Seq-Scope Protocol: Repurposing Illumina Sequencing Flow Cells for High-Resolution Spatial Transcriptomics

Spatial transcriptomics (ST) technologies represent a significant advance in gene expression studies, aiming to profile the entire transcriptome from a single histological slide. These techniques are designed to overcome the constraints faced by traditional methods such as immunostaining and RNA in situ hybridization, which are capable of analyzing only a few target genes simultaneously. However, the application of ST in histopathological analysis is also limited by several factors, including low resolution, a limited range of genes, scalability issues, high cost, and the need for sophisticated equipment and complex methodologies. Seq-Scope-a recently developed novel technology-repurposes the Illumina sequencing platform for high-resolution, high-content spatial transcriptome analysis, thereby overcoming these limitations. Here we provide a detailed step-by-step protocol to implement Seq-Scope with an Illumina NovaSeq 6000 sequencing flow cell that allows for the profiling of multiple tissue sections in an area of 7 mm × 7 mm or larger. In addition to detailing how to prepare a frozen tissue section for both histological imaging and sequencing library preparation, we provide comprehensive instructions and a streamlined computational pipeline to integrate histological and transcriptomic data for high-resolution spatial analysis. This includes the use of conventional software tools for single cell and spatial analysis, as well as our recently developed segmentation-free method for analyzing spatial data at submicrometer resolution. Given its adaptability across various biological tissues, Seq-Scope establishes itself as an invaluable tool for researchers in molecular biology and histology.

Characterization of Mild Delayed Gestational Hypertension in Rats Following Ozone Exposure

The contribution of air pollution induced cardio-pulmonary damage on the development of hypertensive disorders of pregnancy and other adverse outcomes of pregnancy has gained increased attention as epidemiological data continues to highlight spatiotemporal pregnancy trends related to air pollution exposure. However clinical mechanistic data surrounding gestational complications remains sparse, necessitating the need for the use of animal models to study these types of complications of pregnancy. The current study seeks to examine the real-time effects of mid-gestational ozone exposure on maternal blood pressure and body temperature through the use of radiotelemetry in a rat model. The exposure resulted in acute depression of heart rate and core body temperature as compared to control animals. Ozone exposed animals also presented with a slight but significant increase in arterial blood pressure which was perpetuated until term. The data presented here illustrates the feasibility of murine models to assess cardiovascular complications caused by inhaled toxicants during the window of pregnancy.

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

BACKGROUND

Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.

METHODS

This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.

RESULTS

The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.

CONCLUSION

Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely.

The health care experiences of people with head and neck cancer: A scoping review

BACKGROUND

Understanding health care experience in head and neck cancer (HNC) is becoming increasingly important due to changes in the disease profile, survivorship, and a greater appreciation of patient health care experience as an important outcome measure. People with HNC encounter many different types of health care professionals and health care touchpoints.

METHOD

Through systematic database searching, this scoping review of qualitative English-language studies describes the self-reported care experiences of those with HNC across the health care continuum, and describes the current state of the literature.

RESULTS

Overall, the 95 studies identified were heterogeneous and investigated a broad range of topics. Trends across studies showed research centered on hospital-based care, conducted in developed countries, with more studies on feeding than other aspects of care. Generic qualitative research frameworks, with individual interviews, were the preferred method of data collection.

CONCLUSION

Despite identifying many studies, there are significant gaps in our understanding of the HNC patient experience.

Psychoactive substances and previous hospital admissions, triage and length of stay in rural injuries: a prospective observational study

BACKGROUND

Patients admitted to hospital after an injury are often found to have used psychoactive substances prior to the injury. The aim of this study was to investigate the associations between psychoactive substances (alcohol, psychoactive medicinal drugs and illicit drugs) and previous hospital admissions, triage and length of stay in the arctic Norwegian county of Finnmark.

METHODS

Patients ≥ 18 years admitted due to injury to trauma hospitals in Finnmark from January 2015 to August 2016 were approached. Parameters regarding admittance and hospital stay were collected from 684 patients and blood was analysed for psychoactive substances. Using a prospective, observational design, time, triage, length of stay in hospital, use of intensive care unit (ICU), injury severity, Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) and number of previous admittances were investigated by bivariable testing and logistical regression analysis.

RESULTS

Of 943 patients approached, 81% consented and 684 were included in the study. During the weekend, 51.5% tested positive for any substance versus 27.1% Monday-Friday. No associations were identified between testing positive and either triage or injury severity for any substance group although triage level was lower in patients with AUDIT-C ≥ 5. Short length of stay was associated with alcohol use prior to injury [odds ratio (OR) 0.48 for staying > 12 h, confidence interval (CI) 0.25-0.90]. The OR for staying > 24 h in the ICU when positive for an illicit substance was 6.33 (CI 1.79-22.32) while negatively associated with an AUDIT-C ≥ 5 (OR 0.30, CI 0.10-0.92). Patients testing positive for a substance had more often previously been admitted with the strongest association for illicit drugs (OR 6.43 (CI 1.47-28.08), compared to patients in whom no substances were detected.

CONCLUSIONS

Triage level and injury severity were not associated with psychoactive substance use. Patients using alcohol are more often discharged early, but illicit substances were associated with longer ICU stays. All psychoactive substance groups were associated with having been previously admitted.

Financial Improvements from Short Course Adjuvant Vaginal Cuff Brachytherapy (VCB) in Early Endometrial Cancer Compared to Standard of Care, "SAVE" Trial

PURPOSE/OBJECTIVE(S)

Early-stage endometrial cancer is often managed with hysterectomy followed by adjuvant VCB. Financial toxicity from cancer treatment is a strong driver of adherence. The SAVE trial is a multicenter, prospective randomized trial of standard of care (SoC) VCB doses delivered in 3-5 fractions per physician discretion compared to a 2-fraction course. We report on secondary cost endpoints, quantifying the financial impacts of shorter treatment courses on institutions and participating patients.

MATERIALS/METHODS

Technical (TechCs), professional (PCs), and total charges (TotCs) were collected prospectively and are reported as raw and Medicare-adjusted charges per patient. Geographic variations were standardized with CMS Geographic Practice Cost Indices (GPCI), and inflation was adjusted using the Consumer Price Index (CPI): Medical Care. Distance to treatment center was calculated from the patient's zip code to the corresponding treatment center. Cost of commutes was estimated through round-trip travel distance multiplied by average gas MPG for new vehicles by treatment year and state. Median income for each patient's zip code was estimated using 5-year Household income in 2021 inflation-adjusted dollars from the US Census. Mann-Whitney U, T- and Chi-square tests were used to compare characteristics between the two groups.

