Vitamin E: Not only a single stereoisomer

The recent publication by Azzi and colleagues puts forth the argument that only RRR-α-tocopherol should be considered as vitamin E from a physiological point of view. They base their argument primarily on the assertion that only this form has been used to treat stark vitamin E deficiency in humans (known as AVED, or Ataxia with Vitamin E Deficiency). Azzi et al. also argue that other chemically similar molecules, such as tocopherols other than α-tocopherol and tocotrienols do not provide vitamin E activity. Azzi and colleagues are correct on this second point. An investigation into the biological activities of vitamin E, and the mechanisms behind these activities, confirms that physiological vitamin E activity is limited to certain α-tocopherol forms. However, it is also clear that these activities are not restricted only to the RRR-form but include other 2R-forms as well. Indeed, the α-tocopherol transfer protein (α-TTP), which is critical to mediate vitamin E trafficking and biological activity, and genetic defects of which lead to vitamin E deficiency, binds well to all 2R-forms of α-tocopherol. Furthermore, both RRR-α-tocopherol and the other 2R-forms are maintained in human plasma and distributed to tissues and organs, whereas the 2S-stereoisomers are excreted quickly. As such, in recent years the definition of vitamin E including both 2R- and RRR-α-tocopherol has gained both broad scientific and regulatory acceptance. Consistent with this understanding, we provide evidence that AVED has indeed been treated successfully with forms in addition to RRR-α-tocopherol, again arguing against the restriction of the definition to RRR-α-tocopherol only. Finally, we provide evidence against any safety concerns utilizing the currently accepted definition of vitamin E.

Spatio-temporal interactions between the red fox and the wolf in two contrasting European landscapes

Relationships among carnivore species are complex, potentially switching from competition to facilitation on a context-dependent basis. Negative associations are predicted to increase with latitude, due to limited resources emphasising competition and/or intra-guild predation. Accordingly, a stronger negative correlation between large- and meso-carnivore abundances should be expected at higher latitudes, with a substantial spatio-temporal partitioning favouring interspecific coexistence. Human presence may influence spatio-temporal relationships between (meso)carnivore species, as it can be perceived as a risk factor, but anthropogenic food can also provide an important additional food resource. Using camera-trap data, we studied the spatio-temporal associations between two of the most widespread carnivores in Europe, i.e., the red fox and wolf. We compared their monthly/daily spatio-temporal partitioning between two different landscapes: Białowieża Primeval Forest (Poland) and the Mediterranean Maremma Regional Park (Italy). We predicted a stronger interspecific partitioning, as well as more attraction of red foxes to humans in the northern site (Poland). Temporal activity patterns of the two carnivores overlapped in both sites, and their detection rates were positively associated, even though in weaker way in Poland. We observed a positive spatial association of red foxes with human activity in Białowieża, but not in Maremma. This association occurred only at a monthly temporal scale and disappeared at a daily scale, suggesting some disturbance in the shorter term. Our results provided partial support to our predictions and suggest that, despite the ecological differences between our study areas, only weak differences in wolf-fox relations were observed, suggesting that red fox responses to wolves may be relatively comparable over large spatial scales.

The structure of NAD+ consuming protein Acinetobacter baumannii TIR domain shows unique kinetics and conformations

Toll-like and interleukin-1/18 receptor/resistance (TIR) domain-containing proteins function as important signaling and immune regulatory molecules. TIR domain-containing proteins identified in eukaryotic and prokaryotic species also exhibit NAD+ hydrolase activity in select bacteria, plants, and mammalian cells. We report the crystal structure of the Acinetobacter baumannii TIR domain protein (AbTir-TIR) with confirmed NAD+ hydrolysis and map the conformational effects of its interaction with NAD+ using hydrogen-deuterium exchange-mass spectrometry. NAD+ results in mild decreases in deuterium uptake at the dimeric interface. In addition, AbTir-TIR exhibits EX1 kinetics indicative of large cooperative conformational changes, which are slowed down upon substrate binding. Additionally, we have developed label-free imaging using the minimally invasive spectroscopic method 2-photon excitation with fluorescence lifetime imaging, which shows differences in bacteria expressing native and mutant NAD+ hydrolase-inactivated AbTir-TIRE208A protein. Our observations are consistent with substrate-induced conformational changes reported in other TIR model systems with NAD+ hydrolase activity. These studies provide further insight into bacterial TIR protein mechanisms and their varying roles in biology.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Optimization of anastomotic technique and gastric conduit perfusion with hyperspectral imaging and machine learning in an experimental model for minimally invasive esophagectomy

INTRODUCTION

Esophagectomy is the mainstay of esophageal cancer treatment, but anastomotic insufficiency related morbidity and mortality remain challenging for patient outcome. Therefore, the objective of this work was to optimize anastomotic technique and gastric conduit perfusion with hyperspectral imaging (HSI) for total minimally invasive esophagectomy (MIE) with linear stapled anastomosis.

MATERIAL AND METHODS

A live porcine model (n = 58) for MIE was used with gastric conduit formation and simulation of linear stapled side-to-side esophagogastrostomy. Four main experimental groups differed in stapling length (3 vs. 6 cm) and simulation of anastomotic position on the conduit (cranial vs. caudal). Tissue oxygenation around the anastomotic simulation site was evaluated using HSI and was validated with histopathology.

RESULTS

The tissue oxygenation (ΔStO₂) after the anastomotic simulation remained constant only for the short stapler in caudal position (-0.4 ± 4.4%, n.s.) while it was impaired markedly in the other groups (short-cranial: -15.6 ± 11.5%, p = 0.0002; long-cranial: -20.4 ± 7.6%, p = 0.0126; long-caudal: -16.1 ± 9.4%, p < 0.0001). Tissue samples from avascular stomach as measured by HSI showed correspondent eosinophilic pre-necrotic changes in 35.7 ± 9.7% of the surface area.

CONCLUSION

Tissue oxygenation at the site of anastomotic simulation of the gastric conduit during MIE is influenced by stapling technique. Optimal oxygenation was achieved with a short stapler (3 cm) and sufficient distance of the simulated anastomosis to the cranial end of the gastric conduit. HSI tissue deoxygenation corresponded to histopathologic necrotic tissue changes. The experimental model with HSI and ML allow for systematic optimization of gastric conduit perfusion and anastomotic technique while clinical translation will have to be proven.

The impact of accuracy and precision of analytical test methods on the determination of withdrawal periods

Treatment of food-producing animals with veterinary medicinal products (VMPs) can result in residues in foodstuffs (e.g. eggs, meat, milk, or honey) representing a potential consumer health risk. To ensure consumer safety, worldwide regulatory concepts for setting safe limits for residues of VMPs e.g. as tolerances (US) or maximum residue limits (MRLs, EU) are used. Based on these limits so-called withdrawal periods (WP) are determined. A WP represents the minimum period of time required between the last administration of the VMP and the marketing of foodstuff. Usually, WPs are estimated using regression analysis based on residue studies. With high statistical confidence (usually 95% in the EU and 99% in the US) the residues in almost all treated animals (usually 95%) have to be below MRL when edible produce is harvested. Here, uncertainties from both sampling and biological variability are taken into account but uncertainties of measurement associated with the analytical test methods are not systematically considered. This paper describes a simulation experiment to investigate the extent to which relevant sources of measurement uncertainty (accuracy and precision) can impact the length of WPs. A set of real residue depletion data was artificially 'contaminated' with measurement uncertainty related to permitted ranges for accuracy and precision. The results show that both accuracy and precision had a noticeable effect on the overall WP. Due consideration of sources of measurement uncertainty may improve the robustness, quality and reliability of calculations upon which regulatory decisions on consumer safety of residues are based.

