined as (i) occurrence of persisting high pacing threshold (>2.75V/0.4ms), (ii) unresolved phrenic nerve stimulation, (iii) LV lead dislodgement/disruption, (iv) the necessity of re-interventions affecting the LV lead, and (v) LV lead deactivation/explantation. Secondary endpoints were all singular complications and all-cause mortality.

RESULTS

Eligible for the study were 133 patients (IS-4 n = 66; IS-1 n = 67) with a mean FU of 4.03 ± 1.93 years. Baseline characteristics of both patient groups did not differ significantly. Freedom from lead-related complications was higher in patients with an IS-4 lead as compared to an IS-1 lead (Figure 1; 87.9% vs. 65.7%; p = 0.002). The secondary outcomes showed a higher rate of LV lead dislodgement/disruption (4.5% vs. 17.9%; p = 0.015) in the IS-1 patient group and more patients suffered from unresolved phrenic nerve stimulation with an IS-1 lead (3.0% vs. 13.4%; p = 0.029). LV lead deactivation/explantation during FU and LV lead-related re-interventions were fewer in case of an IS-4 lead (4.5% vs 22.4%; p = 0.003; 6.1% vs. 17.9%; p = 0.036, respectively). The rate of persisting high pacing thresholds and all-cause mortality did not differ (4.5% vs. 9.0%; p = 0.492; 22.7% vs 25.4%; p = 0.721, respectively).

CONCLUSION

The quadripolar IS-4 LV lead showed in this retrospective study a better long-term performance than the bipolar IS-1 lead.

Abstract Figure 1

Editorial: Diagnostic Testing for SARS-Coronavirus-2 in the Nursing Facility: Recommendations of a Delphi Panel of Long-Term Care Clinicians

With the COVID-19 pandemic progressing, guidance on strategies to mitigate its devastating effects in nursing facilities (NFs) is critical to preventing additional tragic outcomes. Asymptomatic spread of COVID-19 from nursing facility staff and residents is a major accelerator of infection. Facility-wide point-prevalence testing is an emerging strategy in disease mitigation. Because time is not available to await the results of randomized controlled trials before implementing strategies in this high-risk setting, an expert Delphi panel composed of experienced long-term care medicine professionals has now met to provide testing guidance for SARS-Coronavirus-2 to NFs. After many email and telephone discussions, the panel responded to a questionnaire that included six different scenarios, based on varying availability of Polymerase Chain Reaction (RT-PCR) testing and personal protective equipment (PPE). The panel endorsed facility-wide testing of staff and residents without dissent when diagnostic RT-PCR was available. While the panel recognized the limitations of RT-PCR testing, it strongly recommended this testing for both staff and residents in NFs that were either COVID-19 naive or had limited outbreaks. There was also consensus on testing residents with atypical symptoms in a scenario of limited testing capability. The panel favored testing every 1 to 2 weeks if testing was readily available, reducing the frequency to every month as community prevalence declined or as the collection of additional data further informed clinical critical thinking and decision-making. The panel recognized that frequent testing would have consequences in terms of potential staff shortages due to quarantine after positive tests and increased PPE use. However, the panel felt that not testing would allow new clusters of infection to form. The resulting high mortality rate would outweigh the potential negative consequences of testing. The panel also recognized the pandemic as a rapidly evolving crisis, and that new science and increasing experience might require an updating of its recommendations. The panel hopes that its recommendations will be of value to the long-term care industry and to policy makers as we work together to manage through this challenging and stressful time.

P2855Unexpectedly high rate of lead failure of the Microport (formerly Sorin/Livanova) Beflex and Vega pacemaker electrodes: A single centre experience

Introduction

Pacing leads remain the weak link of current pacemaker systems. Various differences in design and material exist among companies. Lead performance is mainly assessed via post-marketing studies of the manufacturing companies. Reliable independent reports are rare. We aimed to study the early and long-term performance of the Microport (formerly Sorin/Livanova) Beflex and Vega leads at our centre, for which a lead survival >99% at 3 years has been reported by the company.

Method

In this single centre, retrospective study we analysed the performance of all right ventricular Microport pacemaker leads implanted at our centre between January 2014 and January 2018. Only first pacemaker implants were considered. Lead failure was defined as any lead issue requiring reintervention during follow-up (dislocation, perforation, electrical abnormalities such as lead noise or excessively high thresholds).

