Perioperative management of the vulnerable and failing right ventricle

Under recognition combined with suboptimal management of right ventricular (RV) dysfunction and failure is associated with significant perioperative morbidity and mortality. The contemporary perioperative team must be prepared with an approach for early recognition and prompt treatment. In this review, a consensus-proposed scoring system is described to provide a pragmatic approach for expeditious decision-making for these complex patients with a vulnerable RV. Importantly, this proposed scoring system incorporates the context of the planned surgical intervention. Further, as the operating room (OR) represents a unique environment where patients are susceptible to numerous insults, a practical approach to anesthetic management and monitoring both in the OR and in the intensive care unit is detailed. Lastly, an escalating approach to the management of RV failure and options for mechanical circulatory support is provided.

Clinicopathological Profile and Survival Outcomes in Patients with Localised Extremity Synovial Sarcomas

AIMS

Synovial sarcoma is a rare but aggressive variant of soft-tissue sarcoma. Literature is sparse and reported mostly from the West. We analysed the clinical profiles and prognostic factors of extremity synovial sarcoma patients in order to study their clinical journey.

MATERIALS AND METHODS

This was a retrospective analysis. All patients with extremity synovial sarcoma treated between 1992 and 2020 were included. Patients with metastases at presentation were excluded. A descriptive analysis of demographic and clinicopathological features of patients undergoing limb salvage surgery (LSS) or amputation was carried out. Overall survival and disease-free survival were calculated for the entire cohort as well as for the LSS and amputation groups. Factors prognostic for survival were identified.

RESULTS

In total, 157 patients had localised extremity synovial sarcoma. Predominantly, young adults (median 31 years) and males (61%) were affected. Over 70% of patients presented after recurrence or unplanned surgeries. Sixty-seven per cent of tumours were >5 cm, 69% were deep and 23% involved bone. The limb salvage rate was 64%. In the LSS group, adjuvant radiotherapy and chemotherapy were given to 72% and 68% of patients, respectively. In the amputation group, 72% of patients received adjuvant chemotherapy. In a median follow-up of 59 months, 39.4% of patients had recurrences, the majority (61.2%) were systemic. Five-year overall survival and disease-free survival were 53.4% and 49.8%, respectively. Overall survival was 63.9% and 29.7% in the LSS and amputation groups, respectively. On multivariate analysis, tumour size, depth, omission of radiotherapy and bone invasion were found to be the adverse prognostic factors.

CONCLUSION

This is one of the largest studies on extremity synovial sarcoma. Mostly males and young adults were affected. The limb salvage rate was 64%, despite most being referred after unplanned surgery. Almost 70% of patients received radiotherapy and chemotherapy. Overall survival was inferior in the amputation group. Tumour size >5 cm, depth and bone invasion were negative, whereas adjuvant radiotherapy was a positive prognostic factor for survival. Chemotherapy had no impact on survival.

Dissection of QTLs conferring drought tolerance in B. carinata derived B. juncea introgression lines

BACKGROUND

Drought is one of the important abiotic stresses that can significantly reduce crop yields. In India, about 24% of Brassica juncea (Indian mustard) cultivation is taken up under rainfed conditions, leading to low yields due to moisture deficit stress. Hence, there is an urgent need to improve the productivity of mustard under drought conditions. In the present study, a set of 87 B. carinata-derived B. juncea introgression lines (ILs) was developed with the goal of creating drought-tolerant genotypes.

METHOD

The experiment followed the augmented randomized complete block design with four blocks and three checks. ILs were evaluated for seed yield and its contributing traits under both rainfed and irrigated conditions in three different environments created by manipulating locations and years. To identify novel genes and alleles imparting drought tolerance, Quantitative Trait Loci (QTL) analysis was carried out. Genotyping-by-Sequencing (GBS) approach was used to construct the linkage map.

RESULTS

The linkage map consisted of 5,165 SNP markers distributed across 18 chromosomes and spanning a distance of 1,671.87 cM. On average, there was a 3.09 cM gap between adjoining markers. A total of 29 additive QTLs were identified for drought tolerance; among these, 17 (58.6% of total QTLs detected) were contributed by B. carinata (BC 4), suggesting a greater contribution of B. carinata towards improving drought tolerance in the ILs. Out of 17 QTLs, 11 (64.7%) were located on the B genome, indicating more introgression segments on the B genome of B. juncea. Eight QTL hotspots, containing two or more QTLs, governing seed yield contributing traits, water use efficiency, and drought tolerance under moisture deficit stress conditions were identified. Seventeen candidate genes related to biotic and abiotic stresses, viz., SOS2, SOS2 like, NPR1, FAE1-KCS, HOT5, DNAJA1, NIA1, BRI1, RF21, ycf2, WRKY33, PAL, SAMS2, orf147, MAPK3, WRR1 and SUS, were reported in the genomic regions of identified QTLs.

CONCLUSIONS

The significance of B. carinata in improving drought tolerance and WUE by introducing genomic segments in Indian mustard is well demonstrated. The findings also provide valuable insights into the genetic basis of drought tolerance in mustard and pave the way for the development of drought-tolerant varieties.

Bacterial production of recombinant contraceptive vaccine antigen from CatSper displayed on a human papilloma virus-like particle

CatSper is a voltage dependent calcium ion channel present in the principal piece of sperm tail. It plays a crucial role in sperm hyperactivated motility and so in fertilization. Extracellular loops of mouse sperm CatSper were used to develop a vaccine to achieve protection from pregnancy. These loops were inserted at one of the three hypervariable regions of Human Papilloma Virus (HPV) capsid protein (L1). Recombinant vaccines were expressed in E.coli as inclusion body (IB), purified, refolded and assembled into virus-like particles (VLP) in vitro, and adsorbed on alum. Four vaccine candidates were tested in Balb/C mice. All the constructs proved immunogenic, one showed contraceptive efficacy. This recombinant contraceptive vaccine is a non-hormonal intervention and is expected to give long-acting protection from undesired pregnancies.