RESULTS

One hundred eight patients were analyzed. SoC VCB was delivered in 3, 4 and 5 fractions for 27/54 (50%), 11/54 (20%), and 16/54 (30%), respectively. Median total distance traveled per patient for SoC vs. experimental arms was 213 vs 137 miles (p = .12), and median cost of commute for patients was 36.3 vs 18.0 USD (p = .11). Compared to 2-fraction treatment, 5-fraction treatment resulted in longer travel distances (median 462 vs. 137 miles, p < 0.01) and increased travel costs (median 59.3 v. 18.0 USD, p = < 0.01). Median income by zip code for SoC v. experimental arms was 79,704 vs. 79,671 USD (p = 1.0). For SoC v. experimental arms, 11 (20%) vs 7 (13%) of patients had zip codes with median income in the lowest or second lowest quintiles (p = 0.5). Adjusted raw PCs per patient did not differ between SoC vs. experimental arms (9,159$ vs. 7,532$, p = 0.19). TechCs were significantly higher on the SoC arm (35,734$ vs. 24,696$ p = < 0.01), as were TotCs (44,892$ vs. 32,228$, p < 0.01;). Medicare-adjusted PCs, TechCs, and TotCs were higher for the SoC arm (Table 1).

CONCLUSION

Two-fraction VCB resulted in fewer treatments per patient, reduced cost of travel compared to longer courses, and an adjusted reduction in healthcare expenditures compared to standard of care. Ongoing work will include assessment of patient-reported financial toxicities.

Sub-second Dopamine Signals during Risky Decision-Making in Patients with Impulse Control Disorder

Background

Impulse Control Disorder (ICD) in Parkinson's disease is a behavioral addiction arising secondary to dopaminergic therapies, most often dopamine receptor agonists. Prior research implicates changes in striatal function and heightened dopaminergic activity in the dorsal striatum of patients with ICD. However, this prior work does not possess the temporal resolution required to investigate dopaminergic signaling during real-time progression through various stages of decision-making involving anticipation and feedback.

Methods

We recorded high-frequency (10Hz) measurements of extracellular dopamine in the striatum of patients with (N=3) and without (N=3) a history of ICD secondary to dopamine receptor agonist therapy for Parkinson's disease symptoms. These measurements were made using carbon fiber microelectrodes during awake DBS neurosurgery and while participants performed a sequential decision-making task involving risky investment decisions and real monetary gains and losses. Per clinical standard-of-care, participants withheld all dopaminergic medications prior to the procedure.

Results

Patients with ICD invested significantly more money than patients without ICD. On each trial, patients with ICD made smaller adjustments to their investment levels compared to patients without ICD. In patients with ICD, dopamine levels rose or fell on sub-second timescales in anticipation of investment outcomes consistent with increased or decreased confidence in a positive outcome, respectively; dopamine levels in patients without ICD were significantly more stable during this phase. After outcome revelation, dopamine levels in patients with ICD rose significantly more than in inpatients without ICD for better-than-expected gains. For worse-than-expected losses, dopamine levels in patients with ICD remained level whereas dopamine levels in patients without ICD fell.

Conclusion

We report significantly increased risky behavior and exacerbated phasic dopamine signaling, on sub-second timescales, anticipating and following the revelation of the outcomes of risky decisions in patients with ICD. Notably, these results were obtained when patients who had demonstrated ICD in the past but were, at the time of surgery, in an off-medication state. Thus, it is unclear whether observed signals reflect an inherent predisposition for ICD that was revealed when dopamine receptor agonists were introduced or whether these observations were caused by the introduction of dopamine receptor agonists and the patients having experienced ICD symptoms in the past. Regardless, future work investigating dopamine's role in human cognition, behavior, and disease should consider the signals this system generates on sub-second timescales.

Assessing Firefighters' Tourniquet Skill Attainment and Retention: A Controlled Simulation-Based Experiment

BACKGROUND

The aim of this study was to train and assess firefighters' skill attainment in the use of tourniquets, and to assess their skill retention after 3 mo. The purpose is to show if firefighters can successfully apply a tourniquet after a short course based on the Norwegian national recommendation for civil prehospital tourniquet use.

METHODS

This is a prospective experimental study. The study population were firefighters, and the inclusion criterion was any on-duty firefighter. The first phase consisted of baseline precourse testing (T1), a 45-min course, followed by immediate retesting (T2). The second phase consisted of retesting of skill retention after 3 mo (T3).

RESULTS

A total of 109 participants at T1, 105 at T2, and 62 participants at T3. The firefighters achieved a higher proportion of successful tourniquet applications at T2 (91.4%; 96 of 105) as well as T3 (87.1%; 54 of 62) compared with 50.5% at T1 (55 of 109) (P = 0.009). Mean application time was 59.6 s (55.1-64.2) in T1, 34.9 s (33.3-36.6) in T2 and 37.7 s (33.9-41.4) in T3.

CONCLUSION

A sample of firefighters can successfully apply a tourniquet after a 45-min course based on the 2019 Norwegian recommendation for civil prehospital tourniquet use. Skill retention after 3 mo was satisfactory for both successful application and application time.

Anti-Yo paraneoplastic cerebellar degeneration in a patient with stage IV ovarian adenocarcinoma during bevacizumab maintenance therapy

Anti-Yo paraneoplastic cerebellar degeneration (PCD) is a rare autoimmune neurological syndrome characterised by cerebellar symptoms and frequently associated with gynaecological malignancies. While typically preceding the diagnosis of the malignancy, rarely it may present later in the disease course, heralding a recurrence prior to biochemical or radiological confirmation. Disease management is challenging and prognosis remains poor.We present the case of a woman with stage IV ovarian adenocarcinoma who developed anti-Yo PCD 16 months post malignancy diagnosis while receiving bevacizumab maintenance therapy. We review the literature and outline the difficulties in diagnosis and the frequently refractory nature of PCD to available treatments.

Intracranial subsecond dopamine measurements during a "sure bet or gamble" decision-making task in patients with alcohol use disorder suggest diminished dopaminergic signals about relief

OBJECTIVE

To the authors' knowledge, no data have been reported on dopamine fluctuations on subsecond timescales in humans with alcohol use disorder (AUD). In this study, dopamine release was monitored in 2 patients with and 2 without a history of AUD during a "sure bet or gamble" (SBORG) decision-making task to begin to characterize how subsecond dopamine responses to counterfactual information, related to psychological notions of regret and relief, in AUD may be altered.

METHODS

Measurements of extracellular dopamine levels were made once every 100 msec using human voltammetric methods. Measurements were made in the caudate during deep brain stimulation electrode implantation surgeries (for treatment of movement disorders) in patients who did (AUD, n = 2) or did not (non-AUD, n = 2) have a history of AUD. Participants performed an SBORG decision-making task in which they made choices between sure bets and 50%-chance monetary gamble outcomes.

RESULTS

Fast changes were found in dopamine levels that appear to be modulated by "what could have been" and by patients' AUD status. Positive counterfactual prediction errors (related to relief) differentiated patients with versus without a history of AUD.

CONCLUSIONS

Dopaminergic encoding of counterfactual information appears to differ between patients with and without AUD. The current study has a major limitation of a limited sample size, but these data provide a rare insight into dopaminergic physiology during real-time decision-making in humans with an addiction disorder. The authors hope future work will expand the sample size and determine the generalizability of the current results.