Results

A total of 271 Microport right ventricular pacing leads were implanted (233 Beflex and 38 Vega leads). Mean patient age was 76±13.1 years (66% men). Dual chamber pacemakers were implanted in 162 patients (60%) and single chamber in 109 (40%). Mean threshold at implant was 0.6V/0.5ms (range 0.3–1.2V), mean R wave 13.2 mV (range 1.5–30mV) and mean impedance 816 Ohm (range 469–1639 Ohm). Patients without available follow-up information were excluded (N=18, 6.6%). The remaining 253 patients (93.4%) were analysed. Median follow-up was 1.26 years, IQR [25%=0.91 and 75%=2.24]. We observed a total of 25 lead failures (10%). Lead dislocation occurred in 2 cases (0.8%), lead perforation in 5 cases (2%), electrical abnormalities in 6 cases (2.4%) and excessively high threshold in 12 cases (4.8%; mean voltage 4V, range 2–7.5V; mean pulse width 0.75ms, range 0.35–1ms). Yearly incidence of lead failure per 100 leads was 6.1% (95%-CI [4.09–8.98] with a failure rate of 12.74% at 3 year in Kaplan-Meier analysis (Figure).

Figure 1

Conclusion

We found an unexpectedly high rate of lead failure of the Microport Beflex and Vega pacing leads at our centre. The two main reasons for premature lead failure were excessively high thresholds as well as electrical abnormalities during follow-up. Comparison of lead performance with other centres and against other leads are needed to further assess the magnitude of the problem.

P1007Efficacy and safety of atrial ablation procedures in patients with complete d-TGA and atrial switch at a Swiss tertiary center

Introduction

Patients with complete transposition of the great arteries (d-TGA) and atrial switch face a high lifetime risk of arrhythmias. Interventions in these patients are challenging because of their particular anatomy. Reports on ablation procedures in this patient population are scarce and missing for Switzerland.

Method

We retrospectively analyzed all ablation procedures performed in the above-mentioned population at a Swiss tertiary care center.

Results

Among 73 d-TGA pts. (71% male; N=37 Senning; N=36 Mustard) followed at our center, 17 ablations were performed in 11 pts. (15%; one ablation in 8 pts., two in 2 pts. and five in 1 patient). Median age at first ablation was 34 years (range 15–49 years). A total of 17 different intra-atrial reentry tachycardias (IART) and 3 AVNRT were targeted. Of the IART, 10 were cavotricuspid isthmus (CTI)-dependent and 7 were not. In two procedures (12%) only the systemic venous (SV) baffle was accessed for ablation. In 15 procedures (88%), ablation was performed within the pulmonary venous (PV) baffle. Access to the PV baffle was retrograde via the aorta in 6 cases (35%), via a baffle leak in 3 (18%) and via baffle puncture in 6 (35%). All procedures with retrograde approach to the PV baffle or with SV baffle only ablation were performed up to January 2012 and all remaining procedures afterwards. The 3 pts. requiring repeat procedures had retrograde or SV baffle approaches initially, and one additional ablation via baffle puncture was successful. The CTI was targeted in 10 pts. (91%) and ablation was finally successful in all with bidirectional block demonstrated in 8 pts. The coronary sinus was found to drain into the SV baffle in 5 pts. (46%) and useful for assessment of CTI block. The seven CTI-independent IART were scar-related micro-reentries. Ablation of all 3 AVNRTs was successful after one procedure without recurrence. Slow pathway ablation was performed in the SV baffle in two and in the PV baffle in one case (Figure). After a median follow-up of 7 months (range 2–186 months) 9 pts. are without recurrence and in 2 pts. rare self-limited arrhythmias still occur. No procedural complications occurred.

Conclusion

Arrhythmias in patients with complete d-TGA and atrial switch are mainly CTI-dependent IART or scar-related micro-reentries, and a few patients also have AVNRT. Ablation of these arrhythmias is safe and successful if PV baffle access is achieved via a baffle leak or baffle puncture.

5201Intra-cardiac thrombus in patients undergoing ventricular tachycardia ablation. a computed tomographic scan study

Background

Embolic event is one of the complications of VT ablation. This may be due to the presence of intra-cardiac thrombus before ablation. However, there is no clear consensus on how to rule out thrombus before the procedure.

Objective

We sought to examine the prevalence and risk factors of intra-cardiac thrombus with cardiac computed tomographic (CT) scan in patients undergoing scar-related VT ablation.