CT coronary angiography as an alternative imaging method to ascertain cardiac output and its correlation with echocardiography

AIM

To assess the feasibility and accuracy of cardiac output (CO) obtained using a test bolus in patients scanned with single-source prospective-gated cardiac computed tomography (CT), and comparing it with CO obtained from unenhanced two-dimensional (2D) echocardiography using biplane Simpson's method.

MATERIALS AND METHODS

In the present study, 100 patients with a mean age of 55 ± 12 years who underwent coronary CT angiography with prospective electrocardiogram (ECG)-gated CT in which the scan delay was evaluated using a test bolus. The time-attenuation curves obtained from the test bolus were used to calculate the CO of the patients. The CO obtained was then compared with that obtained after follow-up 2D echocardiography using biplane modified Simpson method.

RESULTS

Linear regression was calculated between the CO and contrast enhancement: CO = -0.16(HUmax) + 7.65. The study showed good correlation between the two methods with r=0.77, p<0.001. On Bland-Altman analysis, no significant difference was noted between the two methods.

CONCLUSION

This less researched method for CO estimation appears feasible; however, the clinical usefulness of this parameter is uncertain in absence of further clinical and reference standard validation.

UNVEILING THE COMPLEX ROLE OF NF-ΚB IN ALZHEIMER'S DISEASE: INSIGHTS INTO BRAIN INFLAMMATION AND POTENTIAL THERAPEUTIC TARGETS

Alzheimer's disease (AD) is a progressive neurodegenerative disorder characterized by cognitive decline and dementia. One of the major pathologies underlying AD is chronic neuroinflammation mediated by microglia and astrocytes in the brain. The nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) signalling pathway is a key regulator of inflammation and has been implicated in the neuroinflammatory processes associated with AD. This review comprehensively summarizes current findings on the complex role of NF-κB signalling in AD pathogenesis. The canonical and non-canonical NF-κB activation pathways are described, along with evidence from human studies and animal models demonstrating increased NF-κB activity in AD brains. The deleterious effects of NF-κB-mediated neuroinflammation are discussed, including the upregulation of inflammatory cytokines, chemokines, and enzymes that exacerbate neuronal damage over time. Targeting the NF-κB pathway is proposed as a promising therapeutic approach to dampen neuroinflammation in AD. Preclinical studies utilizing genetic or pharmacological inhibition of NF-κB are reviewed, and key challenges in translating these findings to clinical applications are analyzed. Overall, this review unveils the multifaceted contributions of NF-κB signalling to AD neuropathology and highlights anti-neuroinflammatory NF-κB modulation as a potential avenue for future AD treatments. Further research is warranted to fully elucidate the complex interactions between NF-κB and AD pathogenesis.

Post-COVID-19 vaccine uveitis: A case series

OBJECTIVE

With the recent emergence and worldwide distribution of COVID-19 vaccines, many side effects may be underreported and possibly unknown. Cases of vaccine-associated uveitis have been linked to almost all vaccines administered in the past; however, there is scarcity of literature providing insight into post-COVID-19 vaccine-associated uveitis. This case series documents patients presenting with uveitis after administration of the Pfizer and Moderna mRNA vaccines, in hope of advancing our current understanding of potential ocular complications of COVID-19 vaccines.

METHODS

Patients with ocular symptoms consistent with uveitis within 14 days after administration of the Pfizer or Moderna COVID-19 vaccines were included in this case series.

RESULTS

Eight patients with a mean age of 44.4 years (range, 19-83) were included. Six patients received a Pfizer, and 2 received a Moderna vaccine. Four patients presented after their first dose, 3 after their second dose, and 1 after both doses. The mean onset of ocular symptoms after the vaccine was 5.19 days (range, 1-14), and the mean BCVA was 0.678. Patients were diagnosed with bilateral anterior granulomatous uveitis (case 1), unilateral non-granulomatous anterior uveitis (case 2, 5-8), and bilateral non-granulomatous anterior uveitis (case 3-4).

CONCLUSIONS

The pathogenesis of vaccine-induced uveitis is not properly understood; however, the outcomes of this case series will aid in establishing a temporal association between the Pfizer and Moderna COVID-19 vaccines and the onset of uveitis. As the rate of COVID-19 vaccinations increases globally, it is imperative for physicians to be aware of the possible association and presentation of these ocular findings and diagnoses in order to treat patients effectively.

Evolution of neural network to deep learning in prediction of air, water pollution and its Indian context

The scenario of developed and developing countries nowadays is disturbed due to modern living style which affects environment, wildlife and natural habitat. Environmental quality has become or is a subject of major concern as it is responsible for health hazard of mankind and animals. Measurements and prediction of hazardous parameters in different fields of environment is a recent research topic for safety and betterment of people as well as nature. Pollution in nature is an after-effect of civilization. To combat the damage already happened, some processes should be evolved for measurement and prediction of pollution in various fields. Researchers of all over the world are active to find out ways of predicting such hazard. In this paper, application of neural network and deep learning algorithms is chosen for air pollution and water pollution cases. The purpose of this review is to reveal how family of neural network algorithms has applied on these two pollution parameters. In this paper, importance is given on algorithm, and datasets used for air and water pollution as well as the predicted parameters have also been noted for ease of future development. One major concern of this paper is Indian context of air and water pollution research, and the research potential presents in this area using Indian dataset. Another aspect for including both air and water pollutions in one review paper is to generate an idea of artificial neural network and deep learning techniques which can be cross applicable for future purpose.

