An analog-AI chip for energy-efficient speech recognition and transcription

Models of artificial intelligence (AI) that have billions of parameters can achieve high accuracy across a range of tasks1,2, but they exacerbate the poor energy efficiency of conventional general-purpose processors, such as graphics processing units or central processing units. Analog in-memory computing (analog-AI)3-7 can provide better energy efficiency by performing matrix-vector multiplications in parallel on 'memory tiles'. However, analog-AI has yet to demonstrate software-equivalent (SWeq) accuracy on models that require many such tiles and efficient communication of neural-network activations between the tiles. Here we present an analog-AI chip that combines 35 million phase-change memory devices across 34 tiles, massively parallel inter-tile communication and analog, low-power peripheral circuitry that can achieve up to 12.4 tera-operations per second per watt (TOPS/W) chip-sustained performance. We demonstrate fully end-to-end SWeq accuracy for a small keyword-spotting network and near-SWeq accuracy on the much larger MLPerf8 recurrent neural-network transducer (RNNT), with more than 45 million weights mapped onto more than 140 million phase-change memory devices across five chips.

High sensitivity troponin-I threshold to predict perioperative myocardial infarction

BACKGROUND

High-sensitivity Troponin I (hs-cTnI) has largely replaced conventional troponin assays in an effort to improve detection of myocardial infarction. However, the mean displacement of hs-cTnI following coronary artery bypass graft (CABG) and the optimal threshold to detect perioperative myocardial infarction (MI) is unclear. Our objective is to describe mean hs-cTnI values at 6-12 h post-CABG and to determine the highest specificity while maintaining 100% sensitivity hs-cTnI cut-off values for diagnosis of perioperative or type-5 MI.

METHODS

Between 2016 and 2018, 374 patients underwent non-emergent, isolated CABG. Pre-operative and 6 h post-operative hs-cTnI values were recorded as well as ECG, echocardiographic and angiographic data.

RESULTS

Of 374 patients, 151 (40.3%) had normal and 224 (59.7%) had elevated preoperative hs-cTnI. Patients with normal preoperative hs-cTnI had a mean 6 h hs-cTnI of 9193 ng/l or 270X the upper normal value. Eleven patients (7.3%) presented with post-operative MI with a mean 6 h hs-cTnI of 50,218 ng/l or 1477X the upper normal value. Patients with elevated preoperative hs-cTnI had a mean 6 h hs-cTnI of 9449 ng/l or 292X the upper normal value. Eleven patients (4.9%) who presented with post-operative MI had a mean 6 h hs-cTnI of 26,823 ng/l or 789X the upper normal value.

CONCLUSIONS

We suggest hs-cTnI threshold of 80-fold in patients with normal pre-operative hs-cTnI and 2.7-fold in patients with elevated pre-operative hs-cTnI. These results have important implications for perioperative care and for surgical trial reporting.

Predictors of mitral valve hemodynamics after mitral valve repair for degenerative mitral regurgitation: a subanalysis of the CAMRA randomized trial

Introduction

Intra-operative predictors of mid-to-late mitral valve dysfunction after surgical repair of mitral regurgitation (MR) caused by prolapse remain poorly characterized. This study aims to evaluate the effect of annuloplasty prosthesis size on post-operative MV hemodynamics at rest and during exercise, and to identify perioperative predictors of MV dysfunction.

Methods

104 patients were randomly assigned to resection and preservation for surgical treatment of posterior leaflet prolapse in the Canadian Mitral Research Alliance CardioLink-2 study. Echocardiograms were performed at baseline and 1 year postoperatively. Intraoperative TEE was performed to assess immediate MV gradients. Exercise TTE was performed 1 year after repair. Linear regression analysis was used to identify associations between MV indices (rest and peak exercise gradients) at 12 months, and perioperative echocardiographic and clinical factors.

Results

Mean age of participants was 65±10 years, and 83% were male. Larger annuloplasty size was associated with lower transmitral gradients at rest and during peak exercise. In multivariable analysis, annuloplasty size ≥34mm was associated with lower mean and peak rest and exercise gradients at 12 months, after adjustment for repair type, age, sex, and BSA (p<0.001). Higher pre-operative pulmonary artery pressures were associated with reduced functional capacity post-operatively. Intra-operative TEE gradients predict resting and exercise MV hemodynamics at 1 year.

