The Comet Interceptor Mission

Here we describe the novel, multi-point Comet Interceptor mission. It is dedicated to the exploration of a little-processed long-period comet, possibly entering the inner Solar System for the first time, or to encounter an interstellar object originating at another star. The objectives of the mission are to address the following questions: What are the surface composition, shape, morphology, and structure of the target object? What is the composition of the gas and dust in the coma, its connection to the nucleus, and the nature of its interaction with the solar wind? The mission was proposed to the European Space Agency in 2018, and formally adopted by the agency in June 2022, for launch in 2029 together with the Ariel mission. Comet Interceptor will take advantage of the opportunity presented by ESA's F-Class call for fast, flexible, low-cost missions to which it was proposed. The call required a launch to a halo orbit around the Sun-Earth L2 point. The mission can take advantage of this placement to wait for the discovery of a suitable comet reachable with its minimum Δ V capability of 600  ms - 1 . Comet Interceptor will be unique in encountering and studying, at a nominal closest approach distance of 1000 km, a comet that represents a near-pristine sample of material from the formation of the Solar System. It will also add a capability that no previous cometary mission has had, which is to deploy two sub-probes - B1, provided by the Japanese space agency, JAXA, and B2 - that will follow different trajectories through the coma. While the main probe passes at a nominal 1000 km distance, probes B1 and B2 will follow different chords through the coma at distances of 850 km and 400 km, respectively. The result will be unique, simultaneous, spatially resolved information of the 3-dimensional properties of the target comet and its interaction with the space environment. We present the mission's science background leading to these objectives, as well as an overview of the scientific instruments, mission design, and schedule.

Haemoglobin thresholds for transfusion: how are we doing in the era of Choosing Wisely? A retrospective cohort study

INTRODUCTION

 Clinical practice guidelines and the Choosing Wisely initiative launched in 2012 recommend a haemoglobin (Hb) threshold of 70-80 g/lfor red blood cell (RBC) transfusions in stable hospitalised patients. Data on transfusion practices and their trends in medical inpatients are limited. To address this gap, we investigated transfusion practices and their trends in general internal medicine and other clinics.

METHODS

This retrospective cohort study analysed data from all hospitalisations with RBC transfusions at a Swiss university hospital between 2012 and 2019. We included all first transfusion episodes if pretransfusion Hb was available. The primary endpoint was mean pretransfusion Hb; secondary endpoints included potentially inadequate transfusions (i.e., transfusions at Hb ≥80 g/l) and receipt of a single RBC unit. Trends in mean pretransfusion Hb over time were estimated using generalised estimating equations, and risk factors for potentially inadequate transfusions were identified using multivariable adjusted generalised estimating equations models.

RESULTS

 Of 14,598 hospitalisations with RBC transfusions, 1980 (13.6%) were discharged from general internal medicine. From 2012 to 2019, mean pretransfusion Hb decreased from 74.0 g/l to 68.8 g/l in general internal medicine (mean annual decrease -0.76 g/l, 95% confidence interval [CI] -0.51 to -1.02) and from 78.2 g/l to 72.7 g/l in other clinics (mean annual decrease -0.69, 95% CI -0.62 to -0.77; p for interaction 0.53). The overall proportion of potentially inadequate transfusions was 17.8% in general internal medicine and 24.1% in other clinics (p <0.001) and decreased over the study period from 26.9% to 5.5% in general internal medicine and from 37.0% to 15.2% in other clinics. In contrast, the proportion of cases receiving a single RBC unit increased (39.5% to 81.4% in general internal medicine, 42.7% to 66.1% in other clinics). Older age (adjusted odds ratio [aOR] 1.45, 95% CI 1.32-1.58 for ≥65 vs <65 years), having surgery (aOR 1.24, 95% CI 1.14-1.36), acute haemorrhage (aOR 1.16, 95% CI 1.02-1.33), chronic heart failure (aOR 1.17, 95% CI 1.04-1.32), ischaemic heart diseases (aOR 1.27, 95% CI 1.15-1.41), chronic pulmonary diseases (aOR 1.24, 95% CI 1.08-1.42), malignancy (aOR 1.11, 95% CI 1.01-1.21), and rheumatic disease (aOR 1.27, 95% CI 1.01-1.59) were risk factors for potentially inadequate transfusions.

CONCLUSIONS

 More restrictive transfusion practices were adopted in general internal medicine and other clinics over time, suggesting that guideline recommendations and the Choosing Wisely initiative may have been increasingly followed. Interventions to reduce potentially inadequate transfusions should target providers who care for older patients and those with surgery or chronic cardiac and pulmonary diseases.

Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital complications: a medical record review across nine Swiss hospitals

The validity of the Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) has been established in the USA and Canada. However, these indicators are also used for hospital benchmarking and cross-country comparisons in other nations with different health-care settings and coding systems as well as missing present on admission (POA) flags in the administrative data. This study sought to comprehensively assess and compare the validity of 16 PSIs in Switzerland, where they have not been previously applied. We performed a medical record review using administrative and electronic medical record data from nine Swiss hospitals. Seven independent reviewers evaluated 1245 cases at various hospitals using retrospective data from the years 2014-18. True positives, false positives, positive predictive values (PPVs), and reasons for misclassification were compared across all investigated PSIs, and the documentation quality of the PSIs was examined. PSIs 6 (iatrogenic pneumothorax), 10 (postoperative acute kidney injury), 11 (postoperative respiratory failure), 13 (postoperative sepsis), 14 (wound dehiscence), 17 (birth trauma), and 18 and 19 (obstetric trauma with or without instrument) showed high PPVs (range: 90-99%) and were not strongly influenced by missing POA information. In contrast, PSIs 3 (pressure ulcer), 5 (retained surgical item), 7 (central venous catheter-related bloodstream infection), 8 (fall with hip fracture), and 15 (accidental puncture/laceration) showed low PPVs (range: 18-49%). In the case of PSIs 3, 8, and 12 (perioperative embolism/thrombosis), the low PPVs were largely due to the lack of POA information. Additionally, it was found that the documentation of PSI 3 in discharge letters could be improved. We found large differences in validity across the 16 PSIs in Switzerland. These results can guide policymakers in Switzerland and comparable health-care systems in selecting and prioritizing suitable PSIs for quality initiatives. Furthermore, the national introduction of a POA flag would allow for the inclusion of additional PSIs in quality monitoring.

