Pulmonary hemodynamics and transplant-free survival in sarcoidosis-associated pulmonary hypertension: Results from an international registry

Pulmonary hypertension (PH) is a risk factor for mortality in patients with sarcoidosis. Severe PH in chronic lung disease has previously been defined as mean pulmonary arterial pressure (mPAP) ≥ 35 mmHg or mPAP 25 ≥ mmHg with cardiac index (CI) ≤ 2 L/min/m2. However, there is no clear definition denoting severity of sarcoidosis-associated PH (SAPH). We aimed to determine pulmonary hemodynamic cut-off values where transplant-free survival was worse among patients with SAPH. This was a retrospective cohort analysis of the Registry of SAPH database focusing on pulmonary hemodynamic predictors of transplant-free survival among patients with precapillary SAPH. Cox regression was performed to determine which pulmonary hemodynamic values predicted death or lung transplantation. Kaplan-Meier survival analysis was performed on statistically significant predictors to determine pulmonary hemodynamic cut-off values where transplant-free survival was decreased. Decreased transplant-free survival occurred among SAPH patients with mPAP ≥ 40 mmHg and SAPH patients with pulmonary vascular resistance (PVR) ≥ 5 Woods units (WU). Transplant-free survival was not decreased in patients who fulfilled prior criteria of severe PH in chronic lung disease. We identified new cut-offs with decreased transplant-free survival in the SAPH population. Neither cut-off of mPAP ≥ 40 mmHg nor PVR ≥ 5 WU has previously been shown to be associated with decreased transplant-free survival in SAPH. These values could suggest a new definition of severe SAPH. Our PVR findings are in line with the most recent European Society of Cardiology/European Respiratory Society guideline definition of severe PH in chronic lung disease.

Efzofitimod for the Treatment of Pulmonary Sarcoidosis

BACKGROUND

Pulmonary sarcoidosis is characterized by the accumulation of immune cells that form granulomas affecting the lungs. Efzofitimod (ATYR1923), a novel immunomodulator, selectively binds neuropilin 2, which is upregulated on immune cells in response to lung inflammation.

RESEARCH QUESTION

What is the tolerability, safety, and effect on outcomes of efzofitimod in pulmonary sarcoidosis?

STUDY DESIGN AND METHODS

In this randomized, double-blind, placebo-controlled study evaluating multiple ascending doses of efzofitimod administered intravenously every 4 weeks for 24 weeks, randomized patients (2:1) underwent a steroid taper to 5 mg/d by week 8 or < 5 mg/d after week 16. The primary end point was the incidence of adverse events (AEs); secondary end points included steroid reduction, change in lung function, and patient-reported outcomes on health-related quality-of-life scales.

RESULTS

Thirty-seven patients received at least one dose of study medication. Efzofitimod was well tolerated at all doses, with no new or unexpected AEs and no dose-dependent AE incidence. Average daily steroid doses through end of study were 6.8 mg, 6.5 mg, and 5.6 mg for the 1 mg/kg, 3 mg/kg, and 5 mg/kg groups compared with 7.2 mg for placebo, resulting in a baseline-adjusted relative steroid reduction of 5%, 9%, and 22%, respectively. Clinically meaningful improvements were achieved across several patient-reported outcomes, several of which reached statistical significance in the 5 mg/kg dose arm. A dose-dependent but nonsignificant trend toward improved lung function also was observed for 3 and 5 mg/kg.

INTERPRETATION

Efzofitimod was safe and well tolerated and was associated with dose-dependent improvements of several clinically relevant end points compared with placebo. The results of this study support further evaluation of efzofitimod in pulmonary sarcoidosis.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT03824392; URL: www.

CLINICALTRIALS

gov.

Beam particle identification and tagging of incompletely stripped heavy beams with HEIST

A challenge preventing successful inverse kinematics measurements with heavy nuclei that are not fully stripped is identifying and tagging the beam particles. For this purpose, the HEavy ISotope Tagger (HEIST) has been developed. HEIST utilizes two micro-channel plate timing detectors to measure the time-of-flight, a multi-sampling ion chamber to measure energy loss, and a high-purity germanium detector to identify isomer decays and calibrate the isotope identification system. HEIST has successfully identified ¹⁹⁸Pb and other nearby nuclei at energies of about 75 MeV/A. In the experiment discussed, a typical cut containing 89% of all ¹⁹⁸Pb⁸⁰⁺ in the beam had a purity of 86%. We examine the issues of charge state contamination. The observed charge state populations of these ions are presented and, using an adjusted beam energy, are well described by the charge state model GLOBAL.