Search for Gamma-Ray Spectral Lines from Dark Matter Annihilation up to 100 TeV toward the Galactic Center with MAGIC

Linelike features in TeV γ rays constitute a "smoking gun" for TeV-scale particle dark matter and new physics. Probing the Galactic Center region with ground-based Cherenkov telescopes enables the search for TeV spectral features in immediate association with a dense dark matter reservoir at a sensitivity out of reach for satellite γ-ray detectors, and direct detection and collider experiments. We report on 223 hours of observations of the Galactic Center region with the MAGIC stereoscopic telescope system reaching γ-ray energies up to 100 TeV. We improved the sensitivity to spectral lines at high energies using large-zenith-angle observations and a novel background modeling method within a maximum-likelihood analysis in the energy domain. No linelike spectral feature is found in our analysis. Therefore, we constrain the cross section for dark matter annihilation into two photons to ⟨σv⟩≲5×10^{-28}  cm^{3} s^{-1} at 1 TeV and ⟨σv⟩≲1×10^{-25}  cm^{3} s^{-1} at 100 TeV, achieving the best limits to date for a dark matter mass above 20 TeV and a cuspy dark matter profile at the Galactic Center. Finally, we use the derived limits for both cuspy and cored dark matter profiles to constrain supersymmetric wino models.

The Effects of Long-term Molybdenum Exposure in Drinking Water on Molybdenum Metabolism and Production Performance of Beef Cattle Consuming a High Forage Diet

Fifty-four multiparous beef cows with calves were used to evaluate the effects of Mo source (feed or water) on reproduction, mineral status, and performance over two cow-calf production cycles (553 days). Cows were stratified by age, body weight, liver Cu, and Mo status and were then randomly assigned to one of six treatment groups. Treatments were (1) negative control (NC; basal diet with no supplemental Mo or Cu), (2) positive control (NC + Cu; 3 mg of supplemental Cu/kg DM), (3) NC + 500 µg Mo/L from Na2MoO4·2H2O supplied in drinking water, (4) NC + 1000 µg Mo/L of Na2MoO4·2H2O supplied in drinking water, (5) NC + Mo 1000-water + 3 mg of supplemental Cu/kg DM, and (6) NC + 3.0 mg of supplemental Mo/kg diet DM from Na2MoO4·2H2O. Animals were allowed ad libitum access to both harvested grass hay (DM basis: 6.6% crude protein; 0.15% S, 6.7 mg Cu/kg, 2.4 mg Mo/kg) and water throughout the experiment. Calves were weaned at approximately 6 months of age each year. Dietary Cu concentration below 10.0 mg Cu/kg DM total diet reduced liver and plasma Cu concentrations to values indicative of a marginal Cu deficiency in beef cows. However, no production parameters measured in this experiment were affected by treatment. Results suggest that Mo supplemented in water or feed at the concentrations used in this experiment had minimal impact on Cu status and overall performance.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

POS1263 PRE-EXPOSURE PROPHYLAXIS FOR SARS-CoV-2 INFECTION WITH SUBCUTANEOUS CASIRIVIMAB/IMDEVIMAB IN PATIENTS WITH IMMUNE MEDIATED INFLAMMATORY DISEASES

Background

Patients with immune-mediated inflammatory diseases (IMID), particularly if treated with B-cell depleting therapies, show reduced humoral responses to SARS-CoV-2 vaccines and increased risk of severe COVID-19 (1,2). Since pre-exposure prophylaxis (PrEP) with monoclonal antibodies against SARS-CoV-2 proved effective in preventing infection and COVID-19 (3) in the general population, PrEP could be used for passive immunization of vaccine-refractory patients with IMIDs.

Objectives

To evaluate the persistence of serum and salivary anti-SARS-CoV-2 IgG antibodies in vaccine-refractory patients with IMID after PrEP with casirivimab/imdevimab. Secondary outcomes were safety, SARS-CoV-2 infection, and adverse COVID-19 outcomes.

Methods

We performed a longitudinal analysis on anti-SARS-CoV-2 IgG titers in IMID patients who received a PrEP with 1200 mg of subcutaneous casirivimab/imdevimab due to high infection risk, as they had not developed an adequate humoral response at least 21 days after three COVID-19 vaccinations (Table 1). Serum and salivary anti-SARS-CoV-2 Spike IgG were quantified by ELISA (EUROIMMUN, Lübeck, Germany) before PrEP and after 1, 14, and 30 days. IgG levels are given as antibody ratios by dividing the optical density of the sample by that of the calibrator. A cutoff of ≥1.1 was considered positive. Safety as well as polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection and adverse COVID-19 outcomes (hospitalization, mechanical ventilation, death) after PrEP were recorded.

Table 1.

Baseline characteristics.

N26Age, mean (SD)54 (14)Sex, n (%)Female15 (57.7)Male39 (42.3)Diagnosis, n (%)ANCA-associated vasculitis10 (38.5)Rheumatoid arthritis6 (23.1)Immunoglobulin deficiency4 (15.4)Systemic sclerosis2 (7.7)Psoriatic arthritis1 (3.8)Systemic Lupus Erythematosus1 (3.8)Non-infectious Uveitis1 (3.8)Multiple sclerosis1 (3.8)IgG4-related disease1 (3.8)Autoinflammatory syndrome1 (3.8)CD20-depletionRituximab, n (%)22 (84.6)Other therapies, n (%)Methotrexate6 (23.1)Immunoglobulins4 (15.4)Mycophenolate1 (3.8)Infliximab1 (3.8)CD19+ lymphocytes/mm3, median (IQR)0 (0-9)Serum total IgG, median (IQR)894 (745-987)

SD, standard deviation; IQR, interquartile range; ANCA, anti-neutrophil cytoplasmic antibodies.

Results

We obtained 92 serum and 75 saliva samples from 26 participants at four consecutive timepoints (Figure 1). Anti-SARS-CoV-2 IgG titers were observed in serum and saliva samples of all participants from day 1 and throughout 30 days after PrEP independently of diagnosis, therapy, total IgG, and peripheral CD19+ B-cells. Serum IgG increased rapidly at day 1 and plateaued from day 14 to 30 (Figure 1A), reaching similar levels as seen in healthy subjects after full vaccination (1), while saliva IgG increased steadily from administration up to day 14 and plateaued at day 30 (Figure 1B). No side effects were reported. Five patients (19.2%) had a close contact with a SARS-CoV-2-infected person, after which all but one remained asymptomatic and with a negative PCR test. The patient who tested positive developed mild COVID-19 with fever and cough.

Figure 1.

Temporal pattern and distribution of serum (A) and salivary (B) anti-SARS-CoV-2 IgG levels.

Results from individual participants are represented as line (top) and scatter plots (bottom). Horizontal lines represent median values, the dotted horizontal line represents the positivity cutoff of 1.1.

