Prospective Outpatient Follow-Up of Early Cognitive Impairment in Patients with Mild Traumatic Brain Injury and Intracranial Hemorrhage

INTRODUCTION

Mild traumatic brain injury (mTBI) encompasses a spectrum of disability including early cognitive impairment (ECI). The Brain Injury Guidelines (BIG) suggest mTBI patients can be safely discharged from the Emergency Department. Although half of mTBI patients with intracranial hemorrhage (ICH) have evidence of ECI, it is unclear what percentage of these patients' ECI persists after discharge. We hypothesize a significant proportion of trauma patients with mTBI and ECI at presentation have persistent ECI at 30-day follow-up.

METHODS

A single-center prospective cohort study including adult trauma patients with ICH or skull fracture plus a Glasgow coma scale (GCS) of 13-15 on arrival was performed. Participants were screened for ECI using the Rancho Los Amigos Scale (RLA), and ECI was defined as a RLA < 8. We compared ECI and non-ECI groups for demographics, injury profile, computed tomography (CT) imaging (e.g., Rotterdam CT score) and outcomes with bivariate analysis. 30-day follow up phone calls were performed to re-evaluate RLA for persistent ECI and concussion symptoms.

RESULTS

From 62 patients with ICH or skull fracture and mTBI, 21 (33.9%) had ECI. Patients with ECI had a higher incidence of subarachnoid hemorrhage (85.7% versus 46.3%, p=0.003) and higher Rotterdam CT score (p=0.004) compared to those without ECI. On 30-day follow up, 6 of 21 patients (26.6%) had persistent ECI. In addition, 7 (33.3%) patients had continued concussion symptoms.

CONCLUSION

Over one-third of mTBI patients with ICH had ECI. At 30-day post-discharge follow-up over one-fourth of these patients had persistent ECI and 33% had concussion symptoms. This highlights the importance of identifying ECI prior to discharge as a significant portion may have ongoing difficulties reintegrating into work and society.

Domestic firearm violence against women (2018-2021)

Background

Over 50 % of US female homicides occur during domestic violence, with half involving firearms. Public health measures to control COVID-19 may have isolated individuals with abusive partners at a time when firearm sales and new firearm ownership surged. This study sought to evaluate trends in domestic firearm violence (DFV) over time, hypothesizing that rates of DFV increased in the wake of COVID-19.

Materials and methods

A retrospective query of the Gun Violence Archive (2018-2021) was conducted for incidents of DFV. The primary outcome was the number of DFV-related shootings. Statistical testing, including one-way and two-way ANOVAs, was performed to compare monthly rates of DFV over time and to compare DFV per 100,000 women in states with strong versus weak gun laws.

Results

Average monthly DFV incidents rose nationwide during this study's time period, though injuries and fatalities did not. States with weaker gun laws had increased incidents, deaths, and injuries from 2018 to 2021 (all p<0.05). In a two-way ANOVA, stronger gun laws were associated with fewer incidents of DFV when compared with weaker gun law states. We also found that the use of a long gun in DFV more often resulted in a victim's death when compared to a handgun (p<0.01).

Conclusion

DFV incidents increased over time. States with weaker gun laws bore the brunt of the violence, demonstrating that DFV may be curtailed through legislative efforts. Methods of injury prevention aimed at preventing and reducing domestic violence and improving firearm safety may curtail DFV.

Measuring ART Adherence Among Young Adults with Perinatally Acquired HIV: Comparison Between Self-report, Telephone-Based Pill Count, and Objective Pharmacologic Measures

Tenofovir diphosphate (TVF-DP) can be quantified in red blood cells (RBCs) and dried blood spots (DBS) and can objectively measure ART adherence and predict viral suppression. Data on the association of TFV-DP with viral load are very limited in adolescents and young adults (AYA) living with perinatally-acquired HIV (PHIV), as are data comparing TFV-DP to other measures of ART adherence, such as self-report and unannounced telephone pill count. Viral load and ART adherence (self-report, TFV-DP and unannounced telephone pill count) were assessed and compared among 61 AYAPHIV recruited from an ongoing longitudinal study (CASAH) in New York City.

Obesity Does Not Increase Risk for Mortality in Severe Sepsis Trauma Patients

INTRODUCTION

The prevalence of obesity in the United States is up to 40% in adults. Obese patients with severe sepsis have a lower mortality rate compared with normal body mass index (BMI) patients. We hypothesized that trauma patients with severe sepsis and obese BMI will have a decreased mortality risk in comparison with normal BMI patients.

METHODS

The Trauma Quality Improvement Program (2017) was queried for adult trauma patients with documented BMI and severe sepsis. Patients were grouped based on BMI: non-obese trauma patients (nOTP) BMI <30 kg/m2 and obese trauma patients (OTP) ≥30 kg/m2. A multivariable logistic regression model was used for analysis of mortality.

RESULTS

From 1246 trauma patients with severe sepsis, 566 (42.4%) were nOTP and 680 (57.6%) were OTP. OTP had increased length of stay (LOS) (19 vs 21 days, P < .001), intensive care unit (ICU) LOS (13 vs 18 days, P < .001) and ventilator days (10 vs 11 days, P < .001). After adjusting for covariates, when compared to normal BMI patients, patients who were overweight (OR 1.11 CI .875-1.41 P = .390), obese (OR .797 CI .59-1.06 P = .126), severely obese (OR .926 CI .63-1.36 P = .696) and morbidly obese (OR 1.448 CI 1.01-2.07 P = .04) all had a similar associated risk for mortality compared to patients with normal BMI.

CONCLUSION

In adult trauma patients with severe sepsis, this national analysis demonstrated OTP had increased LOS, ICU LOS, and ventilator days compared to nOTP. However, patients with increasing degrees of obesity had similar associated risk of mortality compared to trauma patients with severe sepsis and a normal BMI.