A resonant sextuplet of sub-Neptunes transiting the bright star HD 110067

Planets with radii between that of the Earth and Neptune (hereafter referred to as 'sub-Neptunes') are found in close-in orbits around more than half of all Sun-like stars1,2. However, their composition, formation and evolution remain poorly understood3. The study of multiplanetary systems offers an opportunity to investigate the outcomes of planet formation and evolution while controlling for initial conditions and environment. Those in resonance (with their orbital periods related by a ratio of small integers) are particularly valuable because they imply a system architecture practically unchanged since its birth. Here we present the observations of six transiting planets around the bright nearby star HD 110067. We find that the planets follow a chain of resonant orbits. A dynamical study of the innermost planet triplet allowed the prediction and later confirmation of the orbits of the rest of the planets in the system. The six planets are found to be sub-Neptunes with radii ranging from 1.94R⊕ to 2.85R⊕. Three of the planets have measured masses, yielding low bulk densities that suggest the presence of large hydrogen-dominated atmospheres.

Predominant myosin superrelaxed state in canine myocardium with naturally occurring dilated cardiomyopathy

Dilated cardiomyopathy (DCM) is a naturally occurring heart failure condition in humans and dogs, notably characterized by a reduced contractility and ejection fraction. As the identification of its underlying cellular and molecular mechanisms remain incomplete, the aim of the present study was to assess whether the molecular motor myosin and its known relaxed conformational states are altered in DCM. For that, we dissected and skinned thin cardiac strips from left ventricle obtained from six DCM Doberman Pinschers and six nonfailing (NF) controls. We then used a combination of Mant-ATP chase experiments and X-ray diffraction to assess both energetic and structural changes of myosin. Using the Mant-ATP chase protocol, we observed that in DCM dogs, the amount of myosin molecules in the ATP-conserving conformational state, also known as superrelaxed (SRX), is significantly increased when compared with NF dogs. This alteration can be rescued by applying EMD-57033, a small molecule activating myosin. Conversely, with X-ray diffraction, we found that in DCM dogs, there is a higher proportion of myosin heads in the vicinity of actin when compared with NF dogs (1,0 to 1,1 intensity ratio). Hence, we observed an uncoupling between energetic (Mant-ATP chase) and structural (X-ray diffraction) data. Taken together, these results may indicate that in the heart of Doberman Pinschers with DCM, myosin molecules are potentially stuck in a nonsequestered but ATP-conserving SRX state, that can be counterbalanced by EMD-57033 demonstrating the potential for a myosin-centered pharmacological treatment of DCM.NEW & NOTEWORTHY The key finding of the present study is that, in left ventricles of dogs with a naturally occurring dilated cardiomyopathy, relaxed myosin molecules favor a nonsequestered superrelaxed state potentially impairing sarcomeric contractility. This alteration is rescuable by applying a small molecule activating myosin known as EMD-57033.

AMPK activation by metformin protects against pulmonary hypertension in rats and relaxes isolated human pulmonary artery

Pulmonary hypertension (PH) is associated with pulmonary vasoconstriction and endothelial dysfunction leading to impaired nitric oxide (NO) and prostacyclin (PGI₂) pathways. Metformin, the first line treatment for type 2 diabetes and AMP-activated protein kinase (AMPK) activator, has been recently highlighted as a potential PH treatment. AMPK activation has been reported to improve endothelial function by enhancing endothelial NO synthase (eNOS) activity and to have relaxant effects in blood vessels. In this study, we examined the effect of metformin treatment on PH as well as on NO and PGI₂ pathways in monocrotaline (MCT)-injected rats with established PH. Moreover, we investigated the anti-contractile effects of AMPK activators on endothelium-denuded human pulmonary arteries (HPA) from Non-PH and Group 3 PH patients (due to lung diseases and/or hypoxia). Furthermore, we explored the interaction between treprostinil and the AMPK/eNOS pathway. Our results showed that metformin protected against PH progression in MCT rats where it reduced the mean pulmonary artery pressure, pulmonary vascular remodeling and right ventricular hypertrophy and fibrosis compared to vehicle-treated MCT rats. The protective effects on rat lungs were mediated in part by increasing eNOS activity and protein kinase G-1 expression but not through the PGI₂ pathway. In addition, incubation with AMPK activators reduced the phenylephrine-induced contraction of endothelium-denuded HPA from Non-PH and PH patients. Finally, treprostinil also augmented eNOS activity in HPA smooth muscle cells. In conclusion, we found that AMPK activation can enhance the NO pathway, attenuate vasoconstriction by direct effects on smooth muscles, and reverse established MCT-induced PH in rats.

Healthcare Costs and Health-Related Quality of Life in Older Multimorbid Patients After Hospitalization

Objectives

We identified factors associated with healthcare costs and health-related quality of life (HRQoL) of multimorbid older adults with polypharmacy.

Methods

Using data from the OPERAM (OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid older people) trial, we described the magnitude and composition of healthcare costs, and time trends of HRQoL, during 1-year after an acute-care hospitalization. We performed a cluster analysis to identify groups with different cost and HRQoL trends. Using multilevel models, we also identified factors associated with costs and HRQoL.

Results

Two months after hospitalization monthly mean costs peaked (CHF 7'124) and HRQoL was highest (0.67). They both decreased thereafter. Age, falls, and comorbidities were associated with higher 1-year costs. Being female and housebound were negatively associated with HRQoL, while moderate alcohol consumption had a positive association. Being independent in daily activities was associated with lower costs and higher HRQoL.

Conclusion

Although only some identified potential influences on costs and HRQoL are modifiable, our observations support the importance of prevention before health deterioration in older people with multimorbid illness and associated polypharmacy.

Prediction of exercise respiratory limitation from pulmonary function tests

BACKGROUND

Evaluation of unexplained exercise intolerance is best resolved by cardiopulmonary exercise testing (CPET) which enables the determination of the exercise limiting system in most cases. Traditionally, pulmonary function tests (PFTs) at rest are not used for the prediction of a respiratory limitation on CPET.