** p =0.0082; *** p <0.001; **** p <0.0001. mAbs: monoclonal antibodies.

Conclusion

SARS-CoV-2 PrEP induces stable serum and salivary antibody levels in IMID patients who did not respond to COVID-19 vaccination, regardless of pre-existing clinical and serological features. In IMID, PrEP with casirivimab/imdevimab is safe and has the potential to prevent infection and severe COVID-19.

References

[1]Simon D, et al. Ann rheum dis. 2021;80:1312-1316.

[2]Fagni F et al, et al. Lancet Rheumatol. 2021; e724-e736.

[3]Flonza I, et al. MedRxiv. 2021. doi: 10.1101/2021.11.10.21265889

Disclosure of Interests

None declared

POS1403 CLINICAL CHARACTERISTICS, HEALTH CARE RESOURCE UTILIZATION, AND COSTS ASSOCIATED WITH FLARES IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS IN GERMANY

Background

Longitudinal data describing real-world systemic lupus erythematosus (SLE) disease characteristics, health care resource utilization (HCRU), and costs associated with flares in Germany are limited.

Objectives

To evaluate the clinical characteristics of patients with SLE and estimate the impact of flares on HCRU and costs in a cohort of adults with SLE in Germany.

Methods

CHaracteristics and impact of flares on clinicAl and econoMic OutcoMes In patients with systemic Lupus Erythematosus: a German Claims Database Study (CHAMOMILE) was an observational, retrospective cohort study. Adult patients with SLE were identified from the German Betriebskrankenkassen health insurance fund database between 1 July 2010 and 31 December 2013, and followed for up to 9 years. Baseline period was defined as the first year since the first quarter with the earliest SLE diagnosis during the identification period, including this quarter. Resource utilization measures included number of hospitalizations, duration of stay, and associated costs per person-year (PY) by follow-up year for patient subgroups defined by flare exposure (no, mild, or moderate/severe flares) during baseline. Cost measures included total PY costs in flare-exposure subgroups.

Results

Of 2088 patients included in the study, the mean (SD) age was 51.4 (16.1) years and 1767 (84.6%) were female. The most common SLE manifestations were cutaneous (66.8%), osteoarticular (28.7%), and vascular (23.0%). Patients were receiving treatment with glucocorticoids (54.8%), antimalarials (40.2%), nonsteroidal anti-inflammatory drugs (39.1%), and/or immunosuppressants (32.7%). During the baseline period, 750 patients (35.9%) experienced moderate/severe flares, 622 (29.8%) experienced mild flares, and 716 (34.3%) experienced no flares. Patients with no flares or mild flares during the baseline period had similar costs, and a similar number and duration of hospital stays per PY, which remained consistent from baseline up to 9 years of follow-up. Patients with moderate/severe flares during the baseline period had 2- to 3-fold higher hospital costs, 1- to 2-fold more hospital stays, and hospital stays that were 2-fold longer in duration, compared with the no-flares or mild-flares groups during baseline and each year of follow-up (Table 1). During the baseline period, annual total costs were more than 2-fold greater for patients with moderate/severe flares (€11,048/PY) than patients with mild (€5148/PY) or no flares (€4734/PY). In all subsequent years, costs for patients with moderate/severe flares exceeded costs for patients with mild or no flares. Annual total costs gradually increased over time to €7761/PY for patients with mild and to €7564/PY for patients with no flares at Year 9, whereas costs reduced sharply at follow-up Year 1 to €8801/PY and remained similar to Year 9 for patients with moderate/severe flares (Figure 1).

Table 1.

Mean Costs, Number, and Duration of Hospital Stays per Person-Year by Baseline Flares

Flare-Exposure SubgroupYearBaseline123456789Patients, nNo716716701676658634603526444315Mild622622613596575559534455348239Moderate/severe750750721690669646624503391263Costs of hospital stays, mean, €No1325179822961725223331261759178617952047Mild1779194415451820165222612390197422902451Moderate/severe5517355034032798272529992663369527142977Number of hospital stays, mean, nNo0.490.460.470.440.510.530.440.410.440.45Mild0.460.480.400.500.420.470.470.480.510.43Moderate/severe1.390.850.760.640.620.670.630.760.600.74Duration of hospital stays, mean, daysNo3.514.664.983.915.025.413.984.584.464.73Mild4.554.914.114.413.764.334.134.054.684.19Moderate/severe13.898.187.587.686.887.106.597.896.546.03

Conclusion

Patients with moderate or severe flares following diagnosis place a large burden on the health care system in Germany. Earlier diagnosis and treatment may reduce flare severity and the associated high health care costs.

Acknowledgements

Writing assistance by Rebecca S. Jones, PhD (Fishawack Health). This study was sponsored by AstraZeneca.

Disclosure of Interests

Bo Ding Employee of: AstraZeneca, Marc Pignot: None declared, Elena Garal-Pantaler: None declared, Beate Villinger Paid instructor for: Novartis, Vertex, Boehringer Ingelheim, UCB, Consultant of: Novartis, Vertex, Boehringer Ingelheim, UCB, AstraZeneca, Employee of: Novartis, AstraZeneca, Barnabas Desta Shareholder of: AstraZeneca, Employee of: AstraZeneca, Katharina Schmidt Employee of: AstraZeneca, Sarowar Golam Employee of: AstraZeneca, Heide Stirnadel-Farrant Shareholder of: AstraZeneca, GSK, Employee of: AstraZeneca, Andreas Schwarting Speakers bureau: AstraZeneca, Genentech, Consultant of: GSK, Astra Zeneca, Grant/research support from: GSK, Pfizer, Novartis

Impact of contact force on local impedance measurements in different atrial locations

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 860974

Regions with pathologically altered substrate have been identified as potentially responsible for atrial fibrillation and atrial flutter maintenance. Also, real time feedback on lesion formation especially in those critical areas is a challenge. The LOCALIZE trial has shown significant value of the usage of the local impedance (LI) drop as a real time indicator during ablation for durable lesion formation. In these procedures, a decrease of 10-20% of the initial LI value is used as a marker of successful ablation. Also known is the fact that low electrode-tissue contact force is associated with ineffective lesion formation, whereas a high value can lead to an increased risk of steam pop. The IntellaNavSTABLEPOINT catheter offers both, LI and contact force, as a novel combined technique to characterize the process of lesion formation. Additionally, LI values are expected to distinguish between healthy and scar tissue independently from the atrial rhythm, which can improve the understanding of underlying substrate, even more, when corrected for an eventual lack of contact by combining it with contact force.

This study aims to: (1) evaluate the relationship between contact force and LI; (2) characterise the contact force during local impedance mapping depending on the wall region of the left atrium (LA).

Patients undergoing LA ablation with the STABLEPOINT catheter were included in this analysis. Contact force and LI data were recorded in four different healthy anatomical points in the LA, two in the anterior wall, and two in the posterior wall, using manually controlled contact force values between 0 g and the saturation point (70 g). When possible, additional points in scar regions were recorded. Data were exported and processed to correlate each LI measurement with the corresponding contact force. Due to the susceptibility of raw LI recordings to oscillations, moving average approach was considered. The clinical cohort comprised ten patients with a mean age of 61 years, one female. De-Novo ablations as well as redo procedures were included. Measurements at different contact force values yielded a non-linear relationship between contact force and LI. Median value of the difference between the moving average LI measurement and the LI bloodpool value were calculated at the anterior and posterior walls of the LA at contact force values from 5 to 40 g (5 g step size). Comparing the LI values at each segment, measurements differ significantly (Mann-Whitney U-test for unpaired samples) between the anterior and the posterior wall of the LA, with an ascending trend. Scar points showed a globally lower curve.