Implications of Using Chatbots for Future Surgical Education

This quality improvement study investigates whether a chatbot can accurately answer surgery clerkship multiple-choice questions, explain incorrect answers, assess question difficulty, and generate a high-quality examination question.

Reducing SDG complexity and informing environmental management education via an empirical six-dimensional model of sustainable development

Effective environmental management higher education programs are essential for achieving the Sustainable Development Goals (SDGs). Yet SDG complexity means many educators focus on environment and avoid critical but challenging social, economic and governance aspects. This undermines the calls for comprehensive environmental management education that effectively integrates all key sustainability dimensions. Various sustainability models, mostly founded on the pillars of sustainability, have consequently evolved. They are generally conceptual and/or involve subjective categorization of the SDGs, which has led to demands for more empirically based models. This study has consequently used a mixed-method approach to model Australian university students' SDG perceptions. The qualitative research identified three items (on average) for each SDG, and a quantitative survey then measured their perceived importance. Factor analysis generated a robust six-dimensional sustainable development model comprised of 37 SDG items, which validates environment and governance aspects of some traditional pillar-based sustainability models. It has also uncovered new social and economic dimensions: social harmony and equality; sustainable consumption and socioeconomic behaviors; sustainable production, industry and infrastructure; and acute poverty reduction. These findings can help educators, organizations and citizens to categorize and integrate SDGs via better understanding of their key dimensions and impacts.

Evaluation of Metastatic Potential in Esophageal and Gastroesophageal Junction (GEJ) Cancer with Adherence to Elective Nodal Volume Guidelines: A Retrospective Analysis of Elective Nodal Irradiation

PURPOSE/OBJECTIVE(S)

In 2015, expert guidelines on esophageal/GEJ cancer contouring for intensity-modulated radiation therapy (IMRT) were published in IJROBP, which delineate recommended elective nodal basins (celiac, para-aortic, gastrohepatic ligament, supraclavicular) to be irradiated depending on the primary tumor location. We hypothesize that incomplete coverage of these areas increases the risk of the development of distant failures.

MATERIALS/METHODS

Patients treated for non-metastatic esophageal or GEJ cancer with chemoradiotherapy pre-operatively or definitively from 2012 to 2021 were retrospectively identified from a single institution database. Radiation plans of eligible patients were then analyzed by tumor location. Plans were deemed guideline-compliant if radiation dose coverage, between 41.4 to 45 Gy, encompassed nodal basins recommended by the 2015 guidelines. The primary endpoint of this study was the overall rate of distant disease. Other endpoints included locoregional failures, defined as failures within the radiation field but outside of the primary tumor, and local failures within the gross tumor volume. Summary and descriptive statistics were used to define collected variables. Differences were measured using chi-square and Fisher's exact test for categorical variables and two-sided t-tests for continuous measures. Assessment of distant, locoregional, and local failures were assessed using univariate logistic regression with statistical significance at p < 0.05.

RESULTS

With a median follow-up of 25.0 months, 37 patients, with a median age of 66, were included in the study. Most patients were male (94.6%) with cT3 (54.1%), cN0 (43.2%), moderately differentiated (47.1%) adenocarcinoma (75.7%) located at the GEJ (56.8%). The median radiation dose used was 50.4 Gy, with the majority of patients receiving concurrent carboplatin and paclitaxel (83.8%). Four patients received induction chemotherapy and 20 (55.6%) underwent esophagectomy. When examining guideline compliance, 17 (46.0%) radiation plans demonstrated adequate ENI. The most common improperly covered nodal basin was para-aortic (65.0%), followed by gastrohepatic (30.0%). No patients with sufficient ENI coverage (0/17) developed distant failure compared to 45.0% (9/20) with insufficient coverage (p = 0.001). There were inappreciable differences in locoregional or local failure rates between those with and without complete ENI. Patients with complete ENI were more likely to be of larger craniocaudal length (p = 0.007) or have N2 disease (p = 0.003). When examining other tumor characteristics (histologic subtype, location, HER2 status, esophagectomy rate) of patients with and without complete ENI, no further differences were noted.

CONCLUSION

These results suggest that proper coverage of nodal basins, when indicated by expert guidelines, could improve distant metastasis. ENI analysis of previous prospective CRT studies for esophageal cancer could validate these findings.

Effect of in-water administration of quorum system inhibitors in broilers' productive performance and intestinal microbiome in a mild necrotic enteritis challenge

The poultry industry has been facing the impact of necrotic enteritis (NE), a disease caused by the bacterium Clostridium perfringens producing the haemolytic toxin NetB. NE severity may vary from mild clinical to prominent enteric signs causing reduced growth rates and affecting feed conversion ratio. NetB production is controlled by the Agr-like quorum-sensing (QS) system, which coordinates virulence gene expression in response to bacterial cell density. In this study, the peptide-containing cell-free spent media (CFSM) from Enterococcus faecium was tested in NE challenged broilers in two battery cage and one floor pen studies. Results showed a significant reduction of NE mortality. Metagenomic sequencing of the jejunum microbiome revealed no impact of the CFSM on the microbial community, and growth of C. perfringens was unaffected by CFSM in vitro. The expression of QS-controlled virulence genes netB, plc and pfoA was found to be significantly repressed by CFSM during the mid-logarithmic stage of C. perfringens growth and this corresponded with a significant decrease in haemolytic activity. Purified fractions of CFSM containing bioactive peptides were found to cause reduced haemolysis. These results showed that bioactive peptides reduce NE mortality in broilers by interfering with the QS system of C. perfringens and reducing bacterial virulence. Furthermore, the microbiome of C. perfringens-challenged broilers is not affected by quorum sensing inhibitor containing CFSM.