OBJECTIVE

We sought cut-off values on PFTs that might, a priori, rule-in or rule-out a respiratory limitation in CPET.

METHODS

Patients who underwent CPET in our institute were divided into two groups according to spirometry: obstructive and non-obstructive. Each group was randomly divided 2:1 into derivation and validation cohorts respectively. We analyzed selected PFTs parameters in the derivation groups in order to establish maximal and minimal cut-off values for which a respiratory limitation could be ruled-in or ruled-out. We then validated these values in the validation cohorts.

RESULTS

Of 593 patients who underwent a CPET, 126 were in the obstructive and 467 in the non-obstructive group. In patients with obstructive lung disease, forced expiratory volume in 1 second (FEV1) ≥ 61% predicted could rule out a respiratory limitation, while FEV1 ≤ 33% predicted was always associated with a respiratory limitation. For patients with non-obstructive spirometry, FEV1 of ≥ 73% predicted could rule-out a respiratory limitation. Application of this algorithm might have saved up to 47% and 71% of CPETs in our obstructive and non-obstructive groups, respectively.

CONCLUSION

Presence or absence of a respiratory limitation on CPET can be predicted in some cases based on a PFTs performed at rest.

A comparison of multiband and multiband multiecho gradient-echo EPI for task fMRI at 3 T

A multiband (MB) echo-planar imaging (EPI) sequence is compared to a multiband multiecho (MBME) EPI protocol to investigate differences in sensitivity for task functional magnetic resonance imaging (fMRI) at 3 T. Multiecho sampling improves sensitivity in areas where single-echo-EPI suffers from dropouts. However, It requires in-plane acceleration to reduce the echo train length, limiting the slice acceleration factor and the temporal and spatial resolution Data were acquired for both protocols in two sessions 24 h apart using an adapted color-word interference Stroop task. Besides protocol comparison statistically, we performed test-retest reliability across sessions for different protocols and denoising methods. We evaluated the sensitivity of two different echo-combination strategies for MBME-EPI. We examined the performance of three different data denoising approaches: "Standard," "AROMA," and "FIX" for MB and MBME, and assessed whether a specific method is preferable. We consider using an appropriate autoregressive model order within the general linear model framework to correct TR differences between the protocols. The comparison between protocols and denoising methods showed at group level significantly higher mean z-scores and the number of active voxels for MBME in the motor, subcortical and medial frontal cortices. When comparing different echo combinations, our results suggest that a contrast-to-noise ratio weighted echo combination improves sensitivity in MBME compared to simple echo-summation. This study indicates that MBME can be a preferred protocol in task fMRI at spatial resolution (≥2 mm), primarily in medial prefrontal and subcortical areas.

Cost-effectiveness of a structured medication review approach for multimorbid older adults: Within-trial analysis of the OPERAM study

Background

Inappropriate polypharmacy has been linked with adverse outcomes in older, multimorbid adults. OPERAM is a European cluster-randomized trial aimed at testing the effect of a structured pharmacotherapy optimization intervention on preventable drug-related hospital admissions in multimorbid adults with polypharmacy aged 70 years or older. Clinical results of the trial showed a pattern of reduced drug-related hospital admissions, but without statistical significance. In this study we assessed the cost-effectiveness of the pharmacotherapy optimisation intervention.

Methods

We performed a pre-planned within-trial cost-effectiveness analysis (CEA) of the OPERAM intervention, from a healthcare system perspective. All data were collected within the trial apart from unit costs. QALYs were computed by applying the crosswalk German valuation algorithm to EQ-5D-5L-based quality of life data. Considering the clustered structure of the data and between-country heterogeneity, we applied Generalized Structural Equation Models (GSEMs) on a multiple imputed sample to estimate costs and QALYs. We also performed analyses by country and subgroup analyses by patient and morbidity characteristics.

Results

Trial-wide, the intervention was numerically dominant, with a potential cost-saving of CHF 3’588 (95% confidence interval (CI): -7’716; 540) and gain of 0.025 QALYs (CI: -0.002; 0.052) per patient. Robustness analyses confirmed the validity of the GSEM model. Subgroup analyses suggested stronger effects in people at higher risk.

Conclusion

We observed a pattern towards dominance, potentially resulting from an accumulation of multiple small positive intervention effects. Our methodological approaches may inform other CEAs of multi-country, cluster-randomized trials facing presence of missing values and heterogeneity between centres/countries.

Management of well appearing infants born to afebrile mothers with inadequate GBS prophylaxis: A retrospective comparison of the three approaches recommended by the COFN

BACKGROUND

There are three different approaches set forth by the Committee on the Fetus and Newborn (COFN) for managing asymptomatic neonates born to mothers with inadequate intrapartum antibiotic prophylaxis (IAP) for early-onset Group B Strep (GBS) infection. The first approach is that of categorical risk factor assessments, and recommends that asymptomatic infants born to afebrile mothers with inadequate IAP for GBS be monitored with clinical observation for 36-48 hours. The second approach recommends serial physical examinations and vital signs for 36-48 hours to closely monitor changes in clinical condition for all patients. The Kaiser Permanente EOS risk calculator (SRC) is an example of the third approach, a multivariate risk assessment, and it takes into consideration several perinatal risk factors. This multivariate risk assessment then provides recommendations for reassessment and management based on presume risk of the infant developing or having Early Onset Sepsis (EOS). The aim of our study was to compare these three recently published recommendations from the COFN for the management of asymptomatic neonates born to afebrile mothers with inadequate IAP for GBS.

STUDY DESIGN

This is a retrospective study of asymptomatic neonates with gestational age ≥35 weeks born to afebrile mothers with indicated inadequate IAP for GBS between April 2017 and July 2020. Management recommendations of the SRC were compared to the recommendations of categorical risk assessment and risk assessment based on clinical condition.

RESULTS

A total of 7,396 infants were born during the study period, 394 (5.3%. to mothers with inadequate IAP. Recommendations for these infants according to both the categorical risk factor guideline and the clinical condition guideline include extended, close observation. However, the SRC recommended routine newborn care for 99.7%.f these infants. None of the infants developed EOS.