First Observation of the Four-Proton Unbound Nucleus ^{18}Mg

^{18}Mg was observed, for the first time, by the invariant-mass reconstruction of ^{14}O+4p events. The ground-state decay energy and width are E_{T}=4.865(34)  MeV and Γ=115(100)  keV, respectively. The observed momentum correlations between the five particles are consistent with two sequential steps of prompt 2p decay passing through the ground state of ^{16}Ne. The invariant-mass spectrum also provides evidence for an excited state at an excitation energy of 1.84(14) MeV, which is likely the first excited 2^{+} state. As this energy exceeds that for the 2^{+} state in ^{20}Mg, this observation provides an argument for the demise of the N=8 shell closure in nuclei far from stability. However, in open systems this classical argument for shell strength is compromised by Thomas-Ehrman shifts.

Impact of intraosseous versus intravenous resuscitation during in-hospital cardiac arrest: A retrospective study

AIM

To compare outcomes between Intraosseous (IO) and peripheral intravenous (PIV) injection during in-hospital cardiac arrest (IHCA) and examine its utility in individuals with obesity.

METHODS

We performed a retrospective cohort analysis of adult, atraumatic IHCA at a single tertiary care center. Subjects were classified as either IO or PIV resuscitation. The primary outcome of interest was survival to hospital discharge. The secondary outcomes of interest were survival with favourable neurologic status, rates-of-ROSC (ROR) and time-to-ROSC (TTR). Subgroup analysis among patients with BMI ≥ 30 kg/m² was performed.

RESULTS

Complete data were available for 1852 subjects, 1039 of whom met eligibility criteria. A total of 832 were resuscitated via PIV route and 207 via IO route. Use of IO compared to PIV was associated with lower overall survival to hospital discharge (20.8% vs 28.4% p = 0.03), lower rates of survival with favourable neurologic status (18.4% vs 25.2% p = 0.04), lower ROR (72.2% vs 80.7%) and longer TTR (12:38 min vs 9:01 min). After multivariate adjustment there was no significant differences between IO and PIV in rates of survival to discharge (OR 0.71, 95% CI 0.47-1.06, p = 0.09) or rates of survival with favourable neurologic status (OR 0.74, 95% CI 0.49-1.13, p = 0.16). The ROR and TTR remained significantly worse in the IO group. Subgroup analysis of patients with BMI ≥ 30 kg/m² identified no benefit or harm with use of IO compared to PIV.

CONCLUSION

Intraosseous medication delivery is associated with inferior rates-of-ROSC and longer times-to-ROSC compared to PIV, but no differences in overall survival to hospital discharge or survival with favourable neurologic status during IHCA.

The SπRIT time projection chamber

The Superconducting Analyzer for MUlti-particles from RAdioIsotope (SAMURAI) Pion-Reconstruction and Ion-Tracker Time Projection Chamber (SπRIT TPC) was designed to enable measurements of heavy ion collisions with the SAMURAI spectrometer at the RIKEN radioactive isotope beam factory and provides constraints on the equation of state of neutron-rich nuclear matter. The SπRIT TPC has a 50.5 cm drift length and an 86.4 × 134.4 cm² pad plane with 12 096 pads that are equipped with the generic electronics for TPCs. The SπRIT TPC allows for an excellent reconstruction of particles and provides isotopic resolution for pions and other light charged particles across a wide range of energy losses and momenta. The details of the SπRIT TPC are presented, along with discussion of the TPC performance based on cosmic rays and charged particles emitted in heavy ion collisions.

Probing the Symmetry Energy with the Spectral Pion Ratio

Many neutron star properties, such as the proton fraction, reflect the symmetry energy contributions to the equation of state that dominate when neutron and proton densities differ strongly. To constrain these contributions at suprasaturation densities, we measure the spectra of charged pions produced by colliding rare isotope tin (Sn) beams with isotopically enriched Sn targets. Using ratios of the charged pion spectra measured at high transverse momenta, we deduce the slope of the symmetry energy to be 42<L<117  MeV. This value is slightly lower but consistent with the L values deduced from a recent measurement of the neutron skin thickness of ^{208}Pb.