Electron Bernstein Wave (EBW) current drive profiles and efficiency for STEP

GENRAY and CQL3D were used to estimate the Electron Bernstein Wave (EBW) current drive profiles and normalised current drive efficiency ζCD (6) for several STEP reactor concepts with varying temperature, density, geometry and magnetic field. ζCD > 1.0 was readily found for ρ = 0.65 − 0.9 while ζCD > 0.5 was found for ρ ≥ 0.5. Okhawa is found to be the most efficient current drive mechanism due to the high trapped fraction in STEP. Optimal current drive was found for 2nd harmonic absorption for ρ ≤ 0.8 due to the higher ν⊥ at the wave-particle resonance. 1st harmonic absorption is required for ρ > 0.8 as there is no access to the 2nd harmonic at the launch frequencies examined. Rays with negative starting N∥ were found to penetrate furthest. Due to the high electron temperature in STEP the relativistic downshift of the harmonic becomes comparable to the Doppler shift, increasing access to the 2nd harmonic.

Microwave current drive for STEP and MAST Upgrade

The UK’s Spherical Tokamak for Energy Production (STEP) reactor design program has recently taken the decision to use exclusively microwave-based heating and current drive (HCD) actuators for its reactor concepts. This is based on a detailed assessment considering all viable HCD concepts, covering the grid to plasma efficiency, physics applications, technology maturity, integration, maintenance, and costs. Of the two microwave techniques: Electron Cyclotron (EC) and Electron Bernstein Wave (EBW), EC was deemed the lowest risk and EBW is retained as a potential path to a more efficient, higher performing device. To assess the ECCD efficiency, the GRAY beam tracing code was employed to perform detailed scans of the launcher position, toroidal and poloidal launch angle, and frequency over the first 3 cyclotron harmonics. For EBW, GENRAY/CQL3D were used to estimate the CD efficiency, demonstrating promising results. To reduce the physics uncertainties in present models for EBW coupling and current drive, MAST Upgrade will install two dual frequency (28, 34.8 GHz), 900kW, 5s gyrotrons from Kyoto Fusioneering, as part of the MAST Upgrade enhancements package. This will be accompanied by a flexible 2D steering launcher system to allow midplane coand counter-CD and above midplane launch for co-direction off-axis CD. Coupling efficiency is quantified by measuring the heating induced by reflected (i.e. non-coupled) power to a plate inserted in the reflected beam path. The experiments will also include EBW driven solenoid-free start-up, increasing power and pulse length by a factor of 10 compared to previous MAST experiments. This presentation will discuss the STEP microwave studies and the MAST Upgrade physics design and capabilities.

Whole blood transfusion and paroxysmal nocturnal haemoglobinuria meet again: Minor incompatibility, major trouble

BACKGROUND AND OBJECTIVES

The field of transfusion medicine started out with whole blood transfusion to treat severe anaemia and other deficiencies, and then transitioned to component therapy, largely leaving the practice, and experiences, of whole blood transfusions behind. Currently, the field is circling back and whole blood is gaining ground as an alternative to massive transfusion protocols.

MATERIALS AND METHODS

Herein we describe a severely anaemic paroxysmal nocturnal haemoglobinuria (PNH) patient initially suspected of suffering from renal haemorrhage, receiving a standard low-titre group O whole blood transfusion during pre-hospital transportation.

RESULTS

Following the transfusion, the patient suffered a clinically unmistakable haemolytic transfusion reaction requiring supportive treatment in the intensive care unit. Clinical observations are consistent with an acute haemolytic reaction. The haemolysis was likely due to minor incompatibility between the plasma from the transfused whole blood and the patient's PNH red cells. Recovery was uneventful.

CONCLUSION

This revealed an unappreciated contraindication to minor incompatible whole blood transfusion, and prompted a discussion on the distinction between whole blood and erythrocyte concentrates, the different indications for use and the importance of emphasizing these differences. It also calls attention to patient groups where minor incompatibility can be of major importance.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Spectral binning as an approach to post-acquisition processing of high resolution FIE-MS metabolome fingerprinting data

INTRODUCTION

Flow infusion electrospray high resolution mass spectrometry (FIE-HRMS) fingerprinting produces complex, high dimensional data sets which require specialist in-silico software tools to process the data prior to analysis.

OBJECTIVES

Present spectral binning as a pragmatic approach to post-acquisition procession of FIE-HRMS metabolome fingerprinting data.

METHODS

A spectral binning approach was developed that included the elimination of single scan m/z events, the binning of spectra and the averaging of spectra across the infusion profile. The modal accurate m/z was then extracted for each bin. This approach was assessed using four different biological matrices and a mix of 31 known chemical standards analysed by FIE-HRMS using an Exactive Orbitrap. Bin purity and centrality metrics were developed to objectively assess the distribution and position of accurate m/z within an individual bin respectively.

RESULTS

The optimal spectral binning width was found to be 0.01 amu. 80.8% of the extracted accurate m/z matched to predicted ionisation products of the chemical standards mix were found to have an error of below 3 ppm. The open-source R package binneR was developed as a user friendly implementation of the approach. This was able to process 100 data files using 4 Central Processing Units (CPU) workers in only 55 seconds with a maximum memory usage of 1.36 GB.

CONCLUSION

Spectral binning is a fast and robust method for the post-acquisition processing of FIE-HRMS data. The open-source R package binneR allows users to efficiently process data from FIE-HRMS experiments with the resources available on a standard desktop computer.

Assessing Adherence to Healthy Dietary Habits Through the Urinary Food Metabolome: Results From a European Two-Center Study

Background

Diet is one of the most important modifiable lifestyle factors in human health and in chronic disease prevention. Thus, accurate dietary assessment is essential for reliably evaluating adherence to healthy habits.

Objectives

The aim of this study was to identify urinary metabolites that could serve as robust biomarkers of diet quality, as assessed through the Alternative Healthy Eating Index (AHEI-2010).

Design

We set up two-center samples of 160 healthy volunteers, aged between 25 and 50, living as a couple or family, with repeated urine sampling and dietary assessment at baseline, and 6 and 12 months over a year. Urine samples were subjected to large-scale metabolomics analysis for comprehensive quantitative characterization of the food-related metabolome. Then, lasso regularized regression analysis and limma univariate analysis were applied to identify those metabolites associated with the AHEI-2010, and to investigate the reproducibility of these associations over time.

Results

Several polyphenol microbial metabolites were found to be positively associated with the AHEI-2010 score; urinary enterolactone glucuronide showed a reproducible association at the three study time points [false discovery rate (FDR): 0.016, 0.014, 0.016]. Furthermore, other associations were found between the AHEI-2010 and various metabolites related to the intake of coffee, red meat and fish, whereas other polyphenol phase II metabolites were associated with higher AHEI-2010 scores at one of the three time points investigated (FDR < 0.05 or β ≠ 0).

Conclusion

We have demonstrated that urinary metabolites, and particularly microbiota-derived metabolites, could serve as reliable indicators of adherence to healthy dietary habits.

Clinical Trail Registration

www.ClinicalTrials.gov, Identifier: NCT03169088.

The Consumption of Two Eggs per Day for 12 Weeks Does Not Significantly Improve Biomarkers of Bone Metabolism or Inflammation in College-Aged Females Running Cross Country

Objectives

The primary aim of this study was to investigate the effects of increased dietary cholesterol intake through the consumption of two eggs per day on biomarkers of bone metabolism and inflammation in female division one cross country and track athletes.