Conclusion

Annuloplasty size ≥34mm is associated with improved MV hemodynamics at rest and during peak exercise 1 year post MV repair. MV repair prior to onset of pulmonary hypertension confers favourable post operative functional capacity. Finally, intra-operative TEE can be used to identify patients at risk of mitral valve dysfunction within 1 year of repair.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The Heart and StrokeFoundation of Ontario (GIA 16-00014666)

POS0776 IMMUNOGENICITY AND SAFETY OF INACTIVATED AND mRNA COVID-19 VACCINES IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Vaccination against SAR-CoV-2 is a new campaign and believed to be the key to end the pandemic. Currently, there are two COVID-19 vaccines with different mechanism of action available in Hong Kong - they are the inactivated virus vaccine and the mRNA-based vaccine. Both vaccines have obtained approval for emergency use by the World Health Organization (WHO) and were widely deployed globally (1). A mass voluntary vaccination program for all Hong Kong residents has started in late February, 2021 (2). However, the efficacy and safety of COVID-19 vaccines in patients with SLE is uncertain due to a complex interplay of underlying autoimmunity and immunosuppressive therapies used.

Objectives

This study was to investigate the effects of both inactivated and mRNA COVID-19 vaccines in patients with SLE.

Methods

This was a prospective, single-centre, case-control study. Patients with SLE planning to receive COVID-19 vaccines were recruited and matched 1:1 with healthy controls. The immunogenicity of the COVID-19 vaccines was assessed by a surrogate neutralization assay at 28 days after the second dose. The main outcomes included the antibody response and adverse effects comparing SLE patients and controls. Predictors of responses in SLE patients were analyzed. The change of SLE disease activity was evaluated.

Results

Sixty-five SLE patients received 2 doses of COVID-19 vaccines (Comirnaty: 38; CoronaVac: 27) were recruited. Many of them were on systemic glucocorticoids (75.8%) and immunosuppressants (54.5%). At day 28 after the second dose of vaccines, 92.3% (Comirnaty: 100%; CoronaVac: 81.5%, p=0.01) had positive neutralizing antibody. However, compared to the age, gender, vaccine type matched controls, the level of neutralizing antibody was significantly lower (p<0.001) in patients with SLE (Figure 1). The self-reported side effects of the vaccines in lupus patients were common but mild, and were more frequent in the Comirnaty group. There was no significant change in lupus disease activity up to 28 days after vaccination. The independent predictors of neutralizing antibody level included the dosage of systemic glucocorticoids, use of mycophenolate and type of vaccines (Table 1).

Table 1.

Multivariate linear regression analysis for neutralizing antibody activity

Beta95% confidence intervalP valueAge-0.022-0.425 – 0.3810.914Gender8.1625 (92.6)0.296SLEDAI-2k-1.96-4.22 – 0.310.088Prednisolone dosage-2.01-3.66 - -0.370.018Mycophenolate mofetil-15.2-24.4 - -6.00.002Type of vaccines: Comirnaty28.820.1 – 37.5<0.001Figure 1.

Distribution of neutralizing antibody levels after COVID-19 vaccines comparing (A) SLE patients and matched controls, (B) SLE patients and matched controls in two vaccine subgroups, and (C) two vaccine types in SLE patients. Data for each group are presented as box plots: central values within boxes correspond to median; the range between the lower (Q1) and upper (Q3) bounds of the boxes is the IQR. Whiskers represent scores outside IQR and ends in maximum (higher “calculated value” = Q3 + 1.5 x IQR) and minimum (lower “calculated value” = Q1 – 1.5 x IQR). Spots are outliers above the maximum or under the minimum values. Data regarding were analyzed using Mann-Whitney-U test. Dotted line denotes the cut-off level for positivity (30%).

Conclusion

COVID-19 vaccines produced satisfactory but impaired serological response in SLE patients compared to controls which was dependent on the immunosuppressive medications use and type of vaccines received. There was no new short-term safety signal noted. Booster dose is recommended.

References

[1]Wouters OJ, Shadlen KC, Salcher-Konrad M, Pollard AJ, Larson HJ, Teerawattananon Y, et al. Challenges in ensuring global access to COVID-19 vaccines: production, affordability, allocation, and deployment. Lancet. 2021;397(10278):1023-34.