Pulmonary actinomycosis and marijuana vaping

A 33-year-old man without significant medical history presented to the emergency department with a 6-month history of fatigue and 30 pounds of unintentional weight loss, with a recent cough and fever over the past week. He recalled two similar illnesses during college that did not require medical care. He denied tobacco use but reported inhaling marijuana 1-2 times daily over the past year with a vaping device. Physical exam was notable for a temperature of 100.0°F and an elevated blood pressure at 161/77 mm Hg. He was diaphoretic with clear breath sounds bilaterally. Chest imaging revealed diffuse ground glass opacities with subpleural sparing and mildly enlarged hilar lymph nodes. Bronchoscopy with transbronchial lung biopsies and needle aspirate of lymph nodes revealed organising pneumonia, and subsequent cultures grew Actinomyces odontolyticus He was treated with amoxicillin and corticosteroids with subsequent resolution on repeat chest imaging.

Echocardiographic estimate of pulmonary artery pressure in sarcoidosis patients - real world data from a multi-national study

INTRODUCTION

Echocardiographic measurement of the right ventricular systolic pressure (RVSP) is commonly used for estimating systolic pulmonary artery pressure (PASP) measured during right heart catheterization (RHC) in patients suspected for pulmonary hypertension (PH). Generally, there seems to be a strong correlation. However, this has been reported as less robust in sarcoidosis. We aim to investigate the correlation between RVSP and RHC measurements using real world data and analyzed factors influencing the relationship between RVSP and PASP in sarcoidosis.

METHODS & RESULTS

Data of patients with and without sarcoidosis associated PH who had both a measurable echocardiographic RVSP and invasive PASP were collected from the RESAPH registry, PULSAR study and Cincinnati Sarcoidosis Clinic database (n=173, 60.1% female, mean age 56.0±9.5 years). Among them, 124 had PH confirmed by RHC. There was a strong correlation between RVSP and PASP (r=0.640). This correlation was significant in both male and female, white or non-white, forced vital capacity (FVC) >60%, and presence of fibrosis (p<0.001). However, it was less robust in patients with FVC of 50% or less. RVSP was considered inaccurate if the difference with PASP was > 10mmHg. Inaccurate echocardiographic estimation of the invasive PASP occurred in 50.8%, with overestimation mostly in patients without PH, and underestimation in patients with severe PH. An RVSP>50mmHg was associated with worse survival.

CONCLUSIONS

In this real world multicenter cohort of sarcoidosis patients, we found a significant correlation between RVSP as determined by echocardiography and invasive PASP. Over- or underestimation of PASP occurred frequently. Therefore, echocardiographic RVSP measurement alone to screen for PH in sarcoidosis should be used with caution.

Physiological predictors of survival in patients with sarcoidosis-associated pulmonary hypertension: results from an international registry

Introduction

Sarcoidosis-associated pulmonary hypertension (SAPH) is associated with reduced survival in single-centre studies. The international Registry for SAPH (ReSAPH) with long-term follow-up was established to enrich our knowledge of this complication of sarcoidosis. This analysis aims to elucidate factors associated with reduced transplant-free survival in SAPH patients.

Methods

ReSAPH contains prospectively collected outcomes of SAPH patients since the time of registry enrolment. Information analysed includes right heart catheterisation data, pulmonary function testing, chest radiography, Scadding stage and 6-min walk distance (6MWD), among others. Cox regression models were used to identify independent predictors of transplant-free survival.

Results

Data from 215 patients followed for a mean±sd 2.5±1.9 years were available for analysis. In the 159 precapillary patients, the Kaplan–Meier-adjusted 1-, 3- and 5-year transplant-free survival was 89.2%, 71.7% and 62.0%, respectively. Kaplan–Meier-adjusted 1-, 3- and 5-year transplant-free survival in the incident group was 83.5%, 70.3% and 58.3%, respectively, and in the prevalent group was 94.7%, 72.2% and 66.3%, respectively. Patients with reduced diffusing capacity of the lung for carbon monoxide (DLCO) (<35% predicted) and 6MWD <300 m in the precapillary cohort had significantly worse transplant-free survival. Reduced 6MWD and preserved forced expiratory volume (FEV1)/forced vital capacity (FVC) ratio were identified as independent risk factors for reduced transplant-free survival in the precapillary cohort.

Conclusion

Reduced DLCO (<35% pred) and 6MWD (<300 m) at the time of registry enrolment were associated with reduced transplant-free survival in the overall precapillary cohort. Preserved FEV1/FVC ratio was identified as an independent risk factor for worsened outcomes.