Trends in mass shootings in the United States (2013-2021): A worsening American epidemic of death

BACKGROUND

Mass shootings represent a significant problem in the United States (US). This study aimed to examine trends in mass shootings in the US over time.

METHODS

Retrospective mass shooting data (1/2013-12/2021) were collected from the Gun Violence Archive. A scatterplot was constructed showing predicted (extrapolated from 2013 to 2019) versus actual total mass shootings in 2020 and 2021. Multivariate linear regressions were performed to evaluate trends in mass shootings over time, associated with gun law strength.

RESULTS

Mass shooting incidents, injuries, and deaths in 2020 and 2021 exceeded extrapolations from previous years. When comparing 2019 to 2020, stronger gun laws were associated with decreased monthly mass shooting deaths. For these same strong gun law states, monthly mass shooting deaths decreased when comparing 2019 to 2021 and comparing 2020 to 2021.

CONCLUSIONS

US mass shootings have increased over the past decade. Stronger gun laws appear associated with fewer monthly mass shooting-related deaths. Firearm-related legislation may at least partially, curtail the worsening of this substantial "American problem" of mass shootings.

A171 INTESTINAL INTERFERON-LAMBDA RECEPTOR 1 EXPRESSION AND RESPONSES ARE SIGNIFICANTLY DECREASED IN PEDIATRIC INFLAMMATORY BOWEL DISEASE PATIENTS

Background

While interferon-lambdas (IFN-λs) were initially discovered for their role in antiviral immunity at mucosal barriers such as the lung and gut, there are many unanswered questions for how IFN-λs uniquely dampen inflammatory immune responses. In mouse colitis models, IFN-λs were shown to play a significant role in promoting epithelial barrier integrity and mucosal healing. Microbes present in the gut naturally induce IFN-λs, but how chronic inflammation, such as in patients with inflammatory bowel diseases (IBD), affects IFN-λ biology has not been well studied, especially in humans.

Purpose

Here, we tested the hypothesis that children with active, more severe IBD would present with lower intestinal IFN-λR levels and IFN-λ responses which could contribute to IBD pathology through exacerbated inflammation, decreased mucosal healing and impaired barrier function.

Method

We screened 14 novel antibodies to find the optimal clone that accurately stains the unique IFN-λ receptor subunit (IFN-λR1) protein in human intestinal tissue and IFN-λR1 levels were quantified by immunohistochemistry and flow cytometry in biopsy samples from children without IBD, Crohn’s disease, or ulcerative colitis (n=35 total). Fresh patient biopsies (ascending colon or terminal ileum) were also treated in media +/- IFN-λ for 24hrs using our novel ex vivo biopsy assay and changes in gene expression were quantified by RT-qPCR. Intestinal washes were also collected and microbes profiled by shotgun metagenomics.

Result(s)

We identified 2 new antibodies that accurately stained human cell lines and immune cells known to express IFN-λR1 protein (gut epithelial cells and B cells). We found that IFN-λ receptor (IFN-λR) levels are significantly reduced in gut epithelial and immune cells within pediatric IBD intestinal tissue, even at non-inflamed sites (p<0.01, 30-50% reduction) and this was even more pronounced when comparing moderate/severe disease compared to children with no disease activity. This led to lower IFN-λ responsiveness in IBD compared to non-IBD biopsies when investigating IFN-stimulated gene expression (p<0.05, up to 7-fold reduction). Paired patient gut microbe analyses identified specific species that correlated with changes in IFN-λ receptor expression.

Conclusion(s)

Together, our findings demonstrate pediatric IBD patients may be less able to induce critical IFN-λ-mediated antimicrobial responses and protective anti-inflammatory pathways. This work supports the goal to restore and promote IFN-λ responses as a novel therapeutic strategy for pediatric IBD.

Please acknowledge all funding agencies by checking the applicable boxes below

Other

Please indicate your source of funding;

Children's Hospital Research Institute of Manitoba

Disclosure of Interest

None Declared

Understanding Audiobook Apps’ Consumption Values and Their Implications for Promoting Audiobooks in Vietnam

Audiobooks have recently become more prevalent in the publishing industry. Vietnam is a potential market for audiobook companies, and audiobook apps are soaring in popularity in this country. This study examines how consumers perceive audiobook apps’ consumption values, including functional value, social value, emotional value, epistemic value, and conditional value. Data were obtained from 1041 Vietnamese consumers using an online survey method. Results show that conditional value had the highest mean score, followed by epistemic value and emotional value. Notably, consumers hold negative perceptions of audiobook apps’ functional value, especially regarding their reliability and consistency. The findings also suggest that consumers will use audiobook apps more if there are more discounts, promotional benefits, and books available in the apps. This study is the first to explain how consumers perceive the different consumption values of audiobook apps, which have important implications for audiobook companies, publishers and app developers to promote audiobooks.

Investigating employees' deviant work behavior in the hotel industry during COVID-19: Empirical evidence from an emerging country

Employees in the hotel industry are among the most vulnerable groups that have been severely affected by the COVID-19 pandemic. Anchored on the general strain theory, transactional theory of stress and coping, and theory of justice, this study investigates the mechanism through which hotel employees' perceived job insecurity affects their deviant work behavior during the COVID-19 pandemic. A survey method was used to collect three-wave sample data from 988 hotel employees in popular tourist destinations in Vietnam. Multivariate data analysis reveals a positive relationship between perceived job insecurity and deviant work behavior, and this relationship is mediated by psychological distress. Furthermore, abusive supervision positively moderates the association between psychological distress-deviant work behavior and the indirect influence of perceived job insecurity on deviant work behavior through psychological distress. These findings are useful for hotel managers seeking to manage and develop employees in a global health crisis such as COVID-19.