Results from this preliminary study showed that LI and contact force are non-linearly dependent and it differs between anterior and posterior atrial walls, as well as between healthy and pathological substrate. Further investigations in a larger clinical cohort will analyse the LI variability to set an optimal contact force technique during LI mapping.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

359 Incidental Fatty Liver Disease; Are We Adhering to Guidelines?

Aim

Hepatic steatosis is an increasingly prevalent condition, with estimates of up to 30% amongst western populations. Fatty liver is a common incidental finding on abdominal imaging. Current British Society of Gastroenterology guidelines suggest the use of scoring systems, such as FIB-4 or NFS, to stratify these patients into risk categories for the development of non-alcoholic steatohepatitis, and subsequent liver failure or hepatocellular carcinoma. We carried out an audit of our own practice, to see if these guidelines were being followed.

Method

We interrogated the national imaging management system to identify all scans performed in Wexford general hospital from 16th April to 16th October 2020 which identified “hepatic steatosis” or “fatty liver”. Data extracted included: patient demographics, imaging modality & finding. We correlated this data with the patient’s LFTs to calculate their FIB-4/NFS score and investigated whether suitable patients had been referred to gastroenterology.

Results

Of the 145 patients identified as having hepatic steatosis on imaging, 65 (44.8%) had ALT derangement, 42 (29%) had ALP derangement, 81 (56%) had GGT derangement and 23 (16%) had an elevated total bilirubin. Only 26 (17.9%) of these patients had evidence of subsequent liver serology studies, and only 11 (7.6%) had been referred to gastroenterology. None of the patient cohort had either a FIB-4 or NFS score calculated.

Conclusions

There is clear evidence that guidelines are not being followed in the management of patients who are incidentally found to have hepatic steatosis.

Frequency and risk factors of post-intensive care syndrome components in a multicenter randomized controlled trial of German sepsis survivors

BACKGROUND

Post-intensive care syndrome (PICS) is a combination of cognitive, psychiatric and physical impairments in survivors of critical illness and intensive care. There is little data on long-term co-occurrence of associated impairments.

METHODS

Analysis of data from 289 sepsis survivors from a German multicenter RCT. Impairments associated with PICS (depression, PTSD, cognitive impairment, chronic pain, neuropathic symptoms, dysphagia) during 24 months follow-up are used to explore the frequency and risk factors of PICS components in three classification models.

RESULTS

The majority of participants showed impairments in 2-3 of 6 domains during follow-up. The overall frequency of PICS according to the classification models ranged from 32.9% to 98.6%. In regression analyses, there were no significant effects in selected ICU-related exposures or covariates for PICS classification models. Regarding individual components, only higher age and longer duration of ICU treatment and mechanical ventilation showed significant positive associations with the occurrence of cognitive impairment during follow-up, as did male gender and higher age for dysphagia.

CONCLUSIONS

Almost all study participants showed impairments associated with PICS in at least one domain. The proposed classification models for PICS appear to be too broad to identify specific risk factors beyond its individual components.

Contribution of the NADase function of bacterial TIR domain proteins to the inhibition of innate immune responses

Pathogenic microbes have evolved various mechanisms to evade recognition by host immune responses, which can lead to the prevalence of disease and infection. Many strains of pathogenic bacteria contain genes encoding Toll/Interleukin-1 receptor (TIR) domain-containing proteins that function through the inhibition of TLR and myeloid differentiation factor 88 (MyD88) signaling. Previous research has also revealed that prokaryotic TIR domains may regulate bacterial and host metabolic pathways by acting as NAD+ glycohydrolases (NADases). We hypothesize that this NADase activity may contribute to the role of bacterial TIRs as virulence factors. In order to test this hypothesis, we observed the effects of TIR NADase activity on the binding interactions between bacterial TIRs and host MyD88, and on the ability of bacterial TIRs to block NF-kB signaling. For this, we have identified amino acids predicted to play a role in TIR NADase activity and have expressed and purified recombinant bacterial TIR proteins that have incorporated these mutations. We then tested the NADase activity of these mutants in comparison with that of wild-type TIR proteins and TIRs with mutations already known to inhibit NADase activity. We are now using mutant TIRs with deficiencies in NADase activity in pull-down assays to test their binding to MyD88 and utilizing reporter assays to analyze the effects of these mutant TIRs on NF-kB signaling. This information will allow us to gain a deeper understanding into the relationship between NADase activity in bacterial TIRs and their virulence activity, and can potentially uncover new mechanisms for pathogenic evasion of host immune defenses.

Bedside hyperspectral imaging indicates a microcirculatory sepsis pattern - an observational study

INTRODUCTION

Microcirculatory alterations are key mechanisms in sepsis pathophysiology leading to tissue hypoxia, edema formation, and organ dysfunction. Hyperspectral imaging (HSI) is an emerging imaging technology that uses tissue-light interactions to evaluate biochemical tissue characteristics including tissue oxygenation, hemoglobin content and water content. Currently, clinical data for HSI technologies in critical ill patients are still limited.

METHODS AND ANALYSIS

TIVITA® Tissue System was used to measure Tissue oxygenation (StO2), Tissue Hemoglobin Index (THI), Near Infrared Perfusion Index (NPI) and Tissue Water Index (TWI) in 25 healthy volunteers and 25 septic patients. HSI measurement sites were the palm, the fingertip, and a suprapatellar knee area. Septic patients were evaluated on admission to the ICU (E), 6 h afterwards (E+6) and three times a day (t3-t9) within a total observation period of 72 h. Primary outcome was the correlation of HSI results with daily SOFA-scores.

RESULTS

Serial HSI at the three measurement sites in healthy volunteers showed a low mean variance expressing high retest reliability. HSI at E demonstrated significantly lower StO2 and NPI as well as higher TWI at the palm and fingertip in septic patients compared to healthy volunteers. StO2 and TWI showed corresponding results at the suprapatellar knee area. In septic patients, palm and fingertip THI identified survivors (E-t4) and revealed predictivity for 28-day mortality (E). Fingertip StO2 and THI correlated to SOFA-score on day 2. TWI was consistently increased in relation to the TWI range of healthy controls during the observation time. Palm TWI correlated positively with SOFA scores on day 3.

DISCUSSION

HSI results in septic patients point to a distinctive microcirculatory pattern indicative of reduced skin oxygenation and perfusion quality combined with increased blood pooling and tissue water content. THI might possess risk-stratification properties and TWI could allow tissue edema evaluation in critically ill patients.

CONCLUSION

HSI technologies could open new perspectives in microcirculatory monitoring by visualizing oxygenation and perfusion quality combined with tissue water content in critically ill patients - a prerequisite for future tissue perfusion guided therapy concepts in intensive care medicine.

Piloting an ICU follow-up clinic to improve health-related quality of life in ICU survivors after a prolonged intensive care stay (PINA): study protocol for a pilot randomised controlled trial

Background

Intensive care unit (ICU) survivors often suffer from cognitive, physical and mental impairments, known as post-intensive care syndrome (PICS). ICU follow-up clinics may improve aftercare of these patients. There is a lack of evidence whether or which concept of an ICU follow-up clinic is effective. Within the PINA study, a concept for an ICU follow-up clinic was developed and will be tested in a pilot randomised controlled trial (RCT), primarily to evaluate the feasibility and additionally the potential efficacy.