CONCLUSION

The SRC recommend routine neonatal care without enhanced and prolonged observation for nearly all asymptomatic infants born to afebrile mothers with inadequate IAP. As none of the infants in this cohort had EOS, further studies in a larger cohort are needed to establish the safety of SRC in neonates born to mothers with inadequate IAP.

Development and validation of a score to assess complexity of general internal medicine patients at hospital discharge: a prospective cohort study

OBJECTIVE

We aimed to develop and validate a score to assess inpatient complexity and compare its performance with two currently used but not validated tools to estimate complexity (ie, Charlson Comorbidity Index (CCI), patient clinical complexity level (PCCL)).

METHODS

Consecutive patients discharged from the department of medicine of a tertiary care hospital were prospectively included into a derivation cohort from 1 October 2016 to 16 February 2017 (n=1407), and a temporal validation cohort from 17 February 2017 to 31 March 2017 (n=482). The physician in charge assessed complexity. Potential predictors comprised 52 parameters from the electronic health record such as health factors and hospital care usage. We fit a logistic regression model with backward selection to develop a prediction model and derive a score. We assessed and compared performance of model and score in internal and external validation using measures of discrimination and calibration.

RESULTS

Overall, 447 of 1407 patients (32%) in the derivation cohort, and 116 of 482 patients (24%) in the validation cohort were identified as complex. Eleven variables independently associated with complexity were included in the score. Using a cut-off of ≥24 score points to define high-risk patients, specificity was 81% and sensitivity 57% in the validation cohort. The score's area under the receiver operating characteristic (AUROC) curve was 0.78 in both the derivation and validation cohort. In comparison, the CCI had an AUROC between 0.58 and 0.61, and the PCCL between 0.64 and 0.69, respectively.

CONCLUSIONS

We derived and internally and externally validated a score that reflects patient complexity in the hospital setting, performed better than other tools and could help monitoring complex patients.

Role of Chiral Two-Body Currents in ^{6}Li Magnetic Properties in Light of a New Precision Measurement with the Relative Self-Absorption Technique

A direct measurement of the decay width of the excited 0_{1}^{+} state of ^{6}Li using the relative self-absorption technique is reported. Our value of Γ_{γ,0_{1}^{+}→1_{1}^{+}}=8.17(14)_{stat.}(11)_{syst.}  eV provides sufficiently low experimental uncertainties to test modern theories of nuclear forces. The corresponding transition rate is compared to the results of ab initio calculations based on chiral effective field theory that take into account contributions to the magnetic dipole operator beyond leading order. This enables a precision test of the impact of two-body currents that enter at next-to-leading order.

ΔK=0 M1 Excitation Strength of the Well-Deformed Nucleus ^{164}Dy from K Mixing

The size of a ΔK=0 M1 excitation strength has been determined for the first time in a predominantly axially deformed even-even nucleus. It has been obtained from the observation of a rare K-mixing situation between two close-lying J^{π}=1^{+} states of the nucleus ^{164}Dy with components characterized by intrinsic projection quantum numbers K=0 and K=1. Nuclear resonance fluorescence induced by quasimonochromatic linearly polarized γ-ray beams provided evidence for K mixing of the 1^{+} states at 3159.1(3) and 3173.6(3) keV in excitation energy from their γ-decay branching ratios into the ground-state band. The ΔK=0 transition strength of B(M1;0_{1}^{+}→1_{K=0}^{+})=0.008(1)μ_{N}^{2} was inferred from a mixing analysis of their M1 transition rates into the ground-state band. It is in agreement with predictions from the quasiparticle phonon nuclear model. This determination represents first experimental information on the M1 excitation strength of a nuclear quantum state with a negative R-symmetry quantum number.

Long-Term Venovenous Connection for Extracorporeal Carbon Dioxide Removal (ECCO2R)-Numerical Investigation of the Connection to the Common Iliac Veins

Purpose

Currently used cannulae for extracorporeal carbon dioxide removal (ECCO₂R) are associated with complications such as thrombosis and distal limb ischemia, especially for long-term use. We hypothesize that the risk of these complications is reducible by attaching hemodynamically optimized grafts to the patient’s vessels. In this study, as a first step towards a long-term stable ECCO₂R connection, we investigated the feasibility of a venovenous connection to the common iliac veins. To ensure its applicability, the drainage of reinfused blood (recirculation) and high wall shear stress (WSS) must be avoided.

Methods

A reference model was selected for computational fluid dynamics, on the basis of the analysis of imaging data. Initially, a sensitivity analysis regarding recirculation was conducted using as variables: blood flow, the distance of drainage and return to the iliocaval junction, as well as the diameter and position of the grafts. Subsequently, the connection was optimized regarding recirculation and the WSS was evaluated. We validated the simulations in a silicone model traversed by dyed fluid.

Results

The simulations were in good agreement with the validation measurements (mean deviation 1.64%). The recirculation ranged from 32.1 to 0%. The maximum WSS did not exceed 5.57 Pa. The position and diameter of the return graft show the highest influence on recirculation. A correlation was ascertained between recirculation and WSS. Overall, an inflow jet directed at a vessel wall entails not only high WSS, but also a flow separation and thereby an increased recirculation. Therefore, return grafts aligned to the vena cava are crucial.

Conclusion

In conclusion, a connection without recirculation could be feasible and therefore provides a promising option for a long-term ECCO₂R connection.

Prevalence of adverse childhood experiences (ACEs) and associated physical and mental health problems amongst hospital patients: Results from a cross-sectional study

BACKGROUND

Adverse childhood experiences (ACEs) can have severe detrimental effects on physical and mental health. This study aimed to present prevalence rates of ACEs amongst a mixed sample of hospital patients.

METHODS

In- and outpatients at seven departments of the University Hospital of Innsbruck (Austria) participated in the study. They completed questionnaires regarding retrospective assessments of ACEs, physical and mental health and experience of domestic violence. The impact of ACEs on patients' health was evaluated by calculation of odds ratios (OR) in binary logistic regressions.

RESULTS

A total of n = 2392 (74.3% of all approached patients) were included in the analyses. The results showed that 36.1% of them reported at least one form of ACEs, and 6.3% were polyvictimized (i.e. they reported ≥4 forms of ACEs). Most frequent forms of ACE were emotional abuse (18.3%), peer abuse (14.2%), and neglect (12.3%). ACEs were significantly associated with increased ORs for various physical diseases, mental health problems and domestic violence.