Methods

Fifteen female Division I student-athletes from university's women's Cross Country/Track and Field Team (age 20.2 + 1.0 yrs.) participated in this study. Prior to the study, subjects were asked to refrain from all egg-based food products for two weeks. After this initial period, subjects were instructed to consume two eggs per day in the form of their choice for 12 weeks. Fasting venous blood samples were collected in the morning hours (0700–1000) following a 12-hour fast and absence of intense exercise training within the last 24 hrs at baseline and after 12 weeks. Serum was collected and immediately stored at -80°C until analysis. Serum bone formation markers; N-terminal propeptide of type I procollagen (PINP) and osteocalcin (OC) and bone resorption marker, C-terminal of telopeptides of type I procollagen (CTXI), and serum inflammatory biomarkers; tumor necrosis factor alpha (TNF-α), interleukin-1 beta (IL-1 β), and IL-6 were measured using ELISA kits.

Results

There were no significant changes in any of the bone metabolism biomarkers, but they were trending in a positive direction. Mean serum CTXI levels were slightly lower at 0.36 vs 0.30 ng/mL after the intervention, but not significantly (p = 0.083). Serum OC levels didn't change 0.35 vs 0.38 ng/mL nor did serum PINP levels, 40.89 vs 42.72 ng/mL after the intervention. For the biomarkers of inflammation we did observe a significant increase in serum IL-6, 3.82 vs 4.27 pg/mL (p = 0.037) after the intervention. However, there were no significant changes in TNF-α, 10.27 vs 9.70 pg/mL or IL-1β, 5.97 vs 6.05 pg/mL after the intervention.

Conclusions

The current study shows no substantial changes in serum biomarkers of bone metabolism or inflammation after intervention with consuming two eggs per day for 12 weeks. However, there was a significant increase in IL-6 after the intervention.

Funding Sources

Supported in part by an Internal Seed Research Grant from the University of Massachusetts Lowell.

Percutaneous Removal of Epicardial Pacing Wire: Nidus for Infective Endocarditis

•

Retained TEPW is fairly common and in rare cases may cause infective endocarditis.

•

Obtaining medical records and using multimodality imaging confirmed diagnosis.

•

The heart team assured full understanding of treatment options to reduce patient risk.

•

Right-side endocarditis caused by retained TEPW was treated without redo sternotomy.

Inhibition of Microtubule Dynamics in Cancer Cells by Indole-Modified Latonduine Derivatives and Their Metal Complexes

Indolo[2,3-d]benzazepines (indololatonduines) are rarely discussed in the literature. In this project, we prepared a series of novel indololatonduine derivatives and their Ru^II and Os^II complexes and investigated their microtubule-targeting properties in comparison with paclitaxel and colchicine. Compounds were fully characterized by spectroscopic techniques (¹H NMR and UV–vis), ESI mass-spectrometry, and X-ray crystallography, and their purity was confirmed by elemental analysis. The stabilities of the compounds in DMSO and water were confirmed by ¹H and ¹³C NMR and UV–vis spectroscopy. Novel indololatonduines demonstrated anticancer activity in vitro in a low micromolar concentration range, while their coordination to metal centers resulted in a decrease of cytotoxicity. The preliminary in vivo activity of the Ru^II complex was investigated. Fluorescence staining and in vitro tubulin polymerization assays revealed the prepared compounds to have excellent microtubule-destabilizing activities, even more potent than the well-known microtubule-destabilizing agent colchicine.

Several synthesized indololatonduine derivatives and their Ru^II and Os^II complexes were investigated for their microtubule-targeting properties in comparison with paclitaxel and colchicine. Fluorescence staining and in vitro tubulin polymerization assays indicate excellent microtubule-destabilizing activity. The compounds were even more potent than the well-known microtubule-destabilizing agent colchicine.

Dietary Oxidized Linoleic Acids Modulate Fatty Acids in Mice

Objective

An elevated concentration of oxidized lipids along with the abnormal accumulation of lipids has been linked to the formation of atheromatous plaque and the development of cardiovascular diseases. This study aims to investigate if consumption of different concentrations of dietary oxidized linoleic acid alters the distribution of long chain fatty acids (LCFAs) within the liver relative to plasma in mice.

Methods

C57BL/6 male mice (n = 40) were divided into 4 groups: Standard chow as plain control (P group, n =10), Chow supplemented with linoleic acid 9 mg/mouse/day, linoleic control (C group, n=0), oxidized linoleic acid; 9 mg/mouse/day (A group, n=10) and oxidized linoleic acid 18 mg/mouse/day diet (B group, n=10). Liver and plasma samples were extracted, trans-esterified and subsequently analyzed using gas chromatography mass spectrometry (GC-MS) for LCFAs; palmitic acid, stearic acid, oleic acid, linoleic acid and arachidonic acid.

Results

LCFA methyl esters were eluted and identified based on their respective physiochemical characteristics of GCMS assay with inter assay coefficient of variation percentage (CV%, 1.81–5.28%), limits of quantification and limit of detection values (2.021–11.402 mg/mL and 1.016–4.430 mg/mL) respectively. Correlation analysis of liver and plasma lipids of the mice groups yielded coefficients (r=0.96, 0.6, 0.8 and 0.33) with fatty acid percentage total of (16%, 10%, 16% and 58%) for the P, C, A and B groups respectively.

Conclusion

The sustained consumption of a diet rich in oxidized linoleic acid disrupted fatty acid metabolism. The intake also resulted in elevated concentration of LCFAs that are precursors of bioactive metabolite molecule.

Early Gestational Exposure to Inhaled Ozone Impairs Maternal Uterine Artery and Cardiac Function

Exposure to air pollutants such as ozone (O3) is associated with adverse pregnancy outcomes, including higher incidence of gestational hypertension, preeclampsia, and peripartum cardiomyopathy; however, the underlying mechanisms of this association remain unclear. We hypothesized that O3 exposures during early placental formation would lead to more adverse cardiovascular effects at term for exposed dams, as compared with late-term exposures. Pregnant Sprague Dawley rats were exposed (4 h) to either filtered air (FA) or O3 (0.3 or 1.0 ppm) at either gestational day (GD)10 or GD20, with longitudinal functional assessments and molecular endpoints conducted at term. Exposure at GD10 led to placental transcriptional changes at term that were consistent with markers in human preeclampsia, including reduced mmp10 and increased cd36, fzd1, and col1a1. O3 exposure, at both early and late gestation, induced a significant increase in maternal circulating soluble FMS-like tyrosine kinase-1 (sFlt-1), a known driver of preeclampsia. Otherwise, exposure to 0.3 ppm O3 at GD10 led to several late-stage cardiovascular outcomes in dams that were not evident in GD20-exposed dams, including elevated uterine artery resistance index and reduced cardiac output and stroke volume. GD10 O3 exposure proteomic profile in maternal hearts characterized by a reduction in proteins with essential roles in metabolism and mitochondrial function, whereas phosphoproteomic changes were consistent with pathways involved in cardiomyopathic responses. Thus, the developing placenta is an indirect target of inhaled O3 and systemic maternal cardiovascular abnormalities may be induced by O3 exposure at a specific window of gestation.