Prevalence and Predictors of Depression, Anxiety and Stress among Elderly during COVID-19: A Cross-sectional Study from Central India

During the COVID-19 pandemic, elderly people have been more prone to depression, anxiety and stress. During these trying times, they require more attention and support for their mental health. This cross-sectional study was performed with the duration of 06 months from March 2021 to August 2021 in AIIMS, Bhopal in the state of Madhya Pradesh, in central India. And the participants recruited by systematic random sampling from a population aged more than 60 years, those who were able to read and write Hindi or English and having at least one family member; who reported to AIIMS, Bhopal during the second wave of COVID-19 in India. Those who were confirmed COVID-19 cases and undergoing treatment for the same, with diagnosed mental health disorders and who didn't give consent were excluded. A Google form based online semi-structured questionnaire along with DASS-21 scale was completed by participants. Elderly (>=60 years) will be selected. Of the 690 participants 7.25% reported mild to moderate depression, whereas 0.58 percent had severe or extremely severe depression. Mild to moderate anxiety were found in 9.56% of people, while 2.46% had severe or extremely severe anxiety. Mildly or moderately were stressed 4.78%, while 0.42% was severely or extremely anxious. Alcoholism and depression were found to have a statistically significant relationship (p=0.028). During the COVID-19 pandemic, elderly subjects who napped during the day were substantially less depressed (p=0.033). The older the respondents were, the more nervous they were during the pandemic (p=0.042). There is a link between alcohol consumption and stress (p=0.043) and it was seen that females were more stressed as compared to males (p=0.045). There was a strong correlation between participants' alcohol addiction and depressive symptoms. Psychological therapies for the elderly are thought to be necessary to enhance their psychological resilience and mental health. We need to tackle the stigma related to the COVID-19 and mental health issues.

Effect of endogenous hormones, antisperm antibody and oxidative stress on semen quality of crossbred bulls

The present study was designed to evaluate the effect of factors like hormones, antisperm antibody (ASA), and oxidative stress and its relation with semen quality in crossbred bulls. Ejaculates from two bulls were categorized into good (n = 12) and poor (n = 12) based on initial progressive motility, that is, ≥70% and ≤50%, respectively. The level of hormones like Testosterone (p < 0.05) and PGE₂ (p < 0.01) was significantly higher in good-quality ejaculates compared to poor-quality ejaculates; however, estradiol (p < 0.05), progesterone, oxidative stress, and ASAs were significantly higher (p < 0.01) in poor-quality ejaculates compared to good-quality ejaculates. Therefore, it could be concluded that oxidative stress and hormonal imbalance might have resulted in high number of dead and defective spermatozoa which was ultimately responsible for poor quality semen ejaculates.

An audit to review high risk asthma patients with over-use of short-acting beta-agonist inhalers

Introduction

The UK National Review of Asthma deaths (NRAD)1 has shown that the over-prescribing of Short Acting Beta Agonist’s (SABA) inhalers is a risk factor for exacerbation and death in asthmatic patients. A quality improvement audit was identified as a priority to review practice performance in line with national guidelines.2,3

Aim

The aim was to identify patients on the asthma register who were prescribed 12 or more SABA inhalers within the preceding 12 months and investigate any reasons for overuse. Additionally, patients were highlighted for review to optimise management in line with national recommendations2,3.

Methods

A search run in a GP practice highlighted high-risk patients on the asthma register prescribed 12 or more SABAs in the preceding 12 months. Audit criteria were defined to assess if 100% of patients had a completed annual asthma review. Patients who were not asthmatics or undergoing investigations for a potential diagnosis of chronic obstructive pulmonary disease (COPD) were excluded. Phase 1 of the audit was notes-based data-collection on recent asthma reviews and reasons for potential overuse. In Phase 2, patients were contacted prioritising those overdue a review. During contact, the Asthma Control Test, checking inhaler technique, discussing any reasons for SABA over-use and patient education on their inhalers were all discussed. Patients requiring treatment optimisation or a follow-up review were highlighted for referral to various members of the multidisciplinary team. This audit did not require ethical approval.

Results

42 out of 988 patients with asthma were identified as being issued more than 12 SABA’s in the preceding 12 months. 1 patient was excluded due to having a diagnosis of COPD. Out of the remaining 41 patients, 16 patients had already had an up to date annual asthma review prior to the search. 13 patients were contacted and referred to the pharmacist or asthma nurse for a review. As a result of the audit, a total of 29 patients had an asthma review conducted. 12 patients were unable to be contacted and follow-up remains outstanding. A number of themes were highlighted during the audit such as patients using the incorrect dose or inhaler, lack of understanding on how the inhaler worked, requests for spare inhalers, absence/lack of using an inhaled corticosteroid (ICS) and worsening asthma.

Discussion/Conclusion

The audit successfully identified reasons for SABA overuse and using the multidisciplinary team to educate patients and optimise medication where needed. Following this audit, the practice has reviewed cohorts of patients that are at high risk of exacerbations and implemented quarterly safety searches to highlight these for review on a regular basis. Two further audits were also identified to improve practice in line with updated national guidance; patients prescribed a SABA alone without an ICS and patients prescribed a Long-acting beta-agonist (LABA) alone without an ICS.

References

1. Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report.2014. [cited 2022 Jul 15] Available from: http://www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-full-report.pdf .

2. National Institute for Health and Care Excellence. Asthma: diagnosis, monitoring and chronic asthma management [internet]. [London] NICE; 2017 [updated 2021 Nov; cited 2022 Jul 15]. NICE Guideline 80 [NG80] Available from: https://www.nice.org.uk/guidance/ng80/chapter/Recommendations-for-research

3. British Thoracic Society, Scottish Intercollegiate Guideline Network. SIGN 158 - The British Guideline on the Management of Asthma. 2019. [Internet]. [London] [cited 2022 July 15]. Available from: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma.