CONCLUSION

Retrospectively assessed ACEs are highly prevalent amongst hospital patients and exposure to high numbers of ACEs is associated with decreased physical and mental health. The identification of patients with symptoms following ACEs and referral to appropriate treatment is a crucial challenge for health-care professionals.

Molecular Basis of CLC Antiporter Inhibition by Fluoride

CLC channels and transporters conduct or transport various kinds of anions, with the exception of fluoride, which acts as an effective inhibitor. Here, we performed sub-nanosecond DFT-based QM/MM simulations of the E. coli anion/proton exchanger ClC-ec1 and observed that fluoride binds incoming protons within the selectivity filter, with excess protons shared with the gating glutamate E148. Depending on E148 conformation, the competition for the proton can involve either a direct F^-/E148 interaction or the modulation of water molecules bridging the two anions. The direct interaction locks E148 in a conformation that does not allow for proton transport, and thus inhibits protein function.

Meta-Analysis of Genomewide Association Studies Reveals Genetic Variants for Hip Bone Geometry

Hip geometry is an important predictor of fracture. We performed a meta-analysis of GWAS studies in adults to identify genetic variants that are associated with proximal femur geometry phenotypes. We analyzed four phenotypes: (i) femoral neck length; (ii) neck-shaft angle; (iii) femoral neck width, and (iv) femoral neck section modulus, estimated from DXA scans using algorithms of hip structure analysis. In the Discovery stage, 10 cohort studies were included in the fixed-effect meta-analysis, with up to 18,719 men and women ages 16 to 93 years. Association analyses were performed with ∼2.5 million polymorphisms under an additive model adjusted for age, body mass index, and height. Replication analyses of meta-GWAS significant loci (at adjusted genomewide significance [GWS], threshold p ≤ 2.6 × 10^-8 ) were performed in seven additional cohorts in silico. We looked up SNPs associated in our analysis, for association with height, bone mineral density (BMD), and fracture. In meta-analysis (combined Discovery and Replication stages), GWS associations were found at 5p15 (IRX1 and ADAMTS16); 5q35 near FGFR4; at 12p11 (in CCDC91); 11q13 (near LRP5 and PPP6R3 (rs7102273)). Several hip geometry signals overlapped with BMD, including LRP5 (chr. 11). Chr. 11 SNP rs7102273 was associated with any-type fracture (p = 7.5 × 10^-5 ). We used bone transcriptome data and discovered several significant eQTLs, including rs7102273 and PPP6R3 expression (p = 0.0007), and rs6556301 (intergenic, chr.5 near FGFR4) and PDLIM7 expression (p = 0.005). In conclusion, we found associations between several genes and hip geometry measures that explained 12% to 22% of heritability at different sites. The results provide a defined set of genes related to biological pathways relevant to BMD and etiology of bone fragility. © 2019 American Society for Bone and Mineral Research.

Diagnostic value and reliability of the present-on-admission indicator in different diagnosis groups: pilot study at a Swiss tertiary care center

Background

With few exceptions the International Statistical Classification of Diseases (ICD) codes for diagnoses and official coding guidelines do not distinguish pre-existing conditions from complications or comorbidities which occur during hospitalization. However, information on diagnosis timing is relevant with regard to the case’s severity, resource consumption and quality of care. In this study we analyzed the diagnostic value and reliability of the present-on-admission (POA) indicator using routinely collected health data.

Methods

We included all inpatient cases of the department of medicine during 2016 with a diagnosis of deep vein thrombosis, decubitus ulcer or delirium. Swiss coding guidelines of 2016 and the definitions of the Swiss medical statistics of hospitals were analyzed to evaluate the potential to encode information on diagnosis timing. The diagnoses were revised by applying the information present-on-admission by a coding specialist and by a medical expert, serving as Gold Standard. The diagnostic value and reliability were evaluated.

Results

The inter-rater reliability for POA of all diagnoses was 0.7133 (Cohen’s kappa), but differed between diagnosis groups (0.558–0.7164). The rate of POA positive of the total applied by the coding specialist versus the expert was similar, but differed between diagnoses. In group “thrombosis” SEN was 0.95, SPE 0.75, PPV 0.97 and NPV 0.60, in group “decubitus ulcer” SEN 0.89, SPE 0.82, PPV 0.89 and NPV 0.82, in group “delirium” SEN 0.91, SPE 0.65, PPV 0.71 and NPV 0.88 For all diagnoses SEN 0.92, SPE 0.73, PPV 0.87, NPV 0.82, summing up the cases of all diagnosis groups.

Conclusions

Coding the POA indicator identified diagnoses which were pre-existent with insufficient reliability on individual patient’s level. The overall fair to sufficient diagnostic quality is appropriate for screening and benchmarking performance on population level. As the medical statistics of hospitals carries no variable on pre-existing conditions, the novel approach to apply the POA indicator to diagnoses gives more information on quality of hospital care and complexity of cases. By preparing documentation for POA reporting diagnostic quality must be increased before implementation for risk-assessment or reimbursement on the individual patient’s level.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3858-3) contains supplementary material, which is available to authorized users.

Shape transitions between and within Zr isotopes

The Zirconium isotopes across the N=56,58 neutron sub­shell closures have been of special interest since years, sparked by the near doubly-magic features of 96Zr and the subsequent rapid onset of collectivity with a deformed ground-state structure already in 100Zr. Recent state-of-the-art shell model approaches did not only correctly describe this shape-phase transition in the Zr isotopic chain, but alsothe coexistence of non-collective structures and pronounced collectivity especially in 96,98Zr. Theisotope 98Zr is located on the transition from spherical to deformed ground state structures. We summarize recent experimental work to obtain the B(E2) excitation strengths of the first 2+ state of98Zr, including a new experiment employing the recoil-distance Doppler-shift method following a two-neutron transfer reaction.