Investigating anti-D in an individual with the weak D type 2 genotype

Anti-D in individuals with a weak D phenotype is an unexpected finding that may require additional investigation to determine whether the anti-D is an autoantibody or alloantibody. Further investigation may also include assessment of the patient's RHD genotype and exclusion of anti-G. We present a case of an 84-year-old man with the weak D type 2 genotype who developed an unexpected anti-D along with anti-C. Individuals with the weak D type 2 genotype are thought not to be at risk for developing alloanti-D, although the distinction between alloanti-D and autoanti-D may be difficult to ascertain. Furthermore, investigations may affect transfusion recommendations. This patient was restricted to crossmatch-compatible, D-C- red blood cells even though the clinical significance of the anti-D was uncertain. This report is one of a few reported cases of an individual with the weak D type 2 genotype with demonstrable anti-D but without evidence for alloanti-D.

Search for an Axionlike Particle in B Meson Decays

Axionlike particles (ALPs) are predicted in many extensions of the standard model, and their masses can naturally be well below the electroweak scale. In the presence of couplings to electroweak bosons, these particles could be emitted in flavor-changing B meson decays. We report herein a search for an ALP, a, in the reaction B^{±}→K^{±}a, a→γγ using data collected by the BABAR experiment at SLAC. No significant signal is observed, and 90% confidence level upper limits on the ALP coupling to electroweak bosons are derived as a function of ALP mass, improving current constraints by several orders of magnitude in the range 0.175  GeV<m_{a}<4.78  GeV.

Factors associated with favorable outcomes in patients undergoing transcatheter edge-to-edge mitral valve repair (TEER) with the mitraclip device

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter edge-to-edge mitral valve repair (TEER) has over the years become a viable alternative to surgery in high-risk patients with severe symptomatic mitral regurgitation (MR). Selection of optimal candidates who will benefit from the procedure remains challenging.

Our study aims to determine clinical, echocardiographic and procedural factors associated with favorable outcomes after mitraclip implantation. 

Methods

We retrospectively analyzed the data concerning patients who underwent MitraClip implantation for symptomatic severe MR in our institution. 

All patients underwent a clinical evaluation and a transthoracic echocardiography before the procedure, and at follow up (between one and up to three months after the index procedure). 

A clinical endpoint combining absence of cardiovascular death, absence of rehospitalization for heart failure and improvement of at least 1 class New York Heart Association NYHA at three months, was used to define a good response.

Results

Among 109 patients referred to our institution for TEER since January 2018, 106 had a successful clip implantation and were included in our study. 76 of them had a primary MR and 30 others a secondary mitral regurgitation (SMR). The primary endpoint was achieved in 65% of those patients.  Reduction of MR severity to less than grade 2+ was achieved in 87% of the patients. 

A high body mass index (p = 0.03), a high level of NT-proBNP at admission (p = 0.02), the association with at least a moderate tricuspid regurgitation prior to mitraclip implantation (p = 0.02) and a severe residual mitral regurgitation (p = 0.01) were predictive of a worse outcome in all patients. In the group of secondary MR, patients who reached the primary endpoint had significantly a lower telediastolic diameter (p = 0.02). A post procedural transvalvular mitral gradient superior to 4.4 mmHg was associated with a worse prognosis in patients with primary mitral regurgitation (p = 0.004) but not in the group of secondary mitral regurgitation (p = 0.7). Furthermore, the ratios EROA/LVEDV and VR/LVEDV defining proportionate mitral regurgitation were not correlated to any benefit in the secondary MR group. 

Conclusion

Our study in real life patients found some elements supporting the results of former studies about predictors of outcomes after mitraclip treatment. Tricuspid regurgitation prior to the procedure and an elevated mitral valve pressure gradient after clip implantation are correlated with a worse prognosis. In accordance with recent literature, an elevate mean gradient seems to have less impact on prognosis in SMR, fostering to get optimal MR reduction in those patients. Identifying criteria that would predict insufficient benefit of Mitraclip implantation is necessary to avoid futility.

Results of a single-arm pilot study of 32P microparticles in unresectable locally advanced pancreatic adenocarcinoma with gemcitabine/nab-paclitaxel or FOLFIRINOX chemotherapy

Background

Unresectable locally advanced pancreatic cancer (LAPC) is generally managed with chemotherapy or chemoradiotherapy, but prognosis is poor with a median survival of ∼13 months (or up to 19 months in some studies). We assessed a novel brachytherapy device, using phosphorous-32 (³²P) microparticles, combined with standard-of-care chemotherapy.

Patients and methods

In this international, multicentre, single-arm, open-label pilot study, adult patients with histologically or cytologically proven unresectable LAPC received ³²P microparticles, via endoscopic ultrasound-guided fine-needle implantation, planned for week 4 of 5-fluorouracil, leucovorin, irinotecan and oxaliplatin (FOLFIRINOX) or gemcitabine/nab-paclitaxel chemotherapy, per investigator’s choice. The primary endpoint was safety and tolerability measured using Common Terminology Criteria for Adverse Events version 4.0. The lead efficacy endpoint was local disease control rate at 16 weeks.

Results

Fifty patients were enrolled and received chemotherapy [intention-to-treat (ITT) population]. Forty-two patients received ³²P microparticle implantation [per protocol (PP) population]. A total of 1102 treatment-emergent adverse events (TEAEs) were reported in the ITT/safety population (956 PP), of which 167 (139 PP) were grade ≥3. In the PP population, 41 TEAEs in 16 (38.1%) patients were possibly or probably related to ³²P microparticles or implantation procedure, including 8 grade ≥3 in 3 (7.1%) patients, compared with 609 TEAEs in 42 (100%) patients attributed to chemotherapy, including 67 grade ≥3 in 28 patients (66.7%). The local disease control rate at 16 weeks was 82.0% (95% confidence interval: 68.6% to 90.9%) (ITT) and 90.5% (95% confidence interval: 77.4% to 97.3%) (PP). Tumour volume, carbohydrate antigen 19-9 levels, and metabolic tumour response at week 12 improved significantly. Ten patients (20.0% ITT; 23.8% PP) had surgical resection and median overall survival was 15.2 and 15.5 months for ITT and PP populations, respectively.