The impact of chronic obstructive pulmonary disease on right ventricular dysfunction and remodeling after aortic valve replacement

Background

Chronic obstructive pulmonary disease (COPD) is one of the most common comorbidities in patients with aortic stenosis (AS) and has been associated with a poor prognosis after both transcatheter and surgical aortic valve replacement (AVR). Since COPD is associated with an increase in right ventricular (RV) afterload, some studies already suggested that COPD causes RV dysfunction (RVD) and dilatation. On the other hand, RVD and remodeling can also occur due to chronic pressure overload secondary to the AS itself. However, there is no data that studied RVD and remodeling in AVR recipients in terms of COPD severity.

Purpose

We aimed to evaluate the impact of COPD on RVD and remodeling in patients with severe AS undergoing AVR before AVR and at 1-year follow-up, as well as the association between COPD severity and all-cause mortality.

Methods

Patients with severe AS who received either transcatheter or surgical AVR were included. Patients' demographic data, medical history and documented spirometry data were carefully collected, while two-dimensional and speckle tracking echocardiography measurements were performed according to recommended guidelines to evaluate RV systolic function and RV size. RVD was defined as tricuspid annular plane systolic excursion (TAPSE) ≤17mm. RV dilatation was defined by RV mid cavity &gt;35 mm, RV basal diameter &gt;42mm, and RV longitudinal diameter &gt;83mm. RV wall thickness above 5mm was considered as RV hypertrophy. Diagnosis of COPD was determined by the Society of Thoracic Surgeons' definition based on forced expiratory volume in first second (FEV 1&lt;75%, cut-off for COPD). The primary outcome was all-cause death at 1-year.

Results

A total of 293 patients (78.0 years, 58.4% male) were included. RVD was detected in 54 (18.4%) patients, while 55 (18.8%) patients had mild COPD and 43 (14.7%) patients had moderate or severe COPD. At 1-year follow-up, the prevalence of RVD significantly increased (18.4% versus 23.6%, p=0.004). Compared to baseline, RV free wall strain of lateral basal segment (p=0.046), TAPSE (p&lt;0.0001) and tricuspid regurgitation gradient (p=0.018) impaired whereas RV wall thickness (p=0.014), RV diameter index of lateral basal segment (p&lt;0.0001), and RV diameter index of lateral mid segment (p&lt;0.0001) increased, respectively. At 1-year follow-up, 33 patients died (Figure 1). On multivariate cox regression analysis, RVD (hazard ratio (HR) 2.781, 95% confidence interval (CI) 1.172–6.598; p=0.020) as well as mild (HR 4.695, 95% CI 1.787–12.336; p=0.002) and moderate-severe COPD (HR 4.725, 95% CI 1.717–13.006; p=0.003) were significantly associated with the endpoint (Table 1).

Conclusions

The prevalence of RVD significantly increased and it deteriorated at 1-year after AVR. RV remodeling observed more at lateral basal and mid segments of RV as well as wall thickness. RV dysfunction and COPD were the strongest predictors of mortality in this population.

Funding Acknowledgement

Type of funding sources: None.

Association between chronic obstructive pulmonary disease and all-cause mortality after aortic valve replacement for aortic stenosis

Introduction

Chronic obstructive pulmonary disease (COPD) and aortic stenosis (AS) are the most common diseases in aging population that their prevalence and percental change in mortality increase over the years. In severe AS, aortic valve replacement (AVR) is the only treatment that has demonstrated to improve survival, however the presence of comorbidities increases the operative risk and influences negatively on the outcomes after AVR. Therefore, the definition of COPD varies across the studies and is not always based on the use of pulmonary functional tests. Accordingly, the aim of the present study is to evaluate the association between pulmonary functional parameters and all-cause mortality after AVR in a large cohort of patients with severe AS.

Methods

Total of 400 patients (78.0 year-old, 56.7% men) with severe AS and documented preoperative pulmonary functional test (PFT) were retrospectively analyzed. Demographic and clinical characteristics were collected from electronic medical records while echocardiography was performed and measured according to the recommendations. PFTs were performed prior to AVR and categories defined in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database: normal pulmonary function was defined by an FEV1 &gt;75% of predicted; mild COPD if FEV1 was 60–75% of predicted; moderate COPD if FEV1 was 50–59% of predicted and severe COPD when FEV1 &lt;50% of predicted.

Results

Mild, moderate and severe COPD were documented in 75 (19%), 31 (8%) and 22 (5%) while the remaining 68% had normal PFTs. Patients with moderate and severe COPD had significantly larger LV mass and LV end-systolic volume whereas LV ejection fraction was significantly lower. The FVC, FEV1, Tiffeneau index, VC, PEF, and IC were the worst among patients with moderate and severe COPD (per definition) (p&lt;0.0001). Over a median follow-up of 32 months, 92 (23%) patients died. The survival rates were significantly lower in patients with moderate and severe COPD (Log rank p=0.003, Figure 1). In multivariable Cox regression analysis, some clinical factors and COPD were independently associated with all-cause mortality (table 1). Remarkably, any grade of COPD was associated with 2-fold increased risk of all cause-mortality (HR 1.933; 95% CI 1.166–3.204; p=0.011 for mild COPD and HR 2.028; 95% CI 1.154–3.564; p=0.014 for moderate/ severe COPD, separately).

Conclusion

Patients with moderate and severe COPD had higher LV hypertrophy and reduced LV ejection fraction while PFT parameters were the worst among these patients. The survival rates were significantly lower in patients with moderate and severe COPD compared with patients without COPD. In addition to other clinical factors, any grade of COPD was associated with 2-fold increased risk of all cause-mortality.

Funding Acknowledgement

Type of funding sources: None.