Association of Postoperative Clinical Outcomes With Sarcopenia, Frailty, and Nutritional Status in Older Patients With Colorectal Cancer: Protocol for a Prospective Cohort Study

Background

Older patients account for a significant proportion of patients undergoing colorectal cancer surgery and are vulnerable to a number of preoperative risk factors that are not often present in younger patients. Further, three preoperative risk factors that are more prevalent in older adults include frailty, sarcopenia, and malnutrition. Although each of these has been studied in isolation, there is little information on the interplay between them in older surgical patients. A particular area of increasing interest is the use of urine metabolomics for the objective evaluation of dietary profiles and malnutrition.

Objective

Herein, we describe the design, cohort, and standard operating procedures of a planned prospective study of older surgical patients undergoing colorectal cancer resection across multiple institutions in the United Kingdom. The objectives are to determine the association between clinical outcomes and frailty, nutritional status, and sarcopenia.

Methods

The procedures will include serial frailty evaluations (Clinical Frailty Scale and Groningen Frailty Indicator), functional assessments (hand grip strength and 4-meter walk test), muscle mass evaluations via computerized tomography morphometric analysis, and the evaluation of nutritional status via the analysis of urinary dietary biomarkers. The primary feasibility outcome is the estimation of the incidence rate of postoperative complications, and the primary clinical outcome is the association between the presence of postoperative complications and frailty, sarcopenia, and nutritional status. The secondary outcome measures are the length of hospital stay, 30-day hospital readmission rate, and mortality rate at days 30 and 90.

Results

Our study was approved by the National Health Service Research Ethics Committee (reference number: 19/WA/0190) via the Integrated Research Application System (project ID: 231694) prior to subject recruitment. Cardiff University is acting as the study sponsor. Our study is financially supported through an external, peer-reviewed grant from the British Geriatrics Society and internal funding resources from Cardiff University. The results will be disseminated through peer-review publications, social media, and conference proceedings.

Conclusions

As frailty, sarcopenia, and malnutrition are all areas of common derangement in the older surgical population, prospectively studying these risk factors in concert will allow for the analysis of their interplay as well as the development of predictive models for those at risk of commonly tracked surgical complications and outcomes.

International Registered Report Identifier (IRRID)

PRR1-10.2196/16846

Sequential immunotherapy in melanoma: is it a realistic alternative to dual immunotherapy?

The treatment of metastatic melanoma has been revolutionised with the emergence of checkpoint inhibitors. The combination of Ipilimumab and Nivolumab offers the longest overall survival but is considerably more toxic than single-agent therapy. For patients who received single-agent immunotherapy it is unclear whether second-line immunotherapy is efficacious or tolerable. This study looked at outcomes for patients treated with sequential immunotherapy and compared them to patients who received dual immunotherapy. Fifty-eight patients received both Ipilimumab and an anti-PD-1 agent during the 5-year period, twenty-seven received dual immunotherapy, twenty received first-line Ipilimumab and eleven received an anti-PD-1 agent first line. The median overall survival (OS) was 24.8 months. The 5 year survival was greatest in patients treated with dual immunotherapy (42%) compared to first-line anti-PD-1 (33.3%) and first-line Ipilimumab (0%). As second-line treatments, anti-PD-1 agents had a median OS of 16.5 months compared to Ipilimumab at 3.4 months. 77.8% of patients had grade 3/4 toxicity with dual immunotherapy compared to 10% of patients treated with first-line Ipilimumab and 0% with anti-PD-1 agents. In the second line, 72.7% of patients treated with Ipilimumab experienced grade 3/4 toxicity, compared to 20% of patients treated with second-line anti-PD-1 agents. This study suggests Ipilimumab is not efficacious in patients who progress after anti-PD-1 agents, and this sequential approach does not avoid toxicity. The emergence of new checkpoint inhibitors will hopefully provide more efficacious treatment options for patients unable to tolerate Ipilimumab.

PARP-Targeted Auger Therapy in p53 Mutant Colon Cancer Xenograft Mouse Models

Despite Auger electrons being highly appealing due to their short-range and high linear energy transfer to surrounding tissues, the progress in the field has been limited due to the challenge in delivering a therapeutic dose within the close proximity of cancer cell's DNA. Here, we demonstrate that the PARP inhibitor ¹²³I-MAPi is a viable agent for the systemic administration and treatment of p53 mutant cancers. Significantly, minimal off-site toxicity was observed in mice administered with up to 74 MBq of ¹²⁷I-PARPi. Taken together, these results lay the foundation for future clinical evaluation and broader preclinical investigations. By harnessing the scaffold of the PARP inhibitor Olaparib, we were able to deliver therapeutic levels of Auger radiation to the site of human colorectal cancer xenograft tumors after systemic administration. In-depth toxicity studies analyzed blood chemistry levels and markers associated with specific organ toxicity. Finally, p53^+/+ and p53^-/- human colorectal cancer cell lines were evaluated for the ability of ¹²³I-MAPi to induce tumor growth delay. Toxicity studies demonstrate that both ¹²³I-MAPi and its stable isotopologue, ¹²⁷I-PARPi, have no significant off-site toxicity when administered systemically. Analysis following ¹²³I-MAPi treatment confirmed its ability to induce DNA damage at the site of xenograft tumors when administered systemically. Finally, we demonstrate that ¹²³I-MAPi generates a therapeutic response in p53^-/-, but not p53^+/+, subcutaneous xenograft tumors in mouse models. Taken together, these results represent the first example of a PARP Auger theranostic agent capable of delivering a therapeutic dose to xenograft human colorectal cancer tumors upon systemic administration without causing significant toxicity to surrounding mouse organs. Moreover, it suggests that a PARP Auger theranostic can act as a targeted therapeutic for cancers with mutated p53 pathways. This landmark goal paves the way for clinical evaluation of ¹²³I-MAPi for pan cancer therapeutics.

Tissue Collection and RNA Extraction from the Human Osteoarthritic Knee Joint

Osteoarthritis (OA) is a chronic and degenerative joint disease most often affecting the knee. As there is currently no cure, total knee arthroplasty (TKA) is a common surgical intervention. Experiments using primary human OA tissues obtained from TKA provide the capability to investigate disease mechanisms ex vivo. While OA was previously thought to impact mainly the cartilage, it is now known to impact multiple tissues in the joint. This protocol describes patient selection, sample processing, tissue homogenization, RNA extraction, and quality control (based on RNA purity, integrity, and yield) from each of seven unique tissues to support disease mechanism investigation in the knee joint. With informed consent, samples were obtained from patients undergoing TKA for OA. Tissues were dissected, washed, and stored within 4 h of surgery by flash freezing for RNA or formalin fixation for histology. Collected tissues included articular cartilage, subchondral bone, meniscus, infrapatellar fat pad, anterior cruciate ligament, synovium, and vastus medialis oblique muscle. RNA extraction protocols were tested for each tissue type. The most significant modification involved the method of disintegration used for low-cell, high-matrix, hard tissues (considered as cartilage, bone, and meniscus) versus relatively high-cell, low-matrix, soft tissues (considered as fat pad, ligament, synovium, and muscle). It was found that pulverization was appropriate for hard tissues, and homogenization was appropriate for soft tissues. A proclivity for some subjects to yield higher RNA integrity number (RIN) values than other subjects consistently across multiple tissues was observed, suggesting that underlying factors such as disease severity may impact RNA quality. The ability to isolate high-quality RNA from primary human OA tissues provides a physiologically relevant model for sophisticated gene expression experiments, including sequencing, that can lead to clinical insights that are more readily translated to patients.