[2]COVID-19 Vaccination Programme.

Disclosure of Interests

None declared

Longitudinal Cytokine Profile in Patients With Mild to Critical COVID-19

The cytokine release syndrome has been proposed as the driver of inflammation in coronavirus disease 2019 (COVID-19). However, studies on longitudinal cytokine profiles in patients across the whole severity spectrum of COVID-19 are lacking. In this prospective observational study on adult COVID-19 patients admitted to two Hong Kong public hospitals, cytokine profiling was performed on blood samples taken during early phase (within 7 days of symptom onset) and late phase (8 to 12 days of symptom onset). The primary objective was to evaluate the difference in early and late cytokine profiles among patient groups with different disease severity. The secondary objective was to assess the associations between cytokines and clinical endpoints in critically ill patients. A total of 40 adult patients (mild = 8, moderate = 15, severe/critical = 17) hospitalized with COVID-19 were included in this study. We found 22 cytokines which were correlated with disease severity, as proinflammatory Th1-related cytokines (interleukin (IL)-18, interferon-induced protein-10 (IP-10), monokine-induced by gamma interferon (MIG), and IL-10) and ARDS-associated cytokines (IL-6, monocyte chemoattractant protein-1 (MCP-1), interleukin-1 receptor antagonist (IL-1RA), and IL-8) were progressively elevated with increasing disease severity. Furthermore, 11 cytokines were consistently different in both early and late phases, including seven (growth-regulated oncogene-alpha (GRO-α), IL-1RA, IL-6, IL-8, IL-10, IP-10, and MIG) that increased and four (FGF-2, IL-5, macrophage-derived chemokine (MDC), and MIP-1α) that decreased from mild to severe/critical patients. IL-8, followed by IP-10 and MDC were the best performing early biomarkers to predict disease severity. Among critically ill patients, MCP-1 predicted the duration of mechanical ventilation, highest norepinephrine dose administered, and length of intensive care stay.

377 Global Recruitment for The RESECT Study (Transurethral Resection and Single-Instillation Intravesical Chemotherapy Evaluation in Bladder Cancer Treatment): An International Observational Cohort Study Aiming to Improve the Quality of Surgery for Non-Muscle Invasive Bladder Cancer

Introduction

Non-muscle invasive bladder cancer (NMIBC) can be curatively treated with ‘good quality’ transurethral resection of the bladder tumour (TURBT). However, despite evidence-based international guidelines, there is anecdotal evidence that practice varies widely, and this may affect oncological outcomes. Launching in 2020, RESECT aims to measure and report variation in TURBT quality globally, and determine if outcome reporting improves outcomes.

Method

RESECT was advertised internationally through social media, mailing lists, websites, and in person. Collaborators at each registered site will collect data about current practice and the experience of local TURBT surgeons. The primary outcome is the rate of achievement of key TURBT quality indicators.

Results

As of August 27, 508 collaborators have registered to participate. Collaborators represent 321 centres from 54 countries, with the highest number from the United Kingdom (54.5%), Spain (5.9%), and Argentina (3.7%). 51.2% are trainees, 29.9% consultants, and 17.5% medical students. Based on current registrations, patient recruitment will far exceed initial projections and considerably improve statistical power.

Conclusions

RESECT has attracted a large number of collaborators globally and from all training levels. Therefore, the RESECT study has the potential to improve the quality of TURBT surgery across the world.

Temporal landscape of human gut RNA and DNA virome in SARS-CoV-2 infection and severity

BACKGROUND

Coronavirus disease 2019 (COVID-19) caused by the enveloped RNA virus SARS-CoV-2 primarily affects the respiratory and gastrointestinal tracts. SARS-CoV-2 was isolated from fecal samples, and active viral replication was reported in human intestinal cells. The human gut also harbors an enormous amount of resident viruses (collectively known as the virome) that play a role in regulating host immunity and disease pathophysiology. Understanding gut virome perturbation that underlies SARS-CoV-2 infection and severity is an unmet need.