Methods/design

Design: Pilot RCT with intervention and control (usual care) arms plus mixed-methods process evaluation. Participants: 100 ICU patients (50 per arm) of three ICUs in a university hospital (Regensburg, Germany), ≥ 18 years with an ICU stay of > 5 days, a sequential organ failure assessment (SOFA) score > 5 during the ICU stay and a life expectancy of more than 6 months.

Intervention: The intervention will contain three components: information, consultation and networking. Information will be available in form of an intensive care guide for patients and next of kin at the ICU and phone support during follow-up. For consultation, patients will visit the ICU follow-up clinic at least once during the first 6 months after discharge from ICU. During these visits, patients will be screened for symptoms of PICS and, if required, referred to specialists for further treatment. The networking part (e.g. special referral letter from the ICU follow-up clinic) aims to provide a network of outpatient care providers for former ICU patients. Feasibility Outcomes: Qualitative and quantitative evaluation will be used to explore reasons for non-participation and the intervention´s acceptability to patients and caregivers. Efficacy Outcomes: Health-related quality of life (HRQOL) will be assessed as primary outcome by the physical component score (PCS) of the Short-Form 12 Questionnaire (SF-12). Secondary outcomes encompass further patient-reported outcomes. All outcomes are assessed at 6 months after discharge from ICU.

Discussion

The PINA study will determine feasibility and potential efficacy of a complex intervention in a pilot RCT to enhance follow-up care of ICU survivors. The pilot study is an important step for further studies in the field of ICU aftercare and especially for the implementation of a pragmatic multi-centre RCT.

Trial registration

ClinicalTrials.gov, NCT04186468. Submitted 2 December 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00796-1.

Exploiting Isospin Symmetry to Study the Role of Isomers in Stellar Environments

Proton capture on the excited isomeric state of ^{26}Al strongly influences the abundance of ^{26}Mg ejected in explosive astronomical events and, as such, plays a critical role in determining the initial content of radiogenic ^{26}Al in presolar grains. This reaction also affects the temperature range for thermal equilibrium between the ground and isomeric levels. We present a novel technique, which exploits the isospin symmetry of the nuclear force, to address the long-standing challenge of determining proton-capture rates on excited nuclear levels. Such a technique has in-built tests that strongly support its veracity and, for the first time, we have experimentally constrained the strengths of resonances that dominate the astrophysical ^{26m}Al(p,γ)^{27}Si reaction. These constraints demonstrate that the rate is at least a factor ∼8 lower than previously expected, indicating an increase in the stellar production of ^{26}Mg and a possible need to reinvestigate sensitivity studies involving the thermal equilibration of ^{26}Al.

β Decay of ^{61}V and its Role in Cooling Accreted Neutron Star Crusts

The interpretation of observations of cooling neutron star crusts in quasipersistent x-ray transients is affected by predictions of the strength of neutrino cooling via crust Urca processes. The strength of crust Urca neutrino cooling depends sensitively on the electron-capture and β-decay ground-state-to-ground-state transition strengths of neutron-rich rare isotopes. Nuclei with a mass number of A=61 are predicted to be among the most abundant in accreted crusts, and the last remaining experimentally undetermined ground-state-to-ground-state transition strength was the β decay of ^{61}V. This Letter reports the first experimental determination of this transition strength, a ground-state branching of 8.1_{-3.1}^{+4.0}%, corresponding to a log ft value of 5.5_{-0.2}^{+0.2}. This result was achieved through the measurement of the β-delayed γ rays using the total absorption spectrometer SuN and the measurement of the β-delayed neutron branch using the neutron long counter system NERO at the National Superconducting Cyclotron Laboratory at Michigan State University. This method helps to mitigate the impact of the pandemonium effect in extremely neutron-rich nuclei on experimental results. The result implies that A=61 nuclei do not provide the strongest cooling in accreted neutron star crusts as expected by some predictions, but that their cooling is still larger compared to most other mass numbers. Only nuclei with mass numbers 31, 33, and 55 are predicted to be cooling more strongly. However, the theoretical predictions for the transition strengths of these nuclei are not consistently accurate enough to draw conclusions on crust cooling. With the experimental approach developed in this work, all relevant transitions are within reach to be studied in the future.

Bounds on Lorentz Invariance Violation from MAGIC Observation of GRB 190114C

On January 14, 2019, the Major Atmospheric Gamma Imaging Cherenkov telescopes detected GRB 190114C above 0.2 TeV, recording the most energetic photons ever observed from a gamma-ray burst. We use this unique observation to probe an energy dependence of the speed of light in vacuo for photons as predicted by several quantum gravity models. Based on a set of assumptions on the possible intrinsic spectral and temporal evolution, we obtain competitive lower limits on the quadratic leading order of speed of light modification.

ESA’s Space-Based Doppler Wind Lidar Mission Aeolus – First Wind and Aerosol Product Assessment Results

The European Space Agency (ESA) wind mission, Aeolus, hosts the first space-based Doppler Wind Lidar (DWL) world-wide. The primary mission objective is to demonstrate the DWL technique for measuring wind profiles from space, intended for assimilation in Numerical Weather Prediction (NWP) models. The wind observations will also be used to advance atmospheric dynamics research and for evaluation of climate models. Mission spin-off products are profiles of cloud and aerosol optical properties. Aeolus was launched on 22 August 2018, and the Atmospheric LAser Doppler INstrument (Aladin) instrument switch-on was completed with first high energy output in wind mode on 4 September 2018 [1], [2]. The on-ground data processing facility worked excellent, allowing L2 product output in near-real-time from the start of the mission. First results from the wind profile product (L2B) assessment show that the winds are of very high quality, with random errors in the free Troposphere within (cloud/aerosol backscatter winds: 2.1 m/s) and larger (molecular backscatter winds: 4.3 m/s) than the requirements (2.5 m/s), but still allowing significant positive impact in first preliminary NWP impact experiments. The higher than expected random errors at the time of writing are amongst others due to a lower instrument out-and input photon budget than designed. The instrument calibration is working well, and some of the data processing steps are currently being refined to allow to fully correct instrument alignment related drifts and elevated detector dark currents causing biases in the first data product version. The optical properties spin-off product (L2A) is being compared e.g. to NWP model clouds, air quality model forecasts, and collocated ground-based observations. Features including optically thick and thin particle and hydrometeor layers are clearly identified and are being validated.

Evaluation of multiplex tandem PCR (MT-PCR) assays for the detection of bacterial resistance genes among Enterobacteriaceae in clinical urines

Background

Increasing resistance drives empirical use of less potent and previously reserved antibiotics, including for urinary tract infections (UTIs). Molecular profiling, without culture, might better guide early therapy.

Objectives

To explore the potential of AusDiagnostics multiplex tandem (MT) PCR UTI assays.

Methods

Two MT-PCR assays were developed successively, seeking 8 or 16 resistance genes. Amplification was tracked in real time, with melting temperatures used to confirm product identity. Assays were variously performed on: (i) extracted DNA; (ii) cultured bacteria; (iii) urine spiked with reference strains; and (iv) bacteria harvested from clinical urines. Results were compared with those from sequencing, real-time SybrGreen PCR or phenotypic susceptibility.