New Heart Failure After Myocardial Infarction (From the National Cardiovascular Data Registries [NCDR] Linked With All-Payer Claims)

Heart failure (HF) is common in patients presenting with acute myocardial infarction (MI), but incidence and predictors of new onset HF after hospitalization for MI are less well characterized. We evaluated patients hospitalized for acute MI without preceding or concurrent HF in the National Cardiovascular Data Registry (NCDR) CathPCI and Chest Pain-MI registries linked with claims data between April 2010 and March 2017. Cumulative incidence and independent predictors of HF after discharge were determined, and a simplified risk score was developed to predict incident HF following MI. In 337,274 patients with acute MI and no history of HF, 8.0% developed incident HF within 1 year after discharge and 18.8% developed HF within 5 years. Significant predictors of HF after MI included advanced chronic kidney disease (CKD) (HR 2.34, 95% confidence interval [CI] 2.23-2.46 for Stage IV vs Stage I, and HR 2.18, 95% CI 2.07-2.29 for Stage V vs. Stage I), recurrent MI following index MI (HR 2.24, 95% CI 2.19-2.28), African-American race (HR 1.44, 95% CI 1.40-1.48), and diabetes (HR 1.39, 95% CI 1.37-1.42). A risk score of 8 variables predicted HF with modest discrimination (optimism-corrected c-statistic 0.64) and good calibration. In conclusion, nearly 1 in 5 patients in a large nationally representative cohort without preceding or concurrent heart failure at time of MI developed incident HF within 5 years after discharge. Advanced CKD and recurrent MI were the strongest predictors of future HF. Increased recognition of specific risk factors for HF may help inform care strategies following MI.

Nutrition and Frailty: Opportunities for Prevention and Treatment

Frailty is a syndrome of growing importance given the global ageing population. While frailty is a multifactorial process, poor nutritional status is considered a key contributor to its pathophysiology. As nutrition is a modifiable risk factor for frailty, strategies to prevent and treat frailty should consider dietary change. Observational evidence linking nutrition with frailty appears most robust for dietary quality: for example, dietary patterns such as the Mediterranean diet appear to be protective. In addition, research on specific foods, such as a higher consumption of fruit and vegetables and lower consumption of ultra-processed foods are consistent, with healthier profiles linked to lower frailty risk. Few dietary intervention studies have been conducted to date, although a growing number of trials that combine supplementation with exercise training suggest a multi-domain approach may be more effective. This review is based on an interdisciplinary workshop, held in November 2020, and synthesises current understanding of dietary influences on frailty, focusing on opportunities for prevention and treatment. Longer term prospective studies and well-designed trials are needed to determine the causal effects of nutrition on frailty risk and progression and how dietary change can be used to prevent and/or treat frailty in the future.

Psychoactive substances have major impact on injuries in rural arctic Norway - A prospective observational study

BACKGROUND

Rural areas have increased injury mortality with a high pre-hospital death rate. Knowledge concerning the impact of psychoactive substances on injury occurrence is lacking for rural arctic Norway. These substances are also known to increase pre-, per- and postoperative risk. The aim was by prospective observational design to investigate the prevalence and characteristics of psychoactive substance use among injured patients in Finnmark county.

METHODS

From January 2015 to August 2016, patients ≥18 years admitted to hospitals in Finnmark due to injury were approached when competent. Blood was analysed for ethanol, sedatives, opioids, hypnotics and illicit substances in consenting patients, who completed a questionnaire gathering demographic factors, self-reported use/behaviour and incident circumstances.

RESULTS

In 684 injured patients who consented to participation (81% consented), psychoactive substances were detected in 35.7%, alcohol being the most prevalent (23%). Patients in whom substances were detected were more often involved in violent incidents (odds ratio 8.92 95% confidence interval 3.24-24.61), indicated harmful use of alcohol (odds ratio 3.56, 95% confidence interval 2.34-5.43), reported the incident being a fall (odds ratio 2.21, 95% confidence interval 1.47-3.33) and presented with a reduced level of consciousness (odds ratio 3.91, 95% confidence interval 1.58-9.67). Subgroup analysis revealed significant associations between testing positive for a psychoactive substance and being diagnosed with a head injury or traumatic brain injury.

CONCLUSION

A significant proportion of injured patients had used psychoactive substances prior to admission. Use was associated with violence, falls, at-risk alcohol consumption, decreased level of consciousness on admittance and head injury.

Post-operative volumes following endoscopic surgery for non-functioning pituitary macroadenomas are predictive of further intervention, but not endocrine outcomes

BACKGROUND

Transsphenoidal surgery (TSS) remains the treatment of choice for non-functioning pituitary macroadenomas (NFPMA). The value of measuring tumour volumes before and after surgery, and its influence on endocrine outcomes and further treatment of the residual or recurrent tumour are unknown.

METHODS

Data from patients who underwent endoscopic TSS for a NFPMA (2009-2018) in a UK tertiary centre were analysed for pre- and post-operative endocrine and surgical outcomes.

RESULTS

Of 173 patients with NFPMA, 159 (61% male) were treatment naïve. At presentation, 76.2% (77/101) had ≥1 pituitary axis deficit. Older age (p = 0.002) was an independent predictor for multiple hormonal deficiencies. Preoperative tumour volume did not correlate with degree of hypopituitarism. Postoperative tumour volume and extent of tumour resection were not predictive of new onset hypopituitarism. Hormonal recovery was observed in 16 patients (20.8%) with impaired pituitary function, with the greatest recovery in the hypothalamic-pituitary-adrenal axis (21.2%, 7/33). A larger residual tumour volume was predictive of adjuvant radiotherapy (3.40 vs. 1.24 cm³, p = 0.005) and likelihood for repeat surgery (5.40 vs. 1.67cm³, p = 0.004).

CONCLUSION

Pre- and post-operative NFPMA volumes fail to predict the number of pituitary hormone deficits, however, greater post-operative residual volumes increase the likelihood of further intervention to control tumour growth.

Consumption of Two Eggs Daily Increases Serum Leptin in Amenorrheic Runners With Low Energy Availability Without Changes in Lipid Profile

Objectives

The primary aim of this study was to investigate the effects of increased dietary cholesterol intake through the consumption of eggs on ovarian sex hormone and leptin levels in amenorrheic female distance athletes.