METHODS

We enrolled 98 COVID-19 patients with varying disease severity (3 asymptomatic, 53 mild, 34 moderate, 5 severe, 3 critical) and 78 non-COVID-19 controls matched for gender and co-morbidities. All subjects had fecal specimens sampled at inclusion. Blood specimens were collected for COVID-19 patients at admission to test for inflammatory markers and white cell counts. Among COVID-19 cases, 37 (38%) patients had serial fecal samples collected 2 to 3 times per week from time of hospitalization until after discharge. Using shotgun metagenomics sequencing, we sequenced and profiled the fecal RNA and DNA virome. We investigated alterations and longitudinal dynamics of the gut virome in association with disease severity and blood parameters.

RESULTS

Patients with COVID-19 showed underrepresentation of Pepper mild mottle virus (RNA virus) and multiple bacteriophage lineages (DNA viruses) and enrichment of environment-derived eukaryotic DNA viruses in fecal samples, compared to non-COVID-19 subjects. Such gut virome alterations persisted up to 30 days after disease resolution. Fecal virome in SARS-CoV-2 infection harbored more stress-, inflammation-, and virulence-associated gene encoding capacities including those pertaining to bacteriophage integration, DNA repair, and metabolism and virulence associated with their bacterial host. Baseline fecal abundance of 10 virus species (1 RNA virus, pepper chlorotic spot virus, and 9 DNA virus species) inversely correlated with disease COVID-19 severity. These viruses inversely correlated with blood levels of pro-inflammatory proteins, white cells, and neutrophils. Among the 10 COVID-19 severity-associated DNA virus species, 4 showed inverse correlation with age; 5 showed persistent lower abundance both during disease course and after disease resolution relative to non-COVID-19 subjects.

CONCLUSIONS

Both enteric RNA and DNA virome in COVID-19 patients were different from non-COVID-19 subjects, which persisted after disease resolution of COVID-19. Gut virome may calibrate host immunity and regulate severity to SARS-CoV-2 infection. Our observation that gut viruses inversely correlated with both severity of COVID-19 and host age may partly explain that older subjects are prone to severe and worse COVID-19 outcomes. Altogether, our data highlight the importance of human gut virome in severity and potentially therapeutics of COVID-19. Video Abstract.

P57 Global recruitment for the RESECT study (transurethral REsection and Single-instillation intravesical chemotherapy Evaluation in bladder Cancer Treatment) - an international observational cohort study aiming to improve the quality of surgery for non-muscle invasive bladder cancer

Introduction

Non-muscle invasive bladder cancer (NMIBC) is one of the most expensive cancers to treat, driven by high recurrence rates and disease progression. Mortality rates in the UK for all bladder cancers have remained relatively stable over the past decade. NMIBC can be curatively treated with transurethral resection of the bladder tumour (TURBT). Despite international evidence-based guidelines on the TURBT procedure and postoperative single instillation of mitomycin-C, TURBT quality continues to vary widely. RESECT will be the first ever international study of TURBT surgery evaluating the achievement of TURBT quality indicators globally and assessing if audit and performance feedback can improve surgical outcomes.

Methods

RESECT is a prospective, multicentre international observational cohort study. Collaborators at each site will collect data using REDCap about local TURBT practice, early recurrence rates and the experience of local TURBT surgeons. The primary outcome is the rate of achievement of key TURBT quality indicators. Advertisement for the study launched in 2020.

Results

As of October 1st, 2020, 524 collaborators have registered to participate. Collaborators represent 334 centres from 54 countries, with the highest number of centres from the United Kingdom (133), Spain (17), and India (16). 50.8% are trainees, 30.3% consultants, and 17.2% medical students. Based on current registrations, patient recruitment will far exceed initial projections and considerably improve statistical power.

Conclusion

RESECT has attracted many collaborators internationally from consultants and trainees at all stages. RESECT has significant potential to positively impact TURBT practice, health economics and ultimately improve outcomes for patients with NMIBC globally.

Gut microbiota composition reflects disease severity and dysfunctional immune responses in patients with COVID-19

OBJECTIVE

Although COVID-19 is primarily a respiratory illness, there is mounting evidence suggesting that the GI tract is involved in this disease. We investigated whether the gut microbiome is linked to disease severity in patients with COVID-19, and whether perturbations in microbiome composition, if any, resolve with clearance of the SARS-CoV-2 virus.