Conclusions

Endoscopic ultrasound-guided ³²P microparticle implantation has an acceptable safety profile. This study also suggests clinically relevant benefits of combining ³²P microparticles with standard-of-care systemic chemotherapy for patients with unresectable LAPC.

•

PanCO is the first prospective study of intratumoural ³²P microparticles for locally advanced pancreatic cancer (LAPC).

•

This single-arm study assessed a novel brachytherapy (³²P microparticles) combined with standard-of-care chemotherapy.

•

Treatment-emergent adverse events attributable to ³²P microparticle implantation were relatively infrequent.

•

Local disease control rate at 16 weeks (82%) and resection rate (20%) suggest a clinical benefit of ³²P microparticles.

•

The results suggest that ³²P microparticles may address a significant unmet need in patients with unresectable LAPC.

Feasibility, safety and long term outcomes of complex left main bifurcation treatment using the nano inverted t stenting: a multicentre registry

Background

The role of double stenting techniques in distal bifurcation left main (LM) disease has gaining interest over the latest years.

Purpose

We present the 3-year multicentre registry outcomes of dual stenting using ultra-thin strut stents and the Nano Inverted-T (NIT) technique in complex unprotected true LM bifurcation disease.

Methods

We analysed the procedural and medical data of consecutive patients enrolled between 1st January 2014 and 1st December 2019 in a multicentre registry for complex LM bifurcation disease treated with the double stenting technique called NIT due contraindications and/or refusal to surgical treatment. Target lesion failure (TLF) was defined as the composite of cardiovascular death, target-vessel MI (TVMI) and clinically driven target lesion revascularization (TLR).

Results

Among two hundred-ninety-five patients (138 males, mean age 70.3±12.8 years), post-operative success was achieved in 100% of cases. Contrast volume, procedural time, and radiation exposure were 139.2±23.4 ml, 15.3±4.9 min, and 1080±1034 cGy/m2 (Figure), respectively. At a mean follow-up of 39.5±0.6 months TLF rate was 6.1% (n=18) while TLR and cardiovascular mortality rates were 3.0 (n=9) and 2.6% (n=8), respectively. Clinically driven angiographic follow-up was available in 26.4% of patients at a mean time from the procedure of 7.5±0.4 months. Clinically restenosis rate was 3.3%.

Conclusions

Revascularization of complex LM bifurcation disease using the NIT double stenting technique resulted feasible and safe with a low incidence of TLF, excellent survival rate and no stent thrombosis. Figure 1.The NIT technique is based on the use of ultra-thin strut (≤80 micron) stents and double stenting starting with side branch stenting frst. The side branch stent is precisely positioned with one possibly only strut protruding into the main vessel which is balloon crushed before the implantation of the main branch stenting. The Proximal optimization technique (POT)–snuggle kissing–POT sequence is mandatory to ensure the coverage of the side branch ostium by both side branch and main branch stents. Snuggle kissing was performed placing the LCX balloon with the proximal marker at the middle rather than at the proximal marker of the LM-LAD balloon, in order to minimize the elliptical deformation of the LM stent.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Amide proton transfer-weighted MRI in the clinical setting - correlation with dynamic susceptibility contrast perfusion in the post-treatment imaging of adult glioma patients at 3T

INTRODUCTION

We investigated the correlation between amide proton transfer-weighted magnetic resonance imaging (APTw MRI) and dynamic susceptibility contrast (DSC) perfusion in order to assess the potential of APTw MRI as an alternative to DSC in adult brain tumor (glioma) imaging.

METHODS

After Ethical Committee approval, forty adult patients, treated for histopathologically confirmed glioma (World Health Organization (WHO) grade II-IV), were prospectively imaged at 3 Tesla (3 T) with DSC perfusion and a commercially available three-dimensional (3D) APTw sequence. Two consultant neuroradiologists independently performed region of interest (ROI) measurements on relative cerebral blood volume (rCBV) and APTw maps, co-registered with anatomical images. The correlation APTw MRI-DSC perfusion was assessed using Spearman's rank-order test. Inter-observer agreement was evaluated by the intraclass correlation coefficient (ICC) and Bland-Altman (BA) plots.

RESULTS

A statistically significant moderately strong positive correlation was observed between maximum rCBV (rCBV_max) and maximum APTw (APTw_max) values (observer 1: r = 0.73; p < 0.01; observer 2: r = 0.62; p < 0.01). We found good inter-observer agreement for APTw_max (ICC = 0.82; 95% confidence interval (CI) 0.66-0.90), with somewhat broad outer 95% CI for the BA Limits of Agreement (LoA) (-1.6 to 1.9). ICC for APTw_max was higher than ICC for rCBV_max (ICC = 0.74; 95%; CI 0.50-0.86), but the difference was not statistically significant.

CONCLUSION

APTw_max values correlate positively with rCBV_max in patients treated for brain glioma. APTw imaging is a reproducible technique, with some observer dependence. Results need to be confirmed by a larger population analysis.

IMPLICATIONS FOR PRACTICE

APTw MRI can be a useful addition to glioma follow-up imaging and a potential alternative to DSC perfusion, especially in patients where contrast agent is contraindicated.