Violence from childhood to adulthood: The influence of child victimization and domestic violence on physical health in later life

OBJECTIVE

Previous research has shown a detrimental effect of child victimization (CV) on physical disease and mortality. Additionally, individuals with adverse experiences in childhood frequently face domestic violence (DV) in later life. As DV has also been observed to harm physical health, a potential cumulative effect has been proposed. Currently, however, only limited data on such a cumulative effect and its impact on patients' physical health are available.

METHODS

A cross-sectional observational study at the University Hospital of Innsbruck was conducted. Data on CV, DV and physical health were collected using self-report questionnaires. To evaluate the impact of CV and DV on patients' health, odds ratios (OR) were calculated using binary logistic regression.

RESULTS

A total of 1480 patients from various departments participated in the study. CV was found for 38% and DV for 16% of participants. A significantly higher occurrence of physical disease was observed in patients with poly-victimization (4+ CVs). When accounting for the cumulative effect of CV and DV, the occurrence was further increased for musculoskeletal disorders (OR:5.1), chronic pain (OR:5.0), gastrointestinal diseases (OR:3.0), metabolic diseases (OR:2.8) and respiratory diseases (OR:2.4).

CONCLUSION

CV and DV were found to be prevalent and highly correlated in patients treated in a primary care hospital. CV and DV - individually, combined and cumulatively - may thus present risks for physical health. Screening patients for the risk of DV as well as assessing CV may aid in early identification and initiation of psychosocial interventions to avoid further aggravation of physical and psychological problems.

Domestic violence victims in a hospital setting: prevalence, health impact and patients' preferences - results from a cross-sectional study

Background: Domestic violence (DV) is a widespread yet commonly underdetected problem with severe impact on physical and mental health. To date, only limited information is available on prevalence and detection-rates of victims of DV in hospital settings. Objective: The aim of this study was (a) to assess the prevalence and impact of DV on physical and mental health as well as risk-factors associated with it, (b) to determine how many patients had been asked directly about DV in the hospital and (c) to investigate patients' preferences about being asked about DV in a hospital setting. Methods: Adult inpatients and outpatients at seven somatic departments at the University Hospital Innsbruck (Austria) were included consecutively in this ad-hoc, cross-sectional paper-and-pencil questionnaire-based study. In total, n = 2,031 patients were assessed regarding their experiences with DV. They also reported on whether they had been asked about DV at the hospital and whether they would mind being asked about it. To evaluate the impact of DV on patients' self-reported physical and mental health, odds ratios were calculated using binary logistic regression. Results: DV was reported by 17.4% of patients, with 4.0% indicating current DV exposure. Lifetime DV exposure was associated with a significant risk for both physical and mental health-problems. Only 4.8% of patients with DV exposure had ever been asked about it by hospital staff. While patients with a history of DV were more open to being asked about DV than patients without DV (78.2% vs. 72.9%), overall acceptance was still high (74%). Conclusion: DV is a frequently overlooked problem with detrimental effects on physical and mental health. While high acceptance of DV assessment was found, only a small proportion of affected patients had indeed been assessed for DV. Screening for DV in hospitals may thus increase the number of identified patients.

A stochastic microstructure model for particle reinforced aluminium matrix composites

Metal matrix composites are complex materials consisting of various phases which can display largely different mechanical properties. The deformation behaviour of these composites cannot be sufficiently modelled by averages or simple particle shapes due to the local stresses that occur on the particle edges. Therefore, a sophisticated model of the microstructure is needed. We introduce a method for stochastic modelling of a silicon carbide (SiC) particle reinforced aluminium matrix composite. The SiC particles are modelled by Laguerre polyhedra generated by densely packed spheres. The shape factors of the polyhedra have been fitted to the particle shapes observed in three-dimensional images. Particle elongation in extrusion direction and the observed log-normal volume distribution of the particles are included in the model by suitable scaling. An outlook is presented on how to model the grains of the polycrystalline aluminium matrix and intermetallic precipitates, which result from the strengthening mechanism of the matrix. LAY DESCRIPTION: Metal matrix composites are complex materials consisting of different phases which can display largely different mechanical properties. The deformation behaviour of these composites cannot be sufficiently modelled by averages or simple particle shapes due to the local stresses that occur on the particle edges. Therefore, a sophisticated model of the microstructure is needed. We introduce a method of stochastic modelling of a silicon carbide (SiC) particle reinforced aluminium matrix composite. The SiC particles are modelled by Laguerre polyhedra generated by densely packed spheres. The shape factors of the polyhedra have been fitted to the SiC shapes observed in three-dimensional images. Additionally, the polyhedra are scaled anisotropically to account for orientation anisotropy and to obtain a log-normal volume distribution. An outlook is presented on how to model the aluminium phase's grains and intermetallic precipitates, which result from the strengthening mechanism of the aluminium matrix alloy.

Effect of pre-operative methylprednisolone on orthostatic hypotension during early mobilization after total hip arthroplasty

BACKGROUND

Orthostatic hypotension (OH) and intolerance (OI) are common after total hip arthroplasty (THA) and may delay early mobilization. The pathology of OH and OI includes a dysregulated post-operative vasopressor response, by a hitherto unknown mechanism. We hypothesized that OI could be related to the inflammatory stress response which is inhibited by steroid administration. Consequently, this study evaluated the effect of a pre-operative high-dose methylprednisolone on OH and OI early after THA.

METHODS

Randomized, double-blind, placebo-controlled study in 59 patients undergoing elective unilateral THA with spinal anesthesia and a standardized multimodal analgesic regime. Patients were allocated (1 : 1) to pre-operative intravenous (IV) methylprednisolone (MP) 125 mg or isotonic saline (C). OH, OI and cardiovascular responses to sitting and standing were evaluated using a standardized mobilization protocol pre-operatively, 6, and 24 h after surgery. Systolic and diastolic arterial pressure and heart rate were measured non-invasively (Nexfin^® ). The systemic inflammation was monitored by the C-reactive protein (CRP) response.

RESULTS

At 6 h post-operatively, 11 (38%) versus 11 (37%) patients had OH in group MP and group C, respectively (RR 1.02 (0.60 to 1.75; P = 1.00)), whereas OI was present in 9 (31%) versus 13 (43%) patients (RR 0.76 (0.42 to 1.36; P = 0.42)), respectively. At 24 h post-operatively, the prevalence of OH and OI did not differ between groups, though CRP levels were significantly reduced in group MP (P < 0.001).