Methods

Division I female distance runners classified as amenorrheic (AMEN, n = 5) or eumenorrheic (EUMEN, n = 5) via self-report questionnaire participated in this study. Participants consumed two eggs per day for 12 weeks over the course of the outdoor track and field season. EA was calculated at baseline and post-intervention using 3-day dietary records, triaxial accelerometers, and heart rate (HR) monitors. Maximal oxygen uptake (VO2max) was measured to calculate exercise energy expenditure with training HR data. Serum hormones, body composition, and blood lipids were measured at baseline and post-intervention.

Results

There were no differences exhibited by AMEN and EUMEN groups in body composition, EA, or sex hormones after the dietary intervention. Serum leptin increased in the AMEN group by 70% (P = 0.02) from baseline following egg consumption, while no change in serum leptin was observed in the EUMEN group. EA was calculated to be below 30 kcal·kg−1·FFM·d−1 in both groups following intervention. No changes in serum lipids and lipoprotein cholesterol levels were observed in AMEN or EUMEN due to egg consumption.

Conclusions

Twelve-week consumption of two eggs per day increased serum leptin in amenorrheic athletes with low EA with no changes in ovarian sex hormones. The serum lipid profile was not adversely affected by increased dietary cholesterol in the form of eggs.

Funding Sources

Egg Nutrition Center Graduate Fellowship Research Grant.

Trocar site closure with a novel anchor-based (neoClose®) system versus standard suture closure: A prospective randomized controlled trial

Objective

Patients with obesity have a higher risk of trocar site hernia. The objective of the present study was to compare a standard suture passer versus the neoClose® device for port site fascial closure in patients with obesity undergoing laparoscopic bariatric surgery.

Methods

This is a randomized, controlled trial with two parallel arms. Thirty five patients with BMI ≥ 35 kg/m2 and undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass were randomized to each group. Port site fascial closure for trocars ≥ 10 mm was performed with the neoClose® device in the study group and the standard suture passer in the control group. Primary outcomes were time required to complete closure and intensity of postoperative pain at the fascial closure sites. Secondary outcomes were intraabdominal needle depth and incidence of trocar site hernia.

Results

The use of the neoClose® device resulted in shorter closure times (20.2 vs 30.0 s, p = 0.0002), less pain (0.3 vs 0.9, p = 0.002) at port closure sites, and decreased needle depth (3.3 cm vs 5.2 cm, p &lt; 0.0001) compared to the standard suture passer. There was no trocar site hernia at the one-year follow-up in either group.

Conclusion

Use of the neoClose® device resulted in faster fascial closure times, decreased intraoperative needle depth, and decreased postoperative abdominal pain at 1 week as compared to the standard suture passer. These data need to be confirmed on larger cohorts of patients with longer follow-up, especially in terms of long-term hernia recurrence rates.

DISAPPEARING CHOROIDAL MELANOMA ON OPTOS: THE NOSE ARTIFACT

PURPOSE

To illustrate a potentially concerning artifact on Optos wide-angle imaging.

METHODS

Case report.

RESULTS

A healthy 11-year-old girl, with no medical history, was found to have a lightly pigmented superotemporal choroidal tumor, suspicious for melanoma, which was detected on Optos wide-angle imaging by her optometrist. On referral to the retinal specialist, the mass was not visible on funduscopy. B-scan ultrasonography depicted flat retina and no visible mass. Review of the Optos image revealed that the pseudomelanoma represented the patient's nose.

CONCLUSION

Optos wide-angle imaging provides broad retinal imaging; however, artifacts from patient positioning can lead to the nose artifact.

Treatment Preferences for Cardiac Procedures of Patients With Chronic Kidney Disease in Acute Coronary Syndrome: Design and Pilot Testing of a Discrete Choice Experiment

Background:

Chronic kidney disease is associated with a high incidence of acute coronary syndrome and related morbidity and mortality. Treatment choices for patients with chronic kidney disease involve trade-offs in the potential benefits and harms of invasive management options.

Objective:

The objective was to quantify preferences of patients with chronic kidney disease toward invasive heart procedures.

Design:

Design and pilot a discrete choice experiment.

Setting:

We piloted the discrete choice experiment in 2 multidisciplinary chronic kidney disease clinics in Calgary, Alberta, using an 8-question survey.

Patients:

Eligible patients included those aged 18 years and older, an estimated glomerular filtration rate < 45 mL/min/1.73 m², not currently receiving dialysis, and able to communicate in English.

Measurements:

Quantification of the average importances of key attributes of invasive heart procedures.

Methods:

We identified attributes most important to patients and physicians concerning invasive versus conservative management for acute coronary syndrome, using semi-structured qualitative interviews. Levels for each attribute were derived from analysis of early invasive versus conservative acute coronary syndrome management clinical trials and cohort studies, where subgroups of patients with chronic kidney disease were reported. We designed the pilot study with patient partners with relevant lived experience and considered statistical efficiency to estimate main effects and interactions, as well as response efficiency. Hierarchical Bayesian estimation was used to quantify average importances of attributes.

Results:

We recruited 43 patients with chronic kidney disease, mean (SD) age 67 (14) years, 67% male, and 35% with a history of cardiovascular disease, of whom 39 completed the survey within 2 weeks of enrollment. The results of the pilot revealed acute kidney injury requiring dialysis and permanent kidney replacement therapy, as well as death within 1 year were the most important attributes. Measures of internal validity for the pilot discrete choice experiment were comparable to those for other published discrete choice experiments.

Limitations:

Discrete choice experiments are complex instruments and often cognitively demanding for patients. This survey included multiple risk attributes which may have been challenging for some patients to understand.

Conclusions:

This pilot study demonstrates the feasibility of a discrete choice experiment to quantify preferences of patients with chronic kidney disease toward the benefits and trade-offs related to invasive versus conservative management for acute coronary syndrome. These preliminary findings suggest that patients with chronic kidney disease may be on average similarly risk averse toward kidney replacement therapy and death. This pilot information will be used to inform a larger discrete choice experiment that will refine these estimates of patient preferences and characterize subgroups with distinct treatment preferences, which should provide new knowledge that can facilitate shared decision-making between patients with chronic kidney disease and their care providers in the setting of acute coronary syndrome.

Challenges Associated With the Design and Deployment of Food Intake Urine Biomarker Technology for Assessment of Habitual Diet in Free-Living Individuals and Populations-A Perspective

Improvement of diet at the population level is a cornerstone of national and international strategies for reducing chronic disease burden. A critical challenge in generating robust data on habitual dietary intake is accurate exposure assessment. Self-reporting instruments (e.g., food frequency questionnaires, dietary recall) are subject to reporting bias and serving size perceptions, while weighed dietary assessments are unfeasible in large-scale studies. However, secondary metabolites derived from individual foods/food groups and present in urine provide an opportunity to develop potential biomarkers of food intake (BFIs). Habitual dietary intake assessment in population surveys using biomarkers presents several challenges, including the need to develop affordable biofluid collection methods, acceptable to participants that allow collection of informative samples. Monitoring diet comprehensively using biomarkers requires analytical methods to quantify the structurally diverse mixture of target biomarkers, at a range of concentrations within urine. The present article provides a perspective on the challenges associated with the development of urine biomarker technology for monitoring diet exposure in free-living individuals with a view to its future deployment in "real world" situations. An observational study (n = 95), as part of a national survey on eating habits, provided an opportunity to explore biomarker measurement in a free-living population. In a second food intervention study (n = 15), individuals consumed a wide range of foods as a series of menus designed specifically to achieve exposure reflecting a diversity of foods commonly consumed in the UK, emulating normal eating patterns. First Morning Void urines were shown to be suitable samples for biomarker measurement. Triple quadrupole mass spectrometry, coupled with liquid chromatography, was used to assess simultaneously the behavior of a panel of 54 potential BFIs. This panel of chemically diverse biomarkers, reporting intake of a wide range of commonly-consumed foods, can be extended successfully as new biomarker leads are discovered. Towards validation, we demonstrate excellent discrimination of eating patterns and quantitative relationships between biomarker concentrations in urine and the intake of several foods. In conclusion, we believe that the integration of information from BFI technology and dietary self-reporting tools will expedite research on the complex interactions between dietary choices and health.