Molecular characterization and genetic diversity analysis in Indian mustard (Brassica juncea L. Czern & Coss.) varieties using SSR markers

In this study, we evaluated genetic diversity in a panel of 87 Indian mustard varieties using 200 genomic-SSR markers. A total of 189 SSRs resulted into positive amplification with 174 (92.06%) SSRs generating polymorphic products and 15 (7.94%) SSRs producing monomorphic amplicons. A total of 552 alleles were obtained and allele number varied from 2–6 with an average number of 3.17 alleles per SSR marker. The major allele frequency ranged from 0.29 (ENA23) to 0.92 (BrgMS841) with an average value of 0.58 per SSR locus. The polymorphic information content (PIC) value ranged from 0.10 (BrgMS841) to 0.68 (BrgMS519) with 0.39 as mean PIC value. The gene diversity per locus ranged from 0.13 (BrgMS841) to 0.72 (ENA23 & BrgMS519) with a mean value of 0.48 per SSR primer pair. Both Unweighted Neighbor Joining-based dendrogram and population structure analysis divided all the 87 varieties into two major groups/subpopulations. Analysis of molecular variance (AMOVA) inferred the presence of more genetic variation (98%) among individuals than among groups (2%). A total of 31 SSRs produced 36 unique alleles for 27 varieties which will serve as unique DNA-fingerprints for the identification and legal protection of these varieties. Further, the results obtained provided a deeper insight into the genetic structure of Indian mustard varieties in India and will assist in formulating future breeding strategies aimed at Indian mustard genetic improvement.

POS1166 GOUT AND SERIOUS KIDNEY DISEASE IN THE US: A NATIONAL PERSPECTIVE

Background

There is a strong association between gout and kidney disease due to the kidney’s key role in uric acid excretion.1-4 Several studies have also demonstrated that serum uric acid is an independent risk factor for decline in renal function1,2. There are little national data available regarding the clinical burden of kidney disease in gout patients in the US.

Objectives

To estimate the percentage of US hospitalizations with a concomitant diagnosis of gout and either acute or chronic kidney disease compared with percentage of hospitalizations with kidney disease in the general population.

Methods

The Nationwide Inpatient Sample (NIS) is a stratified random sample of all US community hospitals. It is the only US national hospital database with information on all patients, regardless of payer, including persons covered by Medicare, Medicaid, private insurance, and the uninsured. Detailed information including clinical and nonclinical data elements on each hospital stay including International Classification of Diseases (ICD) 10 diagnosis, age, gender, length of stay, payer, charges, and comorbidities etc. is available.

We examined all hospitalizations with acute renal failure (ICD10 codes N170-179), chronic kidney disease stages 3-5 (ICD10 codes N183-185), N19 (unspecified kidney failure), and end-stage renal disease (ICD10 code N186) in persons with gout (ICD 10 codes M10.* and M1A.*) and compared these with hospitalizations with kidney disease in the general US population.

Results

In 2019, there were 35.4 million all-cause hospitalizations in the US. Of these, 7.9 million had a diagnosis of serious kidney disease (22.3%). There were 915,070 hospitalizations with primary or secondary diagnosis of gout in the US (mean age 70.8 years, 68.4% men and 31.6% women). Of these 533,365 hospitalizations (mean age 72.6 years, 65.9% men) also had a concomitant diagnosis of serious kidney disease (58.3%, p<0.0001 compared to general population).

Concomitant diagnosis of serious kidney disease increased with age, reaching 38.3% of all hospitalizations in 65 years and older in the general population compared to 62.5% in persons with gout (p<0.001).

Table 1.

Kidney disease-related hospitalization in the US general and gout populations.

GENERAL US HOSPITALIZATIONSUS HOSPITALIZATIONS WITH COMORBID GOUTPatient AgeOverall HospitalizationsNHospitalizations with Serious Kidney Diseasen (%)Overall HospitalizationsNHospitalizations with Serious Kidney Disease n (%)18-44 years8,356,284622,170 (7.4%)32,44513,480 (41.5%)45-64 years8,440,8312,160,220 (25.6%)232,695116,490 (50.1%)≥65 years13,421,1545,257,220 (39.2%)649,865414,620 (83.8%)Total in 201935,419,0237,907,730 (22.3%)915,070533,365 (58.3%)

Note: Total numbers include patients 0-17 years old.

Conclusion

Acute and chronic kidney disease are highly prevalent comorbid conditions in overall US hospitalizations. Among patients admitted with a diagnosis of gout, the proportion of kidney dysfunction is significantly higher affecting 58% of these hospitalizations. The high prevalence of kidney dysfunction in hospitalized gout patients in the US may represent an impactful component to the duration, complexity, and costs of hospital care.

References

[1]Jung SW, et al. Am J Physiol Renal Physiol 2020;318:F1327-40.

[2]Obermayr RP, et al. J Am Soc Nephrol 2008;19:2407-13.

[3]Roughley MJ, et al. Arthritis Res Ther 2015;17:90.

[4]Juraschek SP, et al. Semin Arthritis Rheum 2013;42:551-61.

Disclosure of Interests

Gurkirpal Singh Grant/research support from: Horizon Therapeutics (unrestricted research grant), Maanek Sehgal: None declared, Brad Marder Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Alka Mithal: None declared

Study of factors leading to poor sleep among management students

Sleep is the most important but often neglected element of an individual’s overall health and well-being. Lack of sleep or poor sleep can adversely affect health in an individual and lead to various diseases. At the same time, sleep problems are not uncommon among students. The factors leading to poor sleep among management students who have a comparatively tight schedule are still unclear. The paper aims to understand the factors leading to poor sleep among management students. The study has been focused on the management students (MBA’s) studying in the different management colleges of the state of Maharashtra. A total of 297 management students were surveyed. Apart from factor analysis, the Kessler distress scale was used for Measuring Psychological distress.52% of the respondents fell in the category of likely to have a mental disorder. Managements can draw inference from this and implement strategies to make sure this number reduces.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

Interplay between inter- and intraparticle interactions in bi-magnetic core/shell nanoparticles

The synthesis strategy and magnetic characterisation of two systems consisting of nanoparticles with core/shell morphology are presented: an assembly of hard/soft nanoparticles with cores consisting of magnetically hard cobalt ferrite covered by a magnetically soft nickel ferrite shell, and the inverse system of almost the same size and shape. We have successfully designed these nanoparticle systems by gradually varying the magnetic anisotropy resulting in this way in the modulation of the magnetic dipolar interactions between particles. Both nanoparticle systems exhibit high saturation magnetisation and display superparamagnetic behaviour at room temperature. We have shown strong exchange coupling at the core/shell interface of these nanoparticles systems which was also confirmed by mesoscopic modelling. Our results demonstrate the possibility of modulating magnetic anisotropy not only by chemical composition but also by adopting the proper nano-architecture.