Determination of Pesticide Residues in Nonfatty Fooda by Percritical Extraction aqnd Gas Chromatography/Mass Spectrometry: Collaborative Study

A collaborative study was conducted to determine multiple pesticide residues in apple, green bean, and carrot by using supercritical fluid extraction(SFE) and gas chromatography/mass spectrometry(GC/MS). Seventeen laboratories from 7 countries participated in the final study, and a variety of different instruments was used by collaborators. The procedure simply entails 3 steps: (1) mix 1.1 g drying agent (Hydromatrix) per 1 g frozen precomminuted sample, and load 4–5.5 g of this mixture into a 7–10 mL extraction vessel; (2) perform SFE for 20–30 min with a 1–2 mL/min flow rate of carbon dioxide at 0.85 g/mL density (320 atm, 60°C); and (3) inject the extract, which was collected on a solid–phase or in a liquid trap, into the gas chromatograph/mass spectrometer, using either an ion-trap instrument in full-scan mode or a quadrupole-type instrument in selected-ion monitoring mode. The ability of GC/MS to simultaneously quantitate and confirm the identity of the semivolatile analytes at trace concentrations is a strong feature of the approach. The selectivity of SFE and GC/MS avoids the need for post-extraction cleanup steps, and the conversion of the CO2 solvent to a gas after SFE eliminates the solvent evaporation step common in traditional methods. The approach has several advantages, but its main drawback is the lower recoveries for the most polar analytes, such as methamidophos and acephate, and the most nonpolar analytes, such as pyrethroids. Recoveries for most pesticides are &gt;75%, and recoveries of nonpolar analytes are still &gt;50%. The(within-laboratory) repeatability relative standard deviation (RSDr) values of the recoveries are generally &lt;15%. More specifically, the average results from the 9–14 laboratories in the final analysis of 6 blind duplicates at 3 concentrations for each pesticide are as follows: carbofuran in apple (75–500 ng/g), 89% recovery, 7% RSDr, 9% reproducibility relative standard deviation (RSDR); diazinon in apple (60–400 ng/g), 83% recovery, 13% RSDr, 17% RSDMR; vinclozolin in apple (6–400 ng/g), 97% recovery, 13% RSDr, 18% RSDR; chlorpyrifos in apple (50–300 ng/g), 105% recovery, 11% RSDr, 13% RSDR; endosulfan sulfate in apple (150–1000 ng/g), 95% recovery, 15% RSDr, 17% RSDR; trifluralin in green bean (30–200 ng/g), 58% recovery, 11% RSDr, 27% RSDR; dacthal in green bean (60–400 ng/g), 88% recovery, 11% RSDr, 17% RSDR; quintozene in green bean (60–400 ng/g), 79% recovery, 13% RSDr, 18% RSDR; chlorpyrifos in green bean (50–300 ng/g), 84% recovery, 11% RSDr, 17% RSDR; p,p′ -DDE in green bean (45–300 ng/g), 64% recovery, 14% RSDr, 27% RSDR; atrazine in carrot (75–500 ng/g), 90% recovery, 11% RSDr, 15% RSDR; metalaxyl in carrot (75–500 ng/g), 89% recovery, 8% RSDr, 12% RSDR; parathion–methyl in carrot (75–500 ng/g), 84% recovery, 14% RSDr, 15% RSDR; chlorpyrifos in carrot (50–300 ng/g), 77% recovery, 13% RSDr, 19% RSDR; and bifenthrin in carrot (90–600 ng/g), 63% recovery, 12% RSDr, and 25% RSDR. All analytes except for the nonpolar compound strifluralin, p,p′ -DDE, and bifenthrin gave average Horwitz ratios of &lt;1.0 when AOAC criteria were used. These 3 analytes had high RSDr values but lower RSDR values, which indicated that certainSFE instruments gave consistently lower recoveries for nonpolar compounds. The collaborative study results demonstrate that the method meets the purpose of many monitoring programs for pesticide residue analysis, and the Study Director recommends that it be adopted Official

First Observation of Unbound ^{11}O, the Mirror of the Halo Nucleus ^{11}Li

The structure of the extremely proton-rich nucleus _{8}^{11}O_{3}, the mirror of the two-neutron halo nucleus _{3}^{11}Li_{8}, has been studied experimentally for the first time. Following two-neutron knockout reactions with a ^{13}O beam, the ^{11}O decay products were detected after two-proton emission and used to construct an invariant-mass spectrum. A broad peak of width ∼3.4  MeV was observed. Within the Gamow coupled-channel approach, it was concluded that this peak is a multiplet with contributions from the four lowest ^{11}O resonant states: J^{π}=3/2_{1}^{-}, 3/2_{2}^{-}, 5/2_{1}^{+}, and 5/2_{2}^{+}. The widths and configurations of these states show strong, nonmonotonic dependencies on the depth of the p-^{9}C potential. This unusual behavior is due to the presence of a broad threshold resonant state in ^{10}N, which is an analog of the virtual state in ^{10}Li in the presence of the Coulomb potential. After optimizing the model to the data, only a moderate isospin asymmetry between ground states of ^{11}O and ^{11}Li was found.