Methods

In absence of contra-indication, all patients undergoing scar-related VT ablation at our institution underwent contrast-enhanced cardiac CT within one week before ablation. 324 consecutive patients (292 male, 59±16 yo) have been included in this study. The etiology was ischemic cardiomyopathy (CMP) (n=191), arrhythmogenic right ventricular CMP (ARVC) (n=37), congenital CMP (n=11) or other CMP (n=85). LVEF was <40% in 154 patients (48%).

Results

Intra-cardiac thrombus was diagnosed in 29 (9%) patients: in the left atrium (n=8), in the right atrium (n=1), in the left ventricle (n=15), in the right ventricle (n=3), in right and left atrium (n=1), and in left atrium and right ventricle (n=1). Moreover in 2, a bilateral pulmonary embolism was identified. The population with thrombus was older (65±12 vs 58±16 years, p=0,005), with more permanent atrial fibrillation (AF) (28% vs 8%; p=0.005). Patients with left ventricular (LV) aneurysm were at higher risk of thrombus 50% vs 3% (p<0.001). The average CHADSVASC score was similar for both groups (2,5 vs 2,1; p=0.179). After matching for age and sex, only ischemic CMP and LV aneurysm were risk factors for thrombus. Because of arrhythmic storm, ablation was performed by epicardial approach only, in 5 patients with intra-ventricular thrombus and by retroaortic approach only, in 2 patients with LAA thrombus. No embolic event occurred during these procedures.

Conclusion

CT scans help eliminating intra-cardiac thrombus before VT ablation procedure. A high proportion of thrombus (9%) was identified. Whereas LV thrombus should systematically be ruled out before scar related VT ablation, in patients with AF, a LAA thrombus should also be eliminated as well as RV thrombus in patients with ARVC.

Acknowledgement/Funding

ANR-10-IAHU-04

Heme scavenging reduces pulmonary endoplasmic reticulum stress, fibrosis, and emphysema

Pulmonary fibrosis and emphysema are irreversible chronic events after inhalation injury. However, the mechanism(s) involved in their development remain poorly understood. Higher levels of plasma and lung heme have been recorded in acute lung injury associated with several insults. Here, we provide the molecular basis for heme-induced chronic lung injury. We found elevated plasma heme in chronic obstructive pulmonary disease (COPD) (GOLD stage 4) patients and also in a ferret model of COPD secondary to chronic cigarette smoke inhalation. Next, we developed a rodent model of chronic lung injury, where we exposed C57BL/6 mice to the halogen gas, bromine (Br2) (400 ppm, 30 minutes), and returned them to room air resulting in combined airway fibrosis and emphysematous phenotype, as indicated by high collagen deposition in the peribronchial spaces, increased lung hydroxyproline concentrations, and alveolar septal damage. These mice also had elevated pulmonary endoplasmic reticulum (ER) stress as seen in COPD patients; the pharmacological or genetic diminution of ER stress in mice attenuated Br2-induced lung changes. Finally, treating mice with the heme-scavenging protein, hemopexin, reduced plasma heme, ER stress, airway fibrosis, and emphysema. This is the first study to our knowledge to report elevated heme in COPD patients and establishes heme scavenging as a potential therapy after inhalation injury.

Integrated assessment modelling as a positive science: private passenger road transport policies to meet a climate target well below 2 ∘C

Transport generates a large and growing component of global greenhouse gas emissions contributing to climate change. Effective transport emissions reduction policies are needed in order to reach a climate target well below 2 ^∘C. Representations of technology evolution in current integrated assessment models (IAM) make use of systems optimisations that may not always provide sufficient insight on consumer response to realistic policy packages for extensive use in policy-making. Here, we introduce FTT: transport, an evolutionary technology diffusion simulation model for road transport technology, as an IAM sub-component, which features sufficiently realistic features of consumers and of existing technological trajectories that enables to simulate the impact of detailed climate policies in private passenger road transport. Integrated to the simulation-based macroeconometric IAM E3ME-FTT, a plausible scenario of transport decarbonisation is given, defined by a detailed transport policy package, that reaches sufficient emissions reductions to achieve the 2 ^∘C target of the Paris Agreement.

Diagnosing slipped capital femoral epiphysis amongst various medical specialists

PURPOSE

To evaluate sensitivity, specificity and accuracy of a radiographic slipped capital femoral epiphysis (SCFE)-diagnosis among medical specialists.