CONCLUSION

Pre-operative administration of 125 mg methylprednisolone IV did not reduce OH or OI compared with placebo despite a reduced inflammatory response.

Shell Evolution and E2 Collectivity: New Spectroscopic Information

New spectroscopic information on electric quadrupole collectivity has recently been obtained. We report on our identification of a coexisting deformed structure in the quasi-doubly closed-shell nucleus 96Zr from our measurement of a corresponding absolute E2 intraband transition strength in electron scattering reactions and its small mixing matrix element with the spherical ground state structure. The even-mass zirconium isotopes exhibit a first order quantum shape phase transition between neutron numbers 58 and 60. We have used photon scattering reactions for a first measurement of the E2 decay strength of the nuclear 1+ scissors mode. Evidence for its 2+ rotational excitation and its extraordinarily large rotational moment of inertia are presented.

Tibial plateau fractures: Fracture patterns and computed tomography evaluation of tibial plateau fractures in winter sports

The purpose was to analyze tibial plateau fractures (TPF) by computed tomography (CT) by creating a frequency map (FM). We hypothesized that a FM shows clinically important aspects of involvement that are not expressed in classic classifications. 185 TPF were retrospectively evaluated in this single center study. We created a FM onto an axial template of an intact subarticular tibial plateau and separated the joint surface in 9 areas, counted the frequency of involvement. The FM gives information of location and grade of damage and expressed three major fracture areas in 76%. 5 specific fracture types add up to 51%. The dorsal parts of the tibial plateau are involved in a higher percentage (+8%). True lateral fractures are less often than plane radiographs suggest. An impression was found in 50%. The complexity of TPFs is high, but 5 specific types could be identified in >50%. The complexity is not sufficiently covered in common classifications, especially the dorsal involvement. The FM is a simple and useful tool that complements common classifications and can be used as guideline for surgical treatment.

Whole blood microRNAs as potential biomarkers in post-operative early breast cancer patients

BACKGROUND

microRNAs (miRNAs) are considered promising cancer biomarkers, showing high reliability, sensitivity and stability. Our study aimed to identify associations between whole blood miRNA profiles, presence of circulating tumor cells (CTCs) and clinical outcome in post-operative early breast cancer patients (EBC) to assess the utility of miRNAs as prognostic markers in this setting.

METHOD

A total of 48 post-operative patients, recruited in frame of the SUCCESS A trial, were included in this retrospective study and tested with a panel of 8 miRNAs (miR-10b, -19a, - 21, - 22, -20a, - 127, - 155, -200b). Additional 17 female healthy donors with no previous history of cancer were included in the study as negative controls. Blood samples were collected at different time points (pre-adjuvant therapy, post-adjuvant therapy, 2 years follow up), total RNA was extracted and the relative concentration of each miRNA was measured by quantitative PCR and compared in patients stratified on blood collection time or CTC detection. Furthermore, we compared miRNA profiles of patients, for each time point separately, and healthy donors. CTCs were visualized and quantified with immunocytochemistry analysis. Data were analyzed using non-parametric statistical tests.

RESULTS

In our experimental system, miR-19a, miR-22 and miR-127 showed the most promising results, differentiating patients at different time points and from healthy controls, while miR-20a, miR-21 and miR-200b did not show any difference among the different groups. miR-10b and miR-155 were never detectable in our experimental system. With respect to patients' clinical characteristics, we found a significant correlation between miR-200b and lymph node status and between miR-20a and tumor type. Furthermore, miR-127 correlated with the presence of CTCs. Finally, we found a borderline significance between Progression Free Survival and miR-19a levels.

CONCLUSIONS

This pilot study suggests that profiling whole blood miRNAs could help to better stratify post-operative EBC patients without any sign of metastasis to prevent later relapse or metastatic events.

Disrupted brain network topology in chronic insomnia disorder: A resting-state fMRI study

This study investigated the topological characteristics of brain functional networks in chronic insomnia disorder (CID) patients. The resting-state functional magnetic resonance imaging and graph theory analysis method were applied to investigate the brain functional connectome patterns among 45 CID patients and 32 healthy controls. The brain functional connectome was constructed by thresholding partial correlation matrices of 90 brain regions from an automated anatomical labeling atlas. The topologic properties of brain functional connectomes at both global and nodal levels were tested. The CID patients had decreased number of module (p = .014) and hierarchy (p = .038), and increased assortativity (p = .035). Furthermore, some brain regions located in the default mode network, dorsal attention network, and sensory-motor network in these patients showed altered nodal centralities. Within these areas, the node betweenness of right central paracentral lobule had positive correlation with the Pittsburgh Sleep Quality Index score (R = 0.319, p = .039). The results imply that functional disruptions of CID patients may be related to disruptions in global and regional topological organization of the brain functional connectome, and provide new and important insights to understand the pathophysiological mechanisms of CID.

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Chronic insomnia disorder (CID) patients had disrupted global topological properties.

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Many brain regions of CID patients showed altered nodal centralities involving three different resting networks.

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Functional disruption of right central paracentral lobule may be a target for therapeutic intervention in pediatric CID.

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The disruption of topological organization might be explain the mechanism/reason of functional disruptions of CID.

Novel Liposome-Based Surface-Enhanced Raman Spectroscopy (SERS) Substrate

Although great strides have been made in recent years toward making highly enhancing surface-enhanced Raman spectroscopy (SERS) substrates, the biological compatibility of such substrates remains a crucial problem. To address this issue, liposome-based SERS substrates have been constructed in which the biological probe molecule is encapsulated inside the aqueous liposome compartment, and metallic elements are assembled using the liposome as a scaffold. Therefore, the probe molecule is not in contact with the metallic surfaces. Herein we report our initial characterization of these novel nanoparticle-on-mirror substrates, both experimentally and theoretically, using finite-difference time-domain calculations. The substrates are shown to be structurally stable to laser irradiation, the liposome compartment does not rise above 45 °C, and they exhibit an analytical enhancement factor of 8 × 10⁶ for crystal violet encapsulated in 38 liposomes sandwiched between a 40 nm planar gold mirror and 80 nm gold colloid.