COVID-19-associated mucormycosis presenting to the Emergency Department-an observational study of 70 patients

BACKGROUND

Mucormycosis (MM) is a deadly opportunistic fungal infection and a large surge in COVID-19-associated mucormycosis (CAM) is occurring in India.

AIM

Our aim was to delineate the clinico-epidemiological profile and identify risk factors of CAM patients presenting to the Emergency Department (ED).

DESIGN

This was a retrospective, single-centre, observational study.

METHODS

We included patients who presented with clinical features or diagnosed MM and who were previously treated for COVID-19 in last 3 months of presentation (recent COVID-19) or currently being treated for COVID-19 (active COVID-19). Information regarding clinical features of CAM, possible risk factors, examination findings, diagnostic workup including imaging and treatment details were collected.

RESULTS

Seventy CAM patients (median age: 44.5 years, 60% males) with active (75.7%) or recent COVID-19 (24.3%) who presented to the ED in between 6 May 2021 and 1 June 2021, were included. A median duration of 20 days (interquartile range: 13.5-25) was present between the onset of COVID-19 symptoms and the onset of CAM symptoms. Ninety-three percent patients had at least one risk factor. Most common risk factors were diabetes mellitus (70%) and steroid use for COVID-19 disease (70%). After clinical, microbiological and radiological workup, final diagnosis of rhino-orbital CAM was made in most patients (68.6%). Systemic antifungals were started in the ED and urgent surgical debridement was planned.

CONCLUSION

COVID-19 infection along with its medical management have increased patient susceptibility to MM.

Postprandial endothelial dysfunction and CIMT after oral fat challenge in patients with type 2 diabetes mellitus with and without macrovascular disease - A preliminary study

BACKGROUND

Very few studies have reported on association of postprandial lipids and endothelial dysfunction among patients with diabetes. Whether endothelial dysfunction particularly postprandial FMD is worse in patients with T2DM with macrovascular disease compared to those without and whether this difference is related to postprandial hypertriglyceridemia (PPHTg) is unclear. Therefore, present study was aimed to assess the relationship between PPHTg and endothelial function in patients with T2DM with and without macrovascular disease.

METHOD

Endothelial dysfunction by FMD and CIMT were compared in patients with T2DM with and without macrovascular disease (n = 13 each group) and 13 age, sex and BMI matched healthy individuals after an oral fat challenge.

RESULTS

There was significant postprandial deterioration of FMD 4-hr after fat challenge in patients with diabetes (P < 0.001) as well as healthy individuals (P = 0.004). Patients with diabetes with macrovascular disease had significantly lower fasting (5.7 ± 6.1% vs. 22.7 ± 10.0% and vs. 24.7 ± 5.3%) as well as postprandial (4-hr) (3.1 ± 5.0% vs. 15.3 ± 8.1% and vs. 15.4 ± 5.7%) FMD compared to other two groups. Fasting, postprandial as well as change in FMD and CIMT in patients with diabetes correlated significantly with fasting as well as postprandial triglycerides with stronger correlation in those with macrovascular disease.

CONCLUSION

Study found significant endothelial dysfunction by FMD that shows substantial further deterioration postprandially following high fat meal in patients with diabetes with macrovascular disease compared to patients with diabetes without macrovascular disease and healthy individuals. Study also indicates that PPHTg is a contributor to endothelial dysfunction. However, more studies are required to corroborate these findings.

Echocardiographic global longitudinal strain as a marker of myocardial fibrosis predicts outcomes in aortic stenosis

Background

Left ventricular global longitudinal strain (LV-GLS) by speckle tracking echocardiography (STE) reflects intrinsic myocardial function, influenced by interstitial abnormalities. Cardiovascular magnetic resonance (CMR) detects myocardial fibrosis non-invasively, but it is limited for widespread use. We aim to establish LV-GLS as a marker of replacement myocardial fibrosis on CMR and validate the prognostic value of LV-GLS thresholds associated with fibrosis.

Methods

LV-GLS thresholds of replacement fibrosis were established in the derivation cohort: 151 patients (57±10 years; 58% males) with hypertension who underwent STE to measure LV-GLS and CMR for replacement myocardial fibrosis. Prognostic value of the thresholds was validated in a separate outcome cohort: 261 patients with moderate-severe aortic stenosis (AS; 71±12 years; 58% males; NYHA functional class I-II) and preserved LVEF ≥50%. Primary outcome was a composite of cardiovascular mortality, heart failure hospitalization, myocardial infarction and cerebrovascular events.

Results

In the derivation cohort, LV-GLS demonstrated good discrimination (c-statistics 0.74; 95% confidence interval: 0.66–0.83; P&lt;0.001) and calibration (Hosmer-Lemeshow X2=6.37; P=0.605) for replacement fibrosis. In the outcome cohort, 52 events occurred over 16 [3.1, 42.0] months of follow-up. Patients with LV-GLS &gt;−15.0% (corresponding to 95% specificity to rule-in myocardial fibrosis) had the worst outcomes compared to patients with LV-GLS &lt;−21.0% (corresponding to 95% sensitivity to rule-out myocardial fibrosis) and those between −21.0 and −15.0% (log-rank P&lt;0.001; Figure 1). Furthermore, LV-GLS offered independent prognostic value over clinical variables, AS severity, echocardiographic LVEF and E/e' (hazard ratio 1.18; 95% confidence interval: 1.07 to 1.30; P=0.001).