METHODS

Three paediatricians, three paediatric radiologists and three paediatric orthopaedic surgeons completed two rounds of a survey of anteroposterior and frog-leg lateral radiographs of patients with a diagnosis of SCFE (25), femoroacetabular impingement (four), Legg-Calvé-Perthes (11) or no hip pathology (ten). Intra- and interobserver agreement among specialties regarding the diagnosis of a SCFE were assessed using Cohen's kappa coefficient (κ). Diagnostic accuracy of SCFE relative to the benchmark, a combination of the radiographic diagnosis based on Klein's line, clinical symptoms and surgical treatment, was assessed computing sensitivity, specificity and accuracy.

RESULTS

Intraobserver agreement between the surveys was moderate among paediatricians (κ-range, 0.44 to 0.52), moderate to almost perfect among orthopaedic surgeons (κ-range, 0.79 to 0.88) and almost perfect among paediatric radiologists (κ-range, 0.83 to 1.00). Interobserver agreement for survey 1 and 2 was slight among paediatricians (mean κ, 0.19), substantial among orthopaedic surgeons (mean κ, 0.77) and almost perfect among paediatric radiologists (mean κ, 0.86). Sensitivity of SCFE-diagnosis was high among radiologists and orthopaedic surgeons (88% to 100% for both specialties), but lower for paediatricians (24% to 76%). Specificity was high among radiologists and orthopaedic surgeons (72% to 84%), however, variable among paediatricians (56% to 80%). Accuracy of a SCFE-diagnosis was highest in radiologists (84% to 92%), followed by orthopaedic surgeons (80% to 88%) and paediatricians (48% to 78%).

CONCLUSION

SCFE can be detected on radiographs by different medical specialties. Intra- and interobserver agreement, specificity, sensitivity and accuracy for radiographic SCFE-diagnosis amongst paediatric radiologists and orthopaedic surgeons are better than that of general paediatricians.

LEVEL OF EVIDENCE

II.

The effects of tenure and promotion on surgeon productivity

BACKGROUND

Studies investigating the impact of promotion and tenure on surgeon productivity are lacking. The aim of this study is to elucidate the relationship of promotion and tenure to surgeon productivity.

METHODS

We reviewed data for the Department of Surgery at our institution. Relative value units (RVUs) billed per year, publications per year, and grant funding per year were used to assess productivity from 2010 to 2016. We analyzed tenure-track (TT) and non-tenure-track (NT) surgeons and compared the productivity within these groups by rank: assistant professor (ASST), associate professor (ASSOC), and full professor (FULL). Kruskal-Wallis and Mann-Whitney U tests were used to assess significance and relationships between the groups.

RESULTS

A TT faculty was promoted if they produced more research, with the highest publication rates in TT FULL. TT faculty publishing rates increased from ASST to ASSOC (1 versus 2, P = 0.006) and from ASSOC to FULL (2 versus 4, P < 0.001). There were no differences in the low publication rates among NT ranks. Grant funding was also highest at the TT FULL level. The clinical production (RVUs) was highest between TT ASSOC and NT FULL. TT faculty increased productivity between ASST and ASSOC (7023 versus 8384, P = 0.001) and decreased between ASSOC and FULL (8384 versus 6877, P < 0.001). Among NT faculty, RVUs were stagnant between ASST and ASSOC levels (4877 versus 6313, P = 0.312) and increased between ASSOC and FULL levels (6313 versus 8975, P < 0.001).

CONCLUSIONS

Tenure and nontenure pathways appear to appropriately incentivize surgical faculty over the course of their advancement. TT FULL has the highest research production and grant funding, whereas NT FULL has the highest clinical production.

Monitoring of Physiological Changes of Uric Acid Concentration in the Blood of Snakes