Functional electrical stimulation (FES)-assisted rowing combined with zoledronic acid, but not alone, preserves distal femur strength and stiffness in people with chronic spinal cord injury

We investigated the effect of 12 months of functional electrical stimulation-assisted rowing with and without zoledronic acid (ZA) on computationally estimated bone strength and stiffness in individuals with spinal cord injury. We found that rowing with ZA, but not rowing alone, improved stiffness at the distal femur, but not the proximal tibia.

INTRODUCTION

People with spinal cord injury (SCI) have high fracture risk at the knee after the injury. Therapies that prevent bone loss or stimulate an anabolic response in bone have been proposed to reduce fractures. Zoledronic acid (ZA) is a potent bisphosphonate that inhibits osteoclastic resorption. Functional electrical stimulation (FES)-assisted rowing is a potentially osteogenic exercise involving mechanical stimulation to the lower extremities. Here, we investigated the effect of FES-assisted rowing with and without ZA on bone strength and stiffness in individuals with SCI.

METHODS

Twenty individuals from a cohort of adults with SCI who participated in a clinical trial were included in the study. CT scans of their knees before and after the intervention were converted to finite element models. Bone failure strength (T_ult) and stiffness were calculated at the proximal tibia and distal femur.

RESULTS

T_ult at the distal femur increased 4.6% among people who received rowing + ZA and decreased 13.9% among those with rowing only (p < 0.05 for group). Torsional and compressive stiffness at the femur metaphysis increased in people with rowing + ZA (+ 3 to +4%) and decreased in people with rowing only (- 7 to -8%; p < 0.05). T_ult in the proximal tibia decreased in everyone, but the loss was attenuated in the rowing + ZA group. People with initially stronger bone tended to lose more strength.

CONCLUSION

Overall, we observed increases in bone strength at the distal femur but not the proximal tibia, with FES-assisted rowing combined with ZA treatment. Rowing alone did not significantly prevent bone loss at either site, which might be attributed to insufficient mechanical loading.

Explaining Intentions by Vietnamese Schoolchildren to Adopt Pro-Environmental Behaviors in Response to Climate Change Using Theories of Persuasive Communication

Climate change adaptation capacity remains low among vulnerable communities in developing countries such as Vietnam. Vector-borne diseases as dengue fever are increasing as a result of changing weather patterns. This study aims to examine the impact of key psychological variables in the Theory of Reasoned Action, the Theory of Planned Behavior, an Extended Parallel Process Model and the Social Cognitive Theory on the intention of schoolchildren to engage in climate change adaptation behavior-in this study, practices which would help reduce the risks of contracting dengue fever. It also seeks to identify the most salient predictors of the behavioral intention across these theories. Data were obtained from 796 Vietnamese schoolchildren who completed questionnaires measuring constructs of the four theories. Multivariate data analysis demonstrated that self-efficacy and severity appeared to be significant and consistent predictors of the individual's intention to reduce dengue fever. The results provide practical suggestions for the use of the theorical constructs tested in climate change communication campaigns in Vietnam and insights generally on pro-environmental behavior change.

Selective beta-3 adrenergic receptor blockade increases contractility of human ventricular trabeculae from HFrEF donors

Background

Alterations of the beta-adrenergic system have been extensively described in the setting of heart failure (HF). Upregulation of beta-3 adrenergic receptor (β3-AdrR) expression in human failing hearts depresses myocardial contractility and, during an acute decompensation event, can be considered a maladaptive compensatory mechanism that exacerbates cardiac dysfunction. APD418 is a selective β3-AdrR antagonist currently in development for patients who have acute heart failure with reduced ejection fraction (HFrEF). APD418 is designed to improve myocardial contractility by selectively antagonizing the β3-AdrR and thereby avoiding the cAMP/Ca2+ signaling pathway stimulated by current inotropes.

Purpose

This study evaluated the effect of a selective β3-AdrR antagonist (APD418) on contractile responses in explanted human ventricular trabeculae obtained from normal and HFrEF hearts.

Methods

Left ventricular trabeculae from normal and HFrEF donors were electrically stimulated (1 Hz) ex-vivo to analyze force generated during contractions. First, BRL37344, a selective β3-AdrR agonist, was applied at increasing concentrations (0.01–10 μM) to confirm β3-AdrR mediated negative inotropy in human myocardial tissue. To test the effect of a selective β3-AdrR antagonist on contractile force, myocardial tissue was pre-treated with APD418 or vehicle for 5 minutes, followed by treatment with non-selective β-AdrR agonists isoproterenol (10 nM) or norepinephrine (5 μM).

Results

In heart tissue from normal donors, the β3-AdrR agonist BRL37344 did not affect contractile function at 0.01 and 0.1 μM. However, in heart tissue from HFrEF donors, BRL37344 induced a significant decrease in contractility at 0.01, 0.1 and 1 μM (85.9±1.8% with 0.1 μM BRL37344 vs 104.1±2.9% with vehicle). Selective blockade of β3-AdrR with APD418 had no effect on force of contraction induced by norepinephrine in cardiac tissue from normal donors. In contrast, APD418 potentiated the force of contraction induced by either isoproterenol (49.1±20.6% increase with 0.1 μM APD418 compared to baseline) or norepinephrine (26.5±4.9% increase with 0.01 μM APD418 compared to baseline) in cardiac tissue from HFrEF patients.

Conclusion

This is, to our knowledge, the first evidence showing that selective blockade of β3-AdrR increases contractility of human ventricular trabeculae from HFrEF donors and suggests that further studies evaluating the therapeutic benefit of APD418 in patients with HFrEF are warranted.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Arena Pharmaceuticals

Implementation of a High-Value Care Curriculum for General Surgery Residents

INTRODUCTION

Healthcare expenditures account for more than 3.5 trillion dollars annually with estimates of nearly one-half being wasteful. High-value care (HVC) balances the benefits, harms, and costs of healthcare. Since 2012, the American College of Physicians and Accreditation Council for Graduate Medical Education developed a HVC curriculum and incorporated HVC into milestones for medicine residents. However, currently no HVC curriculum or milestones exist for general surgery residents (GSR). We sought to implement a HVC curriculum for GSR and evaluate awareness and attitudes toward HVC, hypothesizing improved resident awareness and attitudes toward HVC without affecting patient outcomes.