Results

Performance was similar irrespective of whether DNA, cultures or urines were used, with >90% sensitivity and specificity with respect to common β-lactamases, dfr genes and aminoglycoside resistance determinants except aadA1/A2/A3, for which carriage correlated poorly with streptomycin resistance. Fluoroquinolone-susceptible and -resistant Escherichia coli (but not other species) were distinguished by the melting temperatures of their gyrA PCR products. The time from urine to results was <3 h.

Conclusions

The MT-PCR assays rapidly identified resistance genes from Gram-negative bacteria in urines as well as from cultivated bacteria. Used directly on urines, this assay has the potential to guide early therapy.

Development of a CURE course aimed at characterization of bacterial Toll/interleukin 1 receptor (TIR) domain-containing proteins

Course-based undergraduate research experiences (CUREs) can engage a large, diverse group of students in authentic research, promote student research skills, student content knowledge, scientific literacy, critical thinking and analysis skills, support student self-efficacy, and at the same time provide a means to advance faculty research productivity. These varied goals of a CURE course, at times, can prove to be competing. For example, courses aimed at providing advanced levels of student input in design of research questions, hypotheses and protocols can veer from faculty research goals. In an effort to balance these competing objectives, we designed a CURE course engaging students at Towson University with research ongoing at the University of Maryland, School of Medicine aimed at characterizing the function of bacterial Toll/interleukin 1 receptor (TIR) domain containing proteins. Bacterial TIR proteins were originally characterized as virulence factors that impede mammalian innate immune signaling, but recently also have been shown to exhibit enzymatic NADase activity. Students in the CURE course used bioinformatics analysis of modeled structures of bacterial TIRs to predict sites for NADase function and hypothesized the effects of mutations of these sites on TIR functions. Students then designed and created recombinantly-expressed proteins mutated at their predicted sites and tested their mutant proteins for both NADase function and potential inhibition of mammalian innate immune signaling. This course outline thus allowed student engagement in project design and hypothesis formation, while also maintaining projects aimed at advancing a specific faculty research program.

Characterization of a potential Escherichia coli virulence factor identified in a screen using the social amoeba phagocyte, Dictyostelium discoideum

Escherichia coli are a typical component of mammalian gut microbiota; however, a number of pathogenic strains remain a health challenge for developing countries. To identify novel bacterial virulence factors, we used the social amoeba, Dictyostelium discoideum, which preys upon soil bacteria, including E. coli, as a model for mammalian phagocytic cells. Using random mutagenesis, screening for mutant E. coli strains resistant to killing upon phagocytosis, and genomic sequencing of these resistant strains, we identified mutations in several potential genes of interest, including an E. coli gene of unknown function, yfaT. Preliminary results suggest that D. discoideum Erk signaling is reduced in response to yfaT-deficient E. coli. Furthermore, mammalian TLR4 signaling in response to yfaT-deficient E. coli also appears attenuated. Our current studies focus on characterizing differences in growth patterns for wild-type and yfaT-deficient E. coli using Biolog screenings, as well as analyzing potential differences in LPS structure in these strains. These studies are aimed at identification and characterization of novel mechanisms that may be involved in bacterial virulence. In addition, given that the development of mechanisms to resist D. discoideum predation may have contributed to the selection and maintenance of bacterial virulence factors, such as yfaT, against mammalian hosts, these studies may provide insight on the evolution of host-pathogen interactions.

Mirror-symmetry violation in bound nuclear ground states

Conservation laws are deeply related to any symmetry present in a physical system^1,2. Analogously to electrons in atoms exhibiting spin symmetries³, it is possible to consider neutrons and protons in the atomic nucleus as projections of a single fermion with an isobaric spin (isospin) of t = 1/2 (ref. ⁴). Every nuclear state is thus characterized by a total isobaric spin T and a projection T_z-two quantities that are largely conserved in nuclear reactions and decays^5,6. A mirror symmetry emerges from this isobaric-spin formalism: nuclei with exchanged numbers of neutrons and protons, known as mirror nuclei, should have an identical set of states⁷, including their ground state, labelled by their total angular momentum J and parity π. Here we report evidence of mirror-symmetry violation in bound nuclear ground states within the mirror partners strontium-73 and bromine-73. We find that a J^π = 5/2^- spin assignment is needed to explain the proton-emission pattern observed from the T = 3/2 isobaric-analogue state in rubidium-73, which is identical to the ground state of strontium-73. Therefore the ground state of strontium-73 must differ from its J ^π = 1/2^- mirror bromine-73. This observation offers insights into charge-symmetry-breaking forces acting in atomic nuclei.

Prophylactic negative wound therapy in laparotomy wounds (PROPEL trial): randomized controlled trial

BACKGROUND

Superficial surgical site infections are a common post-operative complication. They also place a considerable financial burden on healthcare. The use of prophylactic negative pressure wound therapy has been advocated to reduce wound infection rates. However, there is debate around its routine use. The purpose of this trial is to determine if prophylactic negative pressure wound therapy reduces post-operative wound complications in patients undergoing laparotomy.

METHODS/DESIGN

This multi-centre randomised controlled trial will compare standard surgical dressings (control) to two competing negative pressure wound therapy dressings (Prevena™ and PICO™). All patients will be over 18 years, who are undergoing an emergency or elective laparotomy. It is intended to enrol a total of 271 patients for the trial.

DISCUSSION

The PROPEL trial is a multi-centre randomised controlled trial of patients undergoing laparotomy. The comparison of standard treatment to two commercially available NPWT will help provide consensus on the routine management of laparotomy wounds.

TRIAL REGISTRATION

This study is registered with ClinicalTrials.gov (NCT number NCT03871023).

The importance of Antarctic krill in biogeochemical cycles

Antarctic krill (Euphausia superba) are swarming, oceanic crustaceans, up to two inches long, and best known as prey for whales and penguins - but they have another important role. With their large size, high biomass and daily vertical migrations they transport and transform essential nutrients, stimulate primary productivity and influence the carbon sink. Antarctic krill are also fished by the Southern Ocean's largest fishery. Yet how krill fishing impacts nutrient fertilisation and the carbon sink in the Southern Ocean is poorly understood. Our synthesis shows fishery management should consider the influential biogeochemical role of both adult and larval Antarctic krill.

Constraining the Neutron Star Compactness: Extraction of the ^{23}Al(p,γ) Reaction Rate for the rp Process

The ^{23}Al(p,γ)^{24}Si reaction is among the most important reactions driving the energy generation in type-I x-ray bursts. However, the present reaction-rate uncertainty limits constraints on neutron star properties that can be achieved with burst model-observation comparisons. Here, we present a novel technique for constraining this important reaction by combining the GRETINA array with the neutron detector LENDA coupled to the S800 spectrograph at the National Superconducting Cyclotron Laboratory. The ^{23}Al(d,n) reaction was used to populate the astrophysically important states in ^{24}Si. This enables a measurement in complete kinematics for extracting all relevant inputs necessary to calculate the reaction rate. For the first time, a predicted close-lying doublet of a 2_{2}^{+} and (4_{1}^{+},0_{2}^{+}) state in ^{24}Si was disentangled, finally resolving conflicting results from two previous measurements. Moreover, it was possible to extract spectroscopic factors using GRETINA and LENDA simultaneously. This new technique may be used to constrain other important reaction rates for various astrophysical scenarios.