Conclusions

LV-GLS thresholds associated with replacement myocardial fibrosis is a novel approach to risk-stratify patients with AS and preserved LVEF (Figure 2).

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council Figure 1Figure 2

Monitoring SARS-CoV-2 decontamination by dry heat and ultraviolet treatment with a swine coronavirus as a surrogate

The critical need for reliable methods to validate decontamination protocols for personal protective equipment (PPE) for re-use during the SARS-CoV-2 pandemic is limited by the need for specialized containment facilities to handle the virus. Hence, we have herein validated the use of a swine coronavirus as a surrogate, and tested the effectiveness of dry heat and ultraviolet (UV) rays for PPE decontamination. Exposure of experimentally contaminated N95 masks and hospital gowns to 60°C for 20 min, and UVC at 1800 mJ/cm² resulted in a 4-log reduction and inactivation of the surrogate virus. This study provides a novel alternative to validate PPE reprocessing methods.

Utility of silent magnetic resonance angiography in the evaluation and characterisation of intracranial dural arteriovenous fistula

AIM

To evaluate the utility of silent magnetic resonance angiography (MRA) in the diagnosis, characterisation, and therapeutic planning of intracranial dural arteriovenous fistula (DAVF).

MATERIALS AND METHODS

Twenty consecutive patients with DAVF were enrolled prospectively and were evaluated using silent MRA and digital subtraction angiography (DSA) as a part of routine work-up. The diagnosis and location of fistula, Borden and Cognard classification, entire arterial feeders, and venous drainage were analysed. A therapeutic strategy was formulated, and the accessible route and vessel were predicted, which was confirmed on endovascular treatment.

RESULTS

Silent MRA was 100% sensitive and accurate for location and classification of fistulas. Silent MRA showed a sensitivity of 82% and 76.5% for entire arterial feeders and draining veins, which improved to a sensitivity of 90% and 94% when prominent feeders and immediate venous drainage was considered. Among the missed veins, thrombosed sinus, slow sinus flow, small calibre, reduced image quality were the causes. The therapeutic decision matched with DSA in all cases and silent MRA accurately identified the potential accessible feeder in 94% cases.

CONCLUSION

Silent MRA is a promising MR technique that can provide both diagnostic and therapeutic information similar to that obtained from DSA.

Severe dissecting scalp cellulitis successfully treated with serial excisions in combination with anti-TNF therapy

The management of dissecting scalp cellulitis involves medical treatment with oral antibiotics and isotretinoin, as well as surgical input in more severe cases. In extensive disease, a full scalpectomy with reconstruction can be required. We report a case of severe dissecting scalp cellulitis in a 34-year-old man who underwent serial scalp excisions over three years, with wounds being left to heal by secondary intention. Initially, the excisions helped to control symptoms but, once the patient was on concurrent anti-TNF therapy, further excisions were successful in reducing disease load and inducing remission. He remained disease free at the 20 months follow-up. This case is the first of its kind to be described in the literature and it highlights how a conservative, staged surgical approach, in combination with anti-TNF therapy, can be effective in the management of severe dissecting scalp cellulitis. In doing so, it offers an alternative to full scalpectomy with reconstruction.

POS1143 GOUT AND JOINT REPLACEMENTS IN THE US

Background:

Irreversible joint damage in gout has been linked to a possible increase in knee and hip joint replacements1. In addition, the strong association between gout and osteoarthritis2,3 could also lead to an increased risk of joint replacements in patients with gout. Population-based data from the UK and Taiwan have shown hazard rates of 1.14 and 1.16 respectively for knee replacements in patients with gout compared to age and gender matched controls1. However, there is little national data in the US on clinical and economic burden of joint replacements in patients with gout.

Objectives:

To evaluate total or partial hip and knee joint replacements in patients with gout in the US and to estimate their economic impact

Methods:

The Nationwide Inpatient Sample (NIS) is a stratified random sample of all US community hospitals. It is the only US national hospital database with information on all patients, regardless of payer, including persons covered by Medicare, Medicaid, private insurance, and the uninsured. Detailed information including clinical and nonclinical data elements on each hospital stay including International Classification of Diseases (ICD)10 diagnosis and procedure codes, age, gender, length of stay, payer, charges, comorbidities etc. is available. We examined hospitalizations in patients with gout with hip and knee joint replacements in NIS 2018, the most recent year of data.

Results:

In 2018, there were 914,510 hospitalizations with primary or secondary diagnosis of gout in the US. Of these 43,615 were for joint replacement surgeries (knee (24,840) and hip (18,755)). Patients with knee replacement were on an average 68.5 years old (95% confidence intervals 68.2 years -68.8 years). Patients with hip replacement were slightly older (mean age 70.3 years, 95% confidence intervals 69.8 years -70.7 years). Unlike general population statistics, men formed a majority of these joint replacements (68% for the knee and 72% for the hip). The average charge per hospitalization was $69,279 and $72,944 for knee and hip replacement respectively. The total annual national cost estimate was $3.09 billion, with government insurances (Medicare and Medicaid) responsible for 67% of knee replacement and 70% of hip replacement costs.

Conclusion:

Joint replacements in gout patients have a large clinical and economic burden in the US. This calls for an increased awareness and management of associated hip and knee arthritis in patients with gout.

References:

[1]Kuo CF, Chou IJ, See LC, et al. Urate-lowering treatment and risk of total joint replacement in patients with gout. Rheumatology. Dec 1 2018;57(12):2129-2139.

[2]Howard RG, Samuels J, Gyftopoulos S, et al. Presence of gout is associated with increased prevalence and severity of knee osteoarthritis among older men: results of a pilot study. Journal of clinical rheumatology: practical reports on rheumatic & musculoskeletal diseases. Mar 2015;21(2):63-71.