METHODS

In this two-hospital cohort study, we obtained blood, stool and patient records from 100 patients with laboratory-confirmed SARS-CoV-2 infection. Serial stool samples were collected from 27 of the 100 patients up to 30 days after clearance of SARS-CoV-2. Gut microbiome compositions were characterised by shotgun sequencing total DNA extracted from stools. Concentrations of inflammatory cytokines and blood markers were measured from plasma.

RESULTS

Gut microbiome composition was significantly altered in patients with COVID-19 compared with non-COVID-19 individuals irrespective of whether patients had received medication (p<0.01). Several gut commensals with known immunomodulatory potential such as Faecalibacterium prausnitzii, Eubacterium rectale and bifidobacteria were underrepresented in patients and remained low in samples collected up to 30 days after disease resolution. Moreover, this perturbed composition exhibited stratification with disease severity concordant with elevated concentrations of inflammatory cytokines and blood markers such as C reactive protein, lactate dehydrogenase, aspartate aminotransferase and gamma-glutamyl transferase.

CONCLUSION

Associations between gut microbiota composition, levels of cytokines and inflammatory markers in patients with COVID-19 suggest that the gut microbiome is involved in the magnitude of COVID-19 severity possibly via modulating host immune responses. Furthermore, the gut microbiota dysbiosis after disease resolution could contribute to persistent symptoms, highlighting a need to understand how gut microorganisms are involved in inflammation and COVID-19.

A randomized surgical trial of mitral valve repair with leaflet resection versus leaflet preservation on functional mitral stenosis – primary results of the CAMRA CardioLink-2 trial

Background

The gold standard treatment for mitral valve regurgitation due to prolapse involves surgery with annuloplasty and either leaflet resection or leaflet preservation, with placement of artificial neochordae. It has been suggested that leaflet resection may be prone to functional mitral stenosis, whereby a patient may have a higher mitral gradient at peak exercise compared to a leaflet preservation strategy. Although both techniques are widely used, there has been no prospective randomized study conducted to compare these two techniques, particularly in regard to functional mitral stenosis.

Methods

A total of 104 patients with posterior leaflet prolapse were randomized to undergo mitral repair with either leaflet resection (N=54) or leaflet preservation (N=50) at 7 specialized Canadian cardiac centers. Patient age, proportion of female patients, and mean Society of Thoracic Surgeons risk score was 63.9±10.4 years, 19%, and 1.4% for those who underwent leaflet resection, and 66.3±10.8 years, 16%, and 1.9% for those who underwent leaflet preservation, respectively. The primary endpoint was the mean trans-mitral repair gradient at peak exercise 12-months after repair.

Results

Baseline characteristics were similar between the groups. At 12-months, the mean trans-mitral repair gradient at peak exercise in patients who underwent leaflet resection and preservation was 9.1±5.2 and 8.3±3.3 mmHg (P=0.4), respectively. The two groups had similar mean mitral valve gradient at rest (3.2±1.9 mmHg following resection and 3.1±1.1 mmHg following leaflet preservation, P=0.7). There was no between-group difference for the 6-minute walk distance (451±147 m and 481±95 m for the resection and preservation groups, respectively, P=0.3).

Conclusion

We report the first prospective surgical randomized trial to evaluate commonly used mitral valve repair strategies for posterior leaflet prolapse. Leaflet resection and leaflet preservation both yield acceptable results with no difference in postoperative valve gradient and functional status 12-months after surgical mitral valve repair.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Heart and Stroke Foundation of Canada

Alterations in Gut Microbiota of Patients With COVID-19 During Time of Hospitalization

BACKGROUND & AIMS

Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects gastrointestinal tissues, little is known about the roles of gut commensal microbes in susceptibility to and severity of infection. We investigated changes in fecal microbiomes of patients with SARS-CoV-2 infection during hospitalization and associations with severity and fecal shedding of virus.

METHODS

We performed shotgun metagenomic sequencing analyses of fecal samples from 15 patients with Coronavirus Disease 2019 (COVID-19) in Hong Kong, from February 5 through March 17, 2020. Fecal samples were collected 2 or 3 times per week from time of hospitalization until discharge; disease was categorized as mild (no radiographic evidence of pneumonia), moderate (pneumonia was present), severe (respiratory rate ≥30/min, or oxygen saturation ≤93% when breathing ambient air), or critical (respiratory failure requiring mechanical ventilation, shock, or organ failure requiring intensive care). We compared microbiome data with those from 6 subjects with community-acquired pneumonia and 15 healthy individuals (controls). We assessed gut microbiome profiles in association with disease severity and changes in fecal shedding of SARS-CoV-2.