A Systematic Review of Clinical Practice Guidelines for the Diagnosis and Management of Bronchiolitis

BACKGROUND

Bronchiolitis is the leading cause of hospital admission for respiratory disease among infants aged <1 year. Clinical practice guidelines can benefit patients by reducing the performance of unnecessary tests, hospital admissions, and treatment with lack of a supportive evidence base. This review aimed to identify current clinical practice guidelines worldwide, appraise their methodological quality, and discuss variability across guidelines for the diagnosis and management of bronchiolitis.

METHODS

A systematic literature review of electronic databases EMBASE, Global Health, and Medline was performed. Manual searches of the gray literature, national pediatric society websites, and guideline-focused databases were performed, and select international experts were contacted to identify additional guidelines. The Appraisal of Guidelines for Research and Evaluation assessment tool was used by 2 independent reviewers to appraise each guideline.

RESULTS

Thirty-two clinical practice guidelines met the selection criteria. Quality assessment revealed significant shortcomings in a number of guidelines, including lack of systematic processes in formulating guidelines, failure to state conflicts of interest, and lack of consultation with families of affected children. There was widespread agreement about a number of aspects, such as avoidance of the use of unnecessary diagnostic tests, risk factors for severe disease, indicators for hospital admission, discharge criteria, and nosocomial infection control. However, there was variability, even within areas of consensus, over specific recommendations, such as variable thresholds for oxygen therapy. Guidelines showed significant variability in recommendations for the pharmacological management of bronchiolitis, with conflicting recommendations over whether use of nebulized epinephrine, hypertonic saline, or bronchodilators should be routinely trialled.

CONCLUSIONS

Future guidelines should aim to be compliant with international standards for clinical guidelines to improve their quality and clarity and to promote their adoption into practice. Variable recommendations between guidelines may reflect the evolving evidence base for bronchiolitis management, and platforms should be created to understand this variability and promote evidence-based recommendations.

Cross-Systems Care Integration Impact on Adults With Intellectual Disability Utilizing Risk Weight and Comorbidity Data: A Comparative Effectiveness Study, 2014-2017

Health disparities are documented between adults with intellectual and developmental disabilities (IDD) and neurotypical peers. As progress has been slow in improving health outcomes in people with IDD, the aim of this retrospective study was to compare effectiveness of a new Cross-Systems Care Integration (CSCI) model of care coordination to standard care coordination for 927 adults with IDD receiving Medicaid services in central Colorado from 2014 through 2017. Health care cost risk weight decreased (not statistically significant) only in individuals receiving the CSCI intervention. Depression diagnoses remained statistically unchanged, while both hypertension and hyperlipidemia significantly improved in patients receiving CSCI. Further study is warranted to extend duration of study and to examine additional study variables such as health-related quality of life.

Calystegines are Potential Urine Biomarkers for Dietary Exposure to Potato Products

SCOPE

Metabolites derived from specific foods present in urine samples can provide objective biomarkers of food intake (BFIs). This study investigated the possibility that calystegines (a class of iminosugars) may provide BIFs for potato (Solanum tuberosum L.) product exposure.

METHODS AND RESULTS

Calystegine content is examined in published data covering a wide range of potato cultivars. Rapid methods are developed for the quantification of calystegines in cooked potato products and human urine using triple quadrupole mass spectrometry. The potential of calystegines as BFIs for potato consumption is assessed in a controlled food intervention study in the United Kingdom and validated in an epidemiological study in Portugal. Calystegine concentrations are reproducibly above the quantification limit in first morning void urines the day after potato consumption, showing a good dose-response relationship, particularly for calystegine A₃ . The design of the controlled intervention mimicks exposure to a typical UK diet and showed that neither differences in preparation/cooking method or influence of other foods in the diet has significant impact on biomarker performance. Calystegine biomarkers also perform well in the independent validation study.

CONCLUSION

It is concluded that calystegines have many of the characteristics needed to be considered as specific BFIs for potato product intake.

A Standardized Strategy for Simultaneous Quantification of Urine Metabolites to Validate Development of a Biomarker Panel Allowing Comprehensive Assessment of Dietary Exposure

SCOPE

Metabolites derived from individual foods found in human biofluids after consumption could provide objective measures of dietary intake. For comprehensive dietary assessment, quantification methods would need to manage the structurally diverse mixture of target metabolites present at wide concentration ranges.

METHODS AND RESULTS

A strategy for selection of candidate dietary exposure biomarkers is developed. An analytical method for 62 food biomarkers is validated by extensive analysis of chromatographic and ionization behavior characteristics using triple quadrupole mass spectrometry. Urine samples from two food intervention studies are used: a controlled, inpatient study (n = 19) and a free-living study where individuals (n = 15) are provided with food as a series of menu plans. As proof-of-principle, it is demonstrated that the biomarker panel could discriminate between menu plans by detecting distinctive changes in the concentration in urine of targeted metabolites. Quantitative relationships between four biomarker concentrations in urine and dietary intake are shown.

CONCLUSION

Design concepts for an analytical strategy are demonstrated, allowing simultaneous quantification of a comprehensive panel of chemically-diverse biomarkers of a wide range of commonly-consumed foods. It is proposed that integration of self-reported dietary recording tools with biomarker approaches will provide more robust assessment of dietary exposure.

Changes in Perception of Various Telehealth Topics Before and After a Patient-Centered Outcomes Research Institute Telehealth Research Dissemination Conference

Background: The Telehealth Dissemination Forum brought together a cross section of telehealth providers and constituents to review the latest telehealth research funded by Patient-Centered Outcomes Research Institute (PCORI) and to ascertain whether there were known gaps in the research. Methods: A pre- and postsurvey was conducted before and after the general overview of the market and research presentations. Using elements of human-centered design, participants were exposed to alternative problem solving and program design methods with the goal of translating the research into practice. Participants were stratified into four groups each with a moderator. Designers instructed the group throughout the design session. Results: A debrief was conducted at the end of the day to determine the value of the session as written evaluations were often not completed or less constructive. Postmeeting surveys were analyzed. Conclusions: We determined that the dissemination was effective; knowledge, attitudes, practices, and beliefs changed based on how this information was presented. The forum had an impact on participants as they left with design tools to assist with complex problem solving.