The evaluation of uric acid concentrations in the blood of snakes is a crucial tool in the diagnosis of gout and renal disease; both prevalent diseases in captive reptiles. However, without an understanding of the physiological fluctuations in uric acid levels and the absence of distinction that makes pathological changes, biochemical parameters are devalued. This study focuses on investigating the relationship between feeding rate and plasma-uric acid concentrations of snakes. The aim of this investigation is to facilitate a better understanding of the feed-induced changes that occur, and to render the analysis of this biochemical parameter as a more potent diagnostic tool. A total of 10 snakes were used in the study and the basal concentration of uric acid was established prior to feeding via blood biochemical analysis. The snakes were then fed rats and successive postprandial blood samples were taken for the monitoring of uric acid levels. The results demonstrated that feeding led to substantial elevations in the uric acid values, whereby postprandial concentrations were significantly elevated for up to 5 days after feeding. The postprandial elevations in uric acid documented in these snakes were of similar levels reported in snakes afflicted with gout or renal disease. The results demonstrated the significant changes that occur to uric acid levels after feeding, and highlights the resemblance between postprandial increases in uric acid and concentrations reported in snakes suffering from renal disease or gout. To avoid a misdiagnosis and to distinguish transient postprandial hyperuricemia from pathological elevations, collecting sufficient anamnestic data on time since last feeding in performing repeated sampling after one week period of fasting is suggested.

Development and pre-testing of a rehabilitation planning consultation for head-and-neck cancer

BACKGROUND

In contrast with other major chronic conditions such as heart disease and stroke, cancer care does not routinely integrate evidence-based rehabilitation services within the standard continuum. The objectives of the present project were to develop a rehabilitation planning consultation (rpc) for survivors of head-and-neck (hn) cancer, to test its feasibility, and to make refinements.

METHODS

Using intervention mapping, the rpc-alpha was developed by examining potential theoretical methods and practical applications relative to the program objectives. During feasibility testing, a single case series was conducted with survivors of hn cancer who had completed their cancer treatment within the preceding 11 months; iterative refinements were made after each case.

RESULTS

The rpc-alpha was led by a rehabilitation professional and was based on self-management principles. The initial consultation included instruction in a global cognitive strategy, goal-setting, introduction to available resources, action planning, and coping planning. A follow-up consultation was conducted a few weeks later. Of 9 participants recruited, 5 completed post-intervention assessments. Participants reported that the rpc helped them to make rehabilitation plans.

CONCLUSIONS

The rpc was feasible to use and satisfactory to a small group of hn cancer survivors. A pilot test of the refined version is in process.

Mechanisms and Treatment of Halogen Inhalation-Induced Pulmonary and Systemic Injuries in Pregnant Mice

Inhalation of oxidant gases has been implicated in adverse outcomes in pregnancy, but animal models to address mechanisms and studies to identify potential pregnancy-specific therapies are lacking. Herein, we show that inhalation of bromine at 600 parts per million for 30 minutes by pregnant mice on the 15th day of embryonic development results in significantly lower survival after 96 hours than an identical level of exposure in nonpregnant mice. On the 19th embryonic day, bromine-exposed pregnant mice have increased systemic blood pressure, abnormal placental development, severe fetal growth restriction, systemic inflammation, increased levels of circulating antiangiogenic short fms-like tyrosine kinase-1, and evidence of pulmonary and cardiac injury. Treatment with tadalafil, an inhibitor of type 5 phosphodiesterase, by oral gavage 1 hour post-exposure and then once daily thereafter, attenuated systemic blood pressures, decreased inflammation, ameliorated pulmonary and cardiac injury, and improved maternal survival (from 36% to 80%) and fetal growth. These pathological changes resemble those seen in preeclampsia. Nonpregnant mice did not exhibit any of these pathological changes and were not affected by tadalafil. These findings suggest that pregnant women exposed to bromine may require particular attention and monitoring for signs of preeclampsia-like symptoms.

Role of apoptosis and autophagy in tuberculosis

Tuberculosis (TB) is one of the oldest known human diseases and is transmitted by the bacteria Mycobacterium tuberculosis (Mtb). TB has a rich history with evidence of TB infections dating back to 5,800 bc TB is unique in its ability to remain latent in an individual for decades, with the possibility of later reactivation, causing widespread systemic symptoms. Currently, it is estimated that more than one-third of the world's population (~2 billion people) are infected with Mtb. Prolonged periods of therapy and complexity of treatment regimens, especially in active infection, have led to poor compliance in patients being treated for TB. Therefore, it is vitally important to have a thorough knowledge of the pathophysiology of Mtb to understand the disease progression, as well as to develop novel diagnostic tests and treatments. Alveolar macrophages represent both the primary host cell and the first line of defense against the Mtb infection. Apoptosis and autophagy of macrophages play a vital role in the pathogenesis and also in the host defense against Mtb. This review will outline the role of these two cellular processes in defense against Mtb with particular emphasis on innate immunity and explore developing therapies aimed at altering host responses to the disease.