METHODS

A prospective comparison between pre-HVC curriculum (7/1/2017-11/30/2017) and post-HVC curriculum (2/1/2018-6/30/2018) was performed. The curriculum included 6 didactic lectures with group discussions. A 14-question Likert-scale survey evaluating awareness, use of, and attitudes toward HVC was performed on all GSR. Additional patient outcomes were collected for all trauma patients cared for during the study period. Bivariate analysis using Mann-Whitney U test was performed.

RESULTS

There were 38/38 GSR respondents (100% response rate) for the pre-HVC survey and 35/38 (92.1% response rate) for the post-HVC survey. More post-HVC respondents somewhat agreed (34.3% vs 5.3%) and less strongly disagreed (31.4% vs 52.6%) with improved knowledge of where to find costs of labs/imaging/treatment (p = 0.02) compared to the pre-HVC group. More post-HVC respondents strongly agreed they balanced the benefit of clinical care with costs and harm when treating patients (25.7% vs 21.1%; p = 0.01). More post-HVC respondents strongly agreed they customized care plans to incorporate patients' values/concerns after implementation of the curriculum (51.4% vs 23.7%, p = 0.0006). From 3254 trauma patients studied, 1722 (52.9%) were pre-HVC and 1532 (47.1%) post-HVC patients. There was no difference between the pre- and post-HVC-curriculum trauma patients in terms of demographics and outcomes such as mortality (3.6% vs 2.4%, p = 0.07) and median length of stay (2 vs 2 days, p = 0.6).

CONCLUSIONS

Implementation of a HVC curriculum for GSR led to improved awareness regarding healthcare costs and customizing decision plans for patients, with no difference in trauma patient outcomes. Future research incorporating cost data is needed; however, with implementation of the 2020 general surgery milestones (addition of Systems-Based Practice-3), this curriculum could prove beneficial.

Exploring the Roles of Green Food Consumption and Social Trust in the Relationship between Perceived Consumer Effectiveness and Psychological Wellbeing

Green food consumption is a core issue that contributes to solving environmental pollution and achieving sustainable development. This study aims to investigate the mediating role of green food consumption and social trust in the relationship between perceived consumer effectiveness and psychological wellbeing to provide new insights into green food consumption, based on social ideal theory and social trust theory. Using a sample data of 514 consumers in China, the results of structural equation modeling showed that perceived consumer effectiveness was positively related to psychological wellbeing. Furthermore, green food consumption mediated the relationship between perceived consumer effectiveness and psychological wellbeing. In addition, social trust moderated the relationship between perceived consumer effectiveness and green food consumption. Social trust also moderated the indirect effect of perceived consumer effectiveness on psychological wellbeing through green food consumption. The findings of this study enrich the extant literature relating to green food consumption and have practical implications for business managers and policymakers.

Obstetric admissions to intensive care units in Australia and New Zealand: a registry-based cohort study

OBJECTIVE

Describe the epidemiology of obstetric patients admitted to an Intensive Care Unit (ICU).

DESIGN

Registry-based cohort study.

SETTING

One hundred and eighty-three ICUs in Australia and New Zealand.

POPULATION

Women aged 15-49 years, admitted to ICU between 2008 and 2017, classified as pregnant, postpartum or with an obstetric-related diagnosis.

METHODS

Data were extracted from the Australia and New Zealand Intensive Care Society (ANZICS) Adult Patient Database and national agencies.

MAIN OUTCOME MEASURES

Incidence of ICU admission, cohort characteristics, maternal outcomes and changes over time.

RESULTS

The cohort comprised 16 063 patients. The annual number of obstetric ICU admissions increased, whereas their proportion of total ICU admissions (1.3%) did not change (odds ratio 1.02, 95% CI 0.99-1.04, P = 0.14). There were 10 518 (65%) with an obstetric-related ICU diagnosis, and 5545 (35%) with a non-obstetric ICU diagnosis. Mean (SD) age was 31 (6.4) years, 1463 (9.1%) were Indigenous, 2305 (14%) were transferred from another hospital, and 3008 (19%) received mechanical ventilation. Median [IQR] length of stay in hospital was 5.2 [3.1-7.9] days, which included 1.1 [0.7-1.8] days in ICU. There were 108 (0.7%) maternal deaths, most (n = 97, 90%) having a non-obstetric diagnosis. There was no change in risk-adjusted length of stay or mortality over time.

CONCLUSIONS

Obstetric patients account for a stable proportion of ICU admissions in Australia and New Zealand. These patients typically have a short length of ICU stay and low hospital mortality.

TWEETABLE ABSTRACT

Obstetric patients in Australia/New Zealand ICUs have a short length of ICU stay and low mortality.

Online Book Shopping in Vietnam: The Impact of the COVID-19 Pandemic Situation

The coronavirus disease 2019 (COVID-19) pandemic will have a large impact on the publishing industry. This research aims to investigate the influences of the COVID-19 pandemic situation, utilitarian and hedonic motivations on consumer intention to buy books online. It conceptualizes the effects of the COVID-19 pandemic as situational influences, which involve the closure of physical bookstores, health risks associated with visiting such stores, online shopping trend and additional marketing efforts from online bookstores during the pandemic. Data were collected from 275 Vietnamese consumers using an online survey. Multivariate data analysis reveals that the COVID-19 pandemic situation has a positive and significant impact on consumer intention toward online book shopping. Furthermore, while utilitarian motivation exerts a strong effect on consumer intention to purchase books online, the relationship between hedonic motivation and online purchase intention is positive but insignificant. These findings would assist key stakeholders such as publishers and online bookstores to improve the quality of their websites as well as develop their marketing campaigns.