Current clinical use of intravenous fosfomycin in ICU patients in two European countries

PURPOSE

In Europe, intravenous fosfomycin (IV) is used particularly in difficult-to-treat or complex infections, caused by both Gram-positive and Gram-negative pathogens including multidrug-resistant strains. Here, we investigated the efficacy and safety of intravenous fosfomycin under real-life conditions.

METHODS

Prospective, multi-center, and non-interventional study in patients with bacterial infections from 20 intensive care units (ICU) in Germany and Austria (NCT01173575).

RESULTS

Overall, 209 patients were included (77 females, 132 males, mean age: 59 ± 16 years), 194 of which were treated in intensive care (APACHE II score at the beginning of fosfomycin therapy: 23 ± 8). Main indications (± bacteremia or sepsis) were infections of the CNS (21.5%), community- (CAP) and hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP, 15.3%), bone and joint infections (BJI, 11%), abdominal infections (11%), and bacteremia (10.5%). Most frequently identified pathogens were S. aureus (22.3%), S. epidermidis (14.2%), Enterococcus spp. (10.8%), E. coli (12.3%) and Klebsiella spp. (7.7%). At least one multidrug-resistant (MDR) pathogen was isolated from 51 patients (24.4%). Fosfomycin was administered with an average daily dose of 13.7 ± 3.5 g over 12.4 ± 8.6 days, almost exclusively (99%) in combination with other antibiotics. The overall clinical success was favorable in 81.3% (148/182) of cases, and in 84.8% (39/46) of patients with ≥ 1 MDR pathogen. Noteworthy, 16.3% (34/209) of patients developed at least one, in the majority of cases non-serious, adverse drug reaction during fosfomycin therapy.

CONCLUSION

Our data suggest that IV fosfomycin is an effective and safe combination partner for the treatment of a broad spectrum of severe bacterial infections in critically ill patients.

Influence of patient and tumor characteristics on early therapy persistence with letrozole in postmenopausal women with early breast cancer: results of the prospective Evaluate-TM study with 3941 patients

Background

Patients' compliance and persistence with endocrine treatment has a significant effect on the prognosis in early breast cancer (EBC). The purpose of this analysis was to identify possible reasons for non-persistence, defined as premature cessation of therapy, on the basis of patient and tumor characteristics in individuals receiving adjuvant treatment with letrozole.

Patients and methods

The EvAluate-TM study is a prospective, multicenter, noninterventional study in which treatment with the aromatase inhibitor letrozole was evaluated in postmenopausal women with hormone receptor-positive EBC in the early therapy phase. Treatment persistence was evaluated at two pre-specified study visits after 6 and 12 months. As a measure of early therapy persistence the time from the start to the end of treatment (TTEOT) was analyzed. Cox regression analyses were carried out to identify patient characteristics and tumor characteristics predicting TTEOT.

Results

Out of the total population of 3941 patients with EBC, 540 (13.7%) events involving treatment cessation unrelated to disease progression were observed. This was due to drug-related toxicity in the majority of cases (73.5%). Persistence rates were 92.2%, 86.9%, and 86.3% after 6, 12, and 15 months, respectively. The main factors influencing premature treatment discontinuation were older age [hazard ratio (HR) 1.02/year], comorbidities (HR 1.06 per comorbidity), low body mass index, and lower tumor grade (HR 0.85 per grade unit).

Conclusion

These results support the view that older, multimorbid patients with low tumor grade and low body mass index are at the greatest risk for treatment discontinuation and might benefit from compliance and support programs.

Needs and preferences of informal caregivers regarding outpatient care for the elderly: a systematic literature review

BACKGROUND

Informal caregivers are an essential pillar for ensuring and maintaining the outpatient care of the frail elderly. Due to demographic changes, including an increase in the number of people in need of care as well as changing social structures (full-time employment of women, increasing number of single households, etc.) these informal care structures are fraught by considerable challenges. To support and facilitate informal caregivers in their role of nursing, it is important to identify their preferences, needs, and thus create a preference-oriented system.

METHODS

A systematic review was conducted to identify preferences and needs regarding the organization of informal care. The database searches were performed by using EMBASE, Scopus and Dimdi.

RESULTS

A total of 44 studies were included in the present review. Studies from 17 different countries provide broad international perspectives. Besides the preferences for long-term care structure, the following four principal topics were identified: (1) informational needs; (2) support needs; (3) organizational needs, and (4) needs for societal recognition.

CONCLUSION

To meet the current challenges in the outpatient or home-based care of elders, it is essential to strengthen the role of informal caregivers. Therefore, it is necessary to adopt and further develop informal care structures according to the needs of informal caregivers. However, demographic, financial and cultural aspects of each country need to be considered as these may influence the preferences and needs of informal caregivers.

Influence of side-effects on early therapy persistence with letrozole in post-menopausal patients with early breast cancer: Results of the prospective EvAluate-TM study

BACKGROUND

Endocrine treatment (ET) with an aromatase inhibitor (AI) is the treatment of choice in post-menopausal patients with hormone receptor-positive early breast cancer (EBC). However, adverse events (AEs) often lead to treatment discontinuation. This analysis aimed to identify side-effects that lead to patients failing to persist with letrozole treatment.

PATIENTS AND METHODS

Post-menopausal hormone receptor-positive EBC patients starting ET with letrozole were enroled in EvAluate-TM, a non-interventional study. Information regarding treatment compliance and persistence was gathered in months 6 and 12. Persistence was defined as the time from 30 d after the start to the end of treatment. The influence on persistence of musculoskeletal syndrome, menopausal disorder, sleep disorder and other AEs within the first 30 d was analysed using Cox regression analyses.

RESULTS

Among 3887 patients analysed, the persistence rate after 12 months was >85%. In all, 568 patients (14.6%) discontinued the treatment, 358 of whom (63.0%) did so only because of side-effects. The main AEs influencing persistence were musculoskeletal symptoms (hazard ratio [HR] 2.55; 95% confidence interval [CI], 1.90-3.42), sleep disorders (HR 1.95; 95% CI, 1.41-2.70) and other AEs (HR 2.03; 95% CI, 1.51-2.73). Menopausal disorder was not associated with non-persistence (HR 1.17; 95% CI, 0.74-1.84).

CONCLUSIONS

These results suggest that side-effects of AIs such as musculoskeletal syndrome and sleep disorder lead to ET discontinuation within the first treatment year in significant numbers of EBC patients. Compliance programmes adapted for subgroups that are at risk for early non-persistence might help to ensure the recommended therapy duration.

CLINICAL TRIALS NUMBER

CFEM345DDE19.

Greenland records of aerosol source and atmospheric lifetime changes from the Eemian to the Holocene

The Northern Hemisphere experienced dramatic changes during the last glacial, featuring vast ice sheets and abrupt climate events, while high northern latitudes during the last interglacial (Eemian) were warmer than today. Here we use high-resolution aerosol records from the Greenland NEEM ice core to reconstruct the environmental alterations in aerosol source regions accompanying these changes. Separating source and transport effects, we find strongly reduced terrestrial biogenic emissions during glacial times reflecting net loss of vegetated area in North America. Rapid climate changes during the glacial have little effect on terrestrial biogenic aerosol emissions. A strong increase in terrestrial dust emissions during the coldest intervals indicates higher aridity and dust storm activity in East Asian deserts. Glacial sea salt aerosol emissions in the North Atlantic region increase only moderately (50%), likely due to sea ice expansion. Lower aerosol concentrations in Eemian ice compared to the Holocene are mainly due to shortened atmospheric residence time, while emissions changed little.