A qualitative assessment of internal medicine resident perceptions of graduate medical education following implementation of the 2011 ACGME duty hour standards

BACKGROUND

In 2011, the Accreditation Council of Graduate Medical Education implemented updated guidelines for medical resident duty hours, further limiting continuous work hours for first-year residents. We sought to investigate the impact of these restrictions on graduate medical education among internal medicine residents.

METHODS

We conducted eight focus groups with internal medicine residents at the University of Alabama at Birmingham in 06/2012-07/2012. Discussion questions included, "How do you feel the 2011 ACGME work hour restrictions have impacted your graduate medical education?" Transcripts of the focus groups were reviewed and themes identified using a deductive/inductive approach. Participants completed a survey to collect demographic information and future practice plans.

RESULTS

Thirty-four residents participated in our focus groups. Five themes emerged: decreased teaching, decreased experiential learning, shift-work mentality, tension between residency classes, and benefits and opportunities. Residents reported that since implementation of the guidelines, teaching was often deferred to complete patient-care tasks. Residents voiced concern that PGY-1 s were not receiving adequate clinical experience and that procedural and clinical reasoning skills are being negatively impacted. PGY-1 s reported being well-rested and having increased time for independent study.

CONCLUSIONS

Residents noted a decline in teaching and are concerned with the decrease in "hands-on" clinical education that is inevitably impacted by fewer hours in the hospital, though some benefits were also reported. Future studies are needed to further elucidate the impact of decreased resident work hours on graduate medical education.

Legislative and humanitarian impetus for development of alcohol and other drug policy at an Australian university

The rationale for comprehensive alcohol and other drug policy at a tertiary institution is presented here as a health promotion strategy for educating University policy makers. Particular emphasis is placed on a discussion of humanitarian issues, that is, the right to a healthy environment, and the potential for legal liability in an environment where alcohol is readily available and other drugs are present. There is little attention paid to drug use related legal issues in the University, but at the same time drawing the attention of policy makers to the organisation's vulnerability to lawsuits has been reported to be a motivating force for adoption of drug use policy. Universities do experience problems related to alcohol and other drug use by staff and students. Problem reduction, and better management of problems, are the major goals of policy in this area. Local initiatives, for example at the organisational level, make important contributions to the overall drug prevention efforts of the nation. Well-developed policy and procedures and effective implementation constitute an important structural health promotion strategy. Such policy would comply with the immediate requirements of Occupational Health, Safety and Welfare legislation and provide some protection against wrongful dismissal claims and negligence lawsuits, as well as providing long-term educative effects. Situations for which policies are needed, range widely due to the University's unique environment and complex roles.

An unusual cause of chronic cough. Foreign body aspiration

Foreign body aspiration (FBA) is a serious medical problem, causing thousands of deaths nationally each year. Clinical presentations range from acute suffocation and death to chronic and subtle respiratory symptoms. Although FBA is more common in children, adult patients are also at risk. We present a classic case of FBA in an adult male with a history of alcohol abuse and chronic cough.

Neurological manifestations of aging

A group of 51 socially active, self-declared neurologically normal subjects ranging from 61 to 84 years of age were studied with a battery of clinical neurological examinations and a semiquantitative vibration perception test. None of the subjects showed a consistent pattern of neurological deficit that could be identified as pathological. On review of systems, the most frequent complaints were difficulty remembering names, numbness and tingling of fingers and toes, and headaches. In the neurological examination, the most commonly observed abnormalities were positive palmomental reflex, snout reflex, abnormalities in pursuit eye movements, convergence insufficiency, and minor mistakes in perception of light touch. There was no apparent trend of worsening of symptoms and signs with advancing age. In the semiquantitative testing of vibration perception, there was a slight trend toward worsening of vibration perception in the upper and lower extremities with advancing age. Motor abnormalities were absent, and there were relatively few subjects who showed reflex abnormalities. This study confirms the previously reported diminution of vibration perception with aging. Caution must be exercised before attributing myotatic reflex and motor abnormalities to the aging process alone.