Obesity associated with increased postoperative pulmonary complications and mortality after trauma laparotomy

Background

Patient-related risk factors for the development of postoperative pulmonary complications (PPCs) include age ≥ 60-years, congestive heart failure, hypoalbuminemia and smoking. The effect of obesity is unclear and has not been shown to independently increase the likelihood of PPCs in trauma patients undergoing trauma laparotomy. We hypothesized the likelihood of mortality and PPCs would increase as body mass index (BMI) increases in trauma patients undergoing trauma laparotomy.

Methods

The Trauma Quality Improvement Program (2010–2016) was queried to identify trauma patients ≥ 18-years-old undergoing trauma laparotomy within 6-h of presentation. A multivariable logistic regression analysis was used to determine the likelihood of PPCs and mortality when stratified by BMI.

Results

From 8,330 patients, 2,810 (33.7%) were overweight (25–29.9 kg/m²), 1444 (17.3%) obese (30–34.9 kg/m²), 580 (7.0%) severely obese (35–39.9 kg/m²), and 401 (4.8%) morbidly obese (≥ 40 kg/m²). After adjusting for covariates including age, injury severity score, chronic obstructive pulmonary disease, smoking, and rib/lung injury, the likelihood of PPCs increased with increasing BMI: overweight (OR = 1.37, CI 1.07–1.74, p = 0.012), obese (OR = 1.44, CI 1.08–1.92, p = 0.014), severely obese (OR = 2.20, CI 1.55–3.14, p < 0.001), morbidly obese (OR = 2.42, CI 1.67–3.51, p < 0.001), compared to those with normal BMI. In addition, the adjusted likelihood of mortality increased for the morbidly obese (OR = 2.60, CI 1.78–3.80, p < 0.001) compared to those with normal BMI.

Conclusion

Obese trauma patients undergoing emergent trauma laparotomy have a high likelihood for both PPCs and mortality, with morbidly obese trauma patients having the highest likelihood for both. This suggests obesity should be accounted for in risk prediction models of trauma patients undergoing laparotomy.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01329-w) contains supplementary material, which is available to authorized users.

Some Key Factors Affecting Consumers' Intentions to Purchase Functional Foods: A Case Study of Functional Yogurts in Vietnam

The development of functional foods is key to promoting a healthy diet and preventing certain diseases. This study aims to examine several key factors that affect consumer attitude and intention with respect to purchasing functional foods in an emerging market economy. A research model was developed by extension of the Theory of Reasoned Action (TRA), and then validated through obtaining data from 596 Vietnamese consumers who were interested in functional yogurts using an interviewer-administered questionnaire. Multivariate data analysis reveals that while health consciousness and subjective norm significantly enhance consumers’ attitudes towards purchasing functional yogurts, perceived price of functional yogurts exerts a negative impact on such attitudes. Moreover, subjective norm and attitude appear to be key predictors of consumers’ intentions to buy functional yogurts. These findings extend the extant literature relating to functional food purchase and consumption in emerging markets, and they have several important practical implications for functional yogurt manufacturers, retailers, and policymakers. A major implication is that education and communication programs that aim at increasing consumers’ health consciousness and their awareness of functional foods’ health benefits play an integral role in the success of functional food products such as functional yogurts. Research limitations and future research directions are also presented.

Determination of Low-Level Glucose and Fructose in Raw and Refined Crystalline Sugar by High-Performance Anion-Exchange Chromatography: Collaborative Study

A method was developed and a collaborative study was performed under the auspices of the International Commission of Uniform Methods for Sugar Analysis. The collaborators used high-performance anion-exchange chromatography (HPAEC) to determine trace amounts of glucose and fructose in 3 raw and 3 refined sugar samples provided as blind duplicates. Fourteen laboratories participated in the study. Although difficulties were experienced by a few analysts, 10 laboratories reported positive results. Average repeatabilities and reproducibilities for glucose and fructose in raw sugar were slightly above 5 and 10%, respectively, and the average Horwitz ratios were well under 2. Average repeatabilities and reproducibilities for glucose and fructose in refined sugar were 10 and 22%, respectively; although the Horwitz ratios were &gt;2, they were marginal (2.8). The HPAEC results agreed with results obtained by gas chromatography in an independent laboratory. Because the method was collaboratively studied according to the protocol of the International Union of Pure and Applied Chemistry for collaborative studies, and the results meet its criteria, it is recommended that the method be adopted Official First Action by AOAC INTERNATIONAL.

Investigating Consumer Attitude and Intention towards Online Food Purchasing in an Emerging Economy: An Extended TAM Approach

Along with the development of the Internet and technology, food retailers have increasingly adopted online channels that enable consumers to buy food products online. This research aims to investigate the factors that influence consumer attitude and intention towards online food purchasing. A research framework was developed by combining the technology acceptance model with website trust, which is an important facilitator of online shopping. Using an online survey, data were obtained from 319 online food shoppers in an Asian emerging economy, i.e., Vietnam. Results from structural equation modeling show that perceived usefulness, perceived ease of use, and website trust are important drivers of attitude towards online food purchasing. Among these drivers, perceived ease of use has the greatest impact on attitude. Additionally, attitude and website trust exert a direct and positive effect on intention towards online food purchasing. Taken together, these findings have important managerial implications for key stakeholders, such as online food retailers, associations, and policy makers. One key implication is that online food sellers must endeavor to make their websites simple to use, easy to navigate, reliable, and secure. Several potential caveats for future research studies are also presented in this paper.