Past climate changes in Greenland ice were accompanied by large aerosol concentration changes. Here, the authors show that by correcting for transport effects, reliable source changes for biogenic aerosol from North America, sea salt aerosol from the North Atlantic, and dust from East Asian deserts can be derived.

Medizinische Dokumentation und elektronische Datenverarbeitung in einem Universitätsklinikum (Planungen —Erfahrungen—Vorschläge)

Im Klinikum Steglitz wird eine medizinische Befunddokumentation (Basisdokumentation) aufgebaut, die pro Krankengeschichte 2 bis 38 Lochkarten umfaßt und zunächst auf Magnetband gespeichert wird. Neben 2 Programmen zur Kontrolle, Zusammenführung und Speicherung der Daten gibt es ein Programm zum sachbezogenen Durchmustern des Datenbestandes. Dabei können mehrere Aspekte durch die logischen Verknüpfungen UND sowie UND NICHT zu einer Suchanfrage verbunden werden. Die Ergebnisse der Suchanfrage werden wahlweise in einer Kurzfassung (1 Zeile/Krankengeschichte) oder in einer Langfassung (1 Seite/Krankengeschichte) gedruckt. Diese enthält die Angaben zur Person, Diagnosen, besondere diagnostische und besondere therapeutische Maßnahmen. Danach kann der Anfragende entscheiden, welche Krankenakten er anfordern will.

Phobische, Angst- und Persönlichkeitsstörungen sowie soziale Beeinträchtigung ambulanter erwachsener Patienten mit Aufmerksamkeits-defizit-/Hyperaktivitätsstörungen

Ziel der vorliegenden Arbeit war es, phobische, Angstund Persönlichkeitsstörungen ambulanter Patienten mit Aufmerksamkeitsdefizit-/Hyperaktivitätsstörungen (ADHS) zu erfassen und mit ihrem sozialen Aktivitätsniveau sowie sozialen Belastungen und Einschränkungen in Beziehung zu setzen.

Es wurden 48 unbehandelte ADHS-Patienten auf die genannten psychischen Störungen (nach DSM-IV) und ihre Selbsteinschätzungen hinsichtlich sozialer Funktionen untersucht.

Das soziale Aktivitätsniveau war sehr niedrig, die sozialen Belastungen und Einschränkungen hoch bis sehr hoch. Diese Selbsteinschätzungen korrelierten mit einer erheblichen psychiatrischen Komorbidität, sowohl hinsichtlich phobischer bzw. Angstals auch Persönlichkeitsstörungen. Besonders die Häufigkeit eher internalisierender (phobischer und Cluster-C-)Störungen lässt eine erhebliche epidemiologische Grauzone hinsichtlich Erwachsener mit undiagnostizierter ADHS und psychiatrischer Komorbidität, bei gleichwohl starkem Leidensdruck, vermuten.

First Measurement of Transverse-Spin-Dependent Azimuthal Asymmetries in the Drell-Yan Process

The first measurement of transverse-spin-dependent azimuthal asymmetries in the pion-induced Drell-Yan (DY) process is reported. We use the CERN SPS 190  GeV/c π^{-} beam and a transversely polarized ammonia target. Three azimuthal asymmetries giving access to different transverse-momentum-dependent (TMD) parton distribution functions (PDFs) are extracted using dimuon events with invariant mass between 4.3  GeV/c^{2} and 8.5  GeV/c^{2}. Within the experimental uncertainties, the observed sign of the Sivers asymmetry is found to be consistent with the fundamental prediction of quantum chromodynamics (QCD) that the Sivers TMD PDFs extracted from DY have a sign opposite to the one extracted from semi-inclusive deep-inelastic scattering (SIDIS) data. We present two other asymmetries originating from the pion Boer-Mulders TMD PDFs convoluted with either the nucleon transversity or pretzelosity TMD PDFs. A recent COMPASS SIDIS measurement was obtained at a hard scale comparable to that of these DY results. This opens the way for possible tests of fundamental QCD universality predictions.

Biologic therapies for refractory juvenile dermatomyositis: five years of experience of the Childhood Arthritis and Rheumatology Research Alliance in North America

BACKGROUND

The prognosis of children with juvenile dermatomyositis (JDM) has improved remarkably since the 1960's with the use of corticosteroid and immunosuppressive therapy. Yet there remain a minority of children who have refractory disease. Since 2003 the sporadic use of biologics (genetically-engineered proteins that usually are derived from human genes) for inflammatory myositis has been reported. In 2011-2016 we investigated our collective experience of biologics in JDM through the Childhood Arthritis and Rheumatology Research Alliance (CARRA).

METHODS

The JDM biologic study group developed a survey on the CARRA member experience using biologics for Juvenile DM utilizing Delphi consensus methods in 2011-2012. The survey was completed online by the CARRA members interested in JDM in 2012. A second survey was similarly developed that provided more opportunity to describe their experiences with biologics in JDM in detail and was completed by CARRA members in Feb 2013. During three CARRA meetings in 2013-2015, nominal group techniques were used for achieving consensus on the current choices of biologic drugs. A final survey was performed at the 2016 CARRA meeting.

RESULTS

One hundred and five of a potential 231 pediatric rheumatologists (42%) responded to the first survey in 2012. Thirty-five of 90 had never used a biologic for Juvenile DM at that time. Fifty-five of 91 (denominators vary) had used biologics for JDM in their practice with 32%, 5%, and 4% using rituximab, etanercept, and infliximab, respectively, and 17% having used more than one of the three drugs. Ten percent used a biologic as monotherapy, 19% a biologic in combination with methotrexate (mtx), 52% a biologic in combination with mtx and corticosteroids, 42% a combination of a biologic, mtx, corticosteroids (steroids), and an immunosuppressive drug, and 43% a combination of a biologic, IVIG and mtx. The results of the second survey supported these findings in considerably more detail with multiple combinations of drugs used with biologics and supported the use of rituximab, abatacept, anti-TNFα drugs, and tocilizumab in that order. One hundred percent recommended that CARRA continue studying biologics for JDM. The CARRA meeting survey in 2016 again supported the study and use of these four biologic drug groups.

CONCLUSIONS

Our CARRA JDM biologic work group developed and performed three surveys demonstrating that pediatric rheumatologists in North America have been using multiple biologics for refractory JDM in numerous scenarios from 2011 to 2016. These survey results and our consensus meetings determined our choice of four biologic therapies (rituximab, abatacept, tocilizumab and anti-TNFα drugs) to consider for refractory JDM treatment when indicated and to evaluate for comparative effectiveness and safety in the future. Significance and Innovations This is the first report that provides a substantial clinical experience of a large group of pediatric rheumatologists with biologics for refractory JDM over five years. This experience with biologic therapies for refractory JDM may aid pediatric rheumatologists in the current treatment of these children and form a basis for further clinical research into the comparative effectiveness and safety of biologics for refractory JDM.