[3]Roddy E, Zhang W, Doherty M. Are joints affected by gout also affected by osteoarthritis? Annals of the rheumatic diseases. Oct 2007;66(10):1374-1377.

Disclosure of Interests:

Gurkirpal Singh Shareholder of: Pfizer, Merck, Sanofi, Grant/research support from: Horizon, Maanek Sehgal: None declared, Alka Mithal: None declared.

Should fluorodeoxyglucose positron emission tomography/computed tomography be the first-line imaging investigation for restaging the laryngeal carcinoma patients?

Posttreatment detection of residual/recurrence disease in the head and neck cancers is not an easy task. Treatment induces changes create difficulties in diagnosis on conventional imaging (computed tomography [CT], magnetic resonance imaging) as well as macroscopic inspection (direct laryngoscopy). Hence, we evaluate the diagnostic performance of contract-enhanced F-18 fluorodeoxyglucose positron emission tomography (FDG PET)/CT in restaging of laryngeal carcinoma Postchemotherapy-surgery and/or radiation therapy. We retrospectively analyzed patients of carcinoma larynx (n = 100) who has completed treatment and were referred for FDG PET/CT. Two reviewers performed image analysis to determine recurrence at primary site and/lymph nodes and distant metastases. Receiver operating characteristic (ROC) was used to determine the maximum standardized uptake value (SUV_max) cut off for disease detection. Histopathological examination and clinical or imaging follow-up were taken as gold standard for recurrence. One hundred laryngeal carcinoma patients with mean age of 57.2 years (range of 40–76) were included in the present study. Among the 100 patients, 96 were male and remaining 4 were female. The average interval between completion of treatment and FDG PET/CT scan was 8.5 months (minimum 6 months). Of the 100 patients, FDG PET/CT detected FDG avid lesions in 66 patients. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of FDG PET/CT for residual/recurrence disease detection was 90.3%, 73.7%, 84.8%, 82.3%, and 84.0%, respectively (P < 0.05). In addition, in 10 patients, metachronous primaries were detected (lung-4, thyroid-2, tongue, colon, esophagus, and lymphoma-one each). On ROC curve analysis, SUVmax >6.1 had sensitivity and specificity of 80.6% and 94.7% respectively for detection of recurrent/metastatic disease. FDG PET/CT demonstrates high diagnostic accuracy for detection of residual/recurrent disease in treated laryngeal cancer patients and our findings suggest that this imaging modality should be the first-line diagnostic investigation in this cohort of patients.

On the detection of surface spin freezing in iron oxide nanoparticles and its long-term evolution under ambient oxidation

Exchange bias (EB) effects linked to surface spin freezing (SSF) are commonly found in iron oxide nanoparticles, while signatures of SSF in low-field temperature-dependent magnetization curves have been much less frequently reported. Here, we present magnetic properties of dense assemblies of similar-sized (∼8 nm diameter) particles synthesized by a magnetite (sample S1) and a maghemite (sample S2) method, and the influence of long-term (4 year) sample aging under ambient conditions on these properties. The size of the EB field of the different sample (fresh or aged) states is found to correlate with (a) whether a low-temperature hump feature signaling the SSF transition is detected in out-of-phase ac susceptibility or zero-field-cooled (ZFC) dc magnetization recorded at low field and with (b) the prominence of irreversibility between FC and ZFC curves recorded at high field. Sample S1 displays a lower magnetization than S2, and it is in S1 where the largest SSF effects are found. These effects are significantly weakened by aging but remain larger than the SSF effects in S2, where the influence of aging is considerably smaller. A non-saturating component due to spin disorder in S1 also weakens with aging, accompanied by, we infer, an increase in the superspin and the radius of the ordered nanoparticle cores. X-ray diffraction and Mössbauer spectroscopy provide indication of maghemite-like stoichiometry in both aged samples as well as thicker disordered particle shells in aged-S1 relative to aged-S2 (crystallographically-disordered and spin-disordered according to diffraction and Mössbauer, respectively). The pronounced diminution in SSF effects with aging in S1 is attributed to a (long-term) transition, caused by ambient oxidation, from magnetite-like to maghemite-like stoichiometry, and a concomitant softening of the spin-disordered shell anisotropy. We assess the impact of this anisotropy on the nature of the blocking of the nanoparticle superspins.

Serine-glycine-betaine, a novel dipeptide from an endophyte Macrophomina phaseolina: isolation, bioactivity and biosynthesis

AIMS

Endophytes are a rich source for structurally complex chemical scaffolds with interesting biological activities. Endophytes associated with Brugmansia aurea L. (family: Solanaceae), a medicinal plant, have not yet explored for the bioactive metabolites.

METHOD AND RESULTS

Hence, Macrophomina phaseolina, a fungal endophyte, was isolated from the roots of the plant. Its methanolic extract was found active against human cancer cell lines with IC₅₀ <20 µg ml^-1 . Later, a di-peptide compound, serine-glycine-betaine, was isolated and characterized. Serine-glycine-betaine consists of a unit of an N-trimethyl glycine attached to serine. It exhibited potent activity against MIA PaCa-2 and HCT-116 cell lines with IC₅₀ 8·9 and 15·16 μmol l^-1 , respectively. Furthermore, it induced apoptosis in MIA PaCa-2 cells confirmed by microscopy. The apoptotic cell death in MIA PaCa-2 cells was evidenced biochemically with the generation of intracellular reactive oxygen species level and leading to loss of mitochondrial membrane potential due to activation of the intrinsic pathway. This study describes the plausible biosynthesis of serine-glycine-betaine based on genomics (genome sequencing, annotation and genes alignment).

CONCLUSIONS

A novel di-peptide, serine-glycine-betaine isolated from M. phaseolina induced apoptosis in MIA-Pa-Ca-2 cells.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study confirms that dipeptides like serine-glycine-betaine and tyrosine-betaine might be specific to fungal genera, hence being used for diagnostic purposes.