E2 decay strength of the M1 scissors mode of ^{156}Gd and its first excited rotational state

The E2/M1 multipole mixing ratio δ_{1→2} of the 1_{sc}^{+}→2_{1}^{+} γ-ray decay in ^{156}Gd and hence the isovector E2 transition rate of the scissors mode of a well-deformed rotational nucleus has been measured for the first time. It has been obtained from the angular distribution of an artificial quasimonochromatic linearly polarized γ-ray beam of energy 3.07(6) MeV scattered inelastically off an isotopically highly enriched ^{156}Gd target. The data yield first direct support for the deformation dependence of effective proton and neutron quadrupole boson charges in the framework of algebraic nuclear models. First evidence for a low-lying J^{π}=2^{+} member of the rotational band of states on top of the 1^{+} band head is obtained, too, indicating a significant signature splitting in the K=1 scissors mode rotational band.

Improved systemic treatment for early breast cancer improves cure rates, modifies metastatic pattern and shortens post-metastatic survival: 35-year results from the Munich Cancer Registry

PURPOSE

Systemic therapies (ATHs) in early breast cancer have improved the survival of breast cancer (BC) patients in recent decades. The magnitude of the changes in overall, metastasis-free (MFS) and post-metastatic (PMS) survival and in the metastasis (MET) pattern will be described.

PATIENT AND METHODS

We analysed 60,227 patients with a diagnosis of T-N-M0 BC between 1978 and 2013 and 11,983 patients with metastases (MET) in the Munich Cancer Registry. Patients will be divided into four time periods to identify relationships between BC and METs. Survival was estimated using Kaplan-Meier curves, and Cox proportional hazards models were used to explore the impact of the BC subtype and MET status on survival with the time periods as surrogate markers for ATH evolution.

RESULTS

During the observation period, 5-year relative survival has improved from 80.3 to 93.6% with an adjusted hazard ratio of 0.54 (P < 0.0001). Successful implementation of ATH has changed the MET pattern. The percentage of liver and CNS METs has more than doubled, the rate of lung METs remains stable, and the rate of bone METs has been reduced by approximately 50%. MFS has been prolonged with a hazard ratio 0.75 (P < 0.0001), but PMS has declined (hazard ratio 1.36; P < 0.0001); however, effects of adjuvant and palliative treatments cannot be separated. These results do not contradict improvements in advanced BC and do not suggest alterations of MET tumour biology by ATH.

CONCLUSIONS

Over the past three decades, ATHs have dramatically improved patient survival after BC diagnosis-most likely, by eradicating prevalent micro-METs; as a result, the MET pattern has changed. Eradicating only a portion of the first METs results in delaying the onset of subsequent MET, which leads to an apparently paradoxical effect: an extension of the MET-free interval and a reduction in PMS.

Evaluating the relationship between muscle and bone modeling response in older adults

Bone modeling, the process that continually adjusts bone strength in response to prevalent muscle-loading forces throughout an individual's lifespan, may play an important role in bone fragility with age. Femoral stress, an index of bone modeling response, can be estimated using measurements of DXA derived bone geometry and loading information incorporated into an engineering model. Assuming that individuals have adapted to habitual muscle loading forces, greater stresses indicate a diminished response and a weaker bone. The purpose of this paper was to evaluate the associations of lean mass and muscle strength with the femoral stress measure generated from the engineering model and to examine the extent to which lean mass and muscle strength account for variation in femoral stress among 2539 healthy older adults participating in the Health ABC study using linear regression. Mean femoral stress was higher in women (9.51, SD=1.85Mpa) than in men (8.02, SD=1.43Mpa). Percent lean mass explained more of the variation in femoral stress than did knee strength adjusted for body size (R(2)=0.187 vs. 0.055 in men; R(2)=0.237 vs. 0.095 in women). In models adjusted for potential confounders, for every percent increase in lean mass, mean femoral stress was 0.121Mpa lower (95% CI: -0.138, -0.104; p<0.001) in men and 0.139Mpa lower (95% CI: -0.158, -0.121; p<0.001) in women. The inverse association of femoral stress with lean mass and with knee strength did not differ by category of BMI. Results from this study provide insight into bone modeling differences as measured by femoral stress among older men and women and indicate that lean mass may capture elements of bone's response to load.

Whole-Body Diffusion Imaging Applying Simultaneous Multi-Slice Excitation

PURPOSE

The purpose of this study was to examine the feasibility of a fast protocol for whole-body diffusion-weighted imaging (WB-DWI) using a slice-accelerated echo-planar sequence, which, when using comparable image acquisition parameters, noticeably reduces measurement time compared to a conventional WB-DWI protocol.

MATERIALS AND METHODS

A single-shot echo-planar imaging sequence capable of simultaneous slice excitation and acquisition was optimized for WB-DWI on a 3 T MR scanner, with a comparable conventional WB-DWI protocol serving as the reference standard. Eight healthy individuals and one oncologic patient underwent WB-DWI. Quantitative analysis was carried out by measuring the apparent diffusion coefficient (ADC) and its coefficient of variation (CV) in different organs. Image quality was assessed qualitatively by two independent radiologists using a 4-point Likert scale.

RESULTS

Using our proposed protocol, the scan time of the WB-DWI measurement was reduced by up to 25.9 %. Both protocols, the slice-accelerated protocol and the conventional protocol, showed comparable image quality without statistically significant differences in the reader scores. Similarly, no significant differences of the ADC values of parenchymal organs were found, whereas ADC values of brain tissue were slightly higher in the slice-accelerated protocol.

CONCLUSION

It was demonstrated that slice-accelerated DWI can be applied to WB-DWI protocols with the potential to greatly reduce the required measurement time, thereby substantially increasing clinical applicability.

KEY POINTS

•Whole-body diffusion-weighted imaging (WB-DWI) using simultaneous multi-slice and blipped-CAIPIRINHA reduces the measurement time strongly without having a significant impact on image quality. •The reduction in measurement time might strongly contribute to the clinical applicability of WB-DWI. •However, further refinement of the slice-accelerated EPI sequence, and the WB-DWI protocol applying this sequence type seems necessary; and the value of such WB-DWI protocols for assessment of systemic oncological diseases needs to be investigated in further clinical studies.