RESULTS

Patients with COVID-19 had significant alterations in fecal microbiomes compared with controls, characterized by enrichment of opportunistic pathogens and depletion of beneficial commensals, at time of hospitalization and at all timepoints during hospitalization. Depleted symbionts and gut dysbiosis persisted even after clearance of SARS-CoV-2 (determined from throat swabs) and resolution of respiratory symptoms. The baseline abundance of Coprobacillus, Clostridium ramosum, and Clostridium hathewayi correlated with COVID-19 severity; there was an inverse correlation between abundance of Faecalibacterium prausnitzii (an anti-inflammatory bacterium) and disease severity. Over the course of hospitalization, Bacteroides dorei, Bacteroides thetaiotaomicron, Bacteroides massiliensis, and Bacteroides ovatus, which downregulate expression of angiotensin-converting enzyme 2 (ACE2) in murine gut, correlated inversely with SARS-CoV-2 load in fecal samples from patients.

CONCLUSIONS

In a pilot study of 15 patients with COVID-19, we found persistent alterations in the fecal microbiome during the time of hospitalization, compared with controls. Fecal microbiota alterations were associated with fecal levels of SARS-CoV-2 and COVID-19 severity. Strategies to alter the intestinal microbiota might reduce disease severity.

Triple combination of interferon beta-1b, lopinavir-ritonavir, and ribavirin in the treatment of patients admitted to hospital with COVID-19: an open-label, randomised, phase 2 trial

BACKGROUND

Effective antiviral therapy is important for tackling the coronavirus disease 2019 (COVID-19) pandemic. We assessed the efficacy and safety of combined interferon beta-1b, lopinavir-ritonavir, and ribavirin for treating patients with COVID-19.

METHODS

This was a multicentre, prospective, open-label, randomised, phase 2 trial in adults with COVID-19 who were admitted to six hospitals in Hong Kong. Patients were randomly assigned (2:1) to a 14-day combination of lopinavir 400 mg and ritonavir 100 mg every 12 h, ribavirin 400 mg every 12 h, and three doses of 8 million international units of interferon beta-1b on alternate days (combination group) or to 14 days of lopinavir 400 mg and ritonavir 100 mg every 12 h (control group). The primary endpoint was the time to providing a nasopharyngeal swab negative for severe acute respiratory syndrome coronavirus 2 RT-PCR, and was done in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT04276688.

FINDINGS

Between Feb 10 and March 20, 2020, 127 patients were recruited; 86 were randomly assigned to the combination group and 41 were assigned to the control group. The median number of days from symptom onset to start of study treatment was 5 days (IQR 3-7). The combination group had a significantly shorter median time from start of study treatment to negative nasopharyngeal swab (7 days [IQR 5-11]) than the control group (12 days [8-15]; hazard ratio 4·37 [95% CI 1·86-10·24], p=0·0010). Adverse events included self-limited nausea and diarrhoea with no difference between the two groups. One patient in the control group discontinued lopinavir-ritonavir because of biochemical hepatitis. No patients died during the study.

INTERPRETATION

Early triple antiviral therapy was safe and superior to lopinavir-ritonavir alone in alleviating symptoms and shortening the duration of viral shedding and hospital stay in patients with mild to moderate COVID-19. Future clinical study of a double antiviral therapy with interferon beta-1b as a backbone is warranted.

FUNDING

The Shaw-Foundation, Richard and Carol Yu, May Tam Mak Mei Yin, and Sanming Project of Medicine.

A Randomized Assessor-Blinded Wait-List-Controlled Trial to Assess the Effectiveness of Acupuncture in the Management of Chemotherapy-Induced Peripheral Neuropathy

Purpose: Chemotherapy-induced peripheral neuropathy is a complex side effect with few available treatment options. The aim of the study was to test the effectiveness of an 8-week course of acupuncture in the management of chemotherapy-induced peripheral neuropathy in cancer patients who were receiving or had received neurotoxic chemotherapy. Methods: Randomized assessor-blinded controlled trial with 2 arms; one arm received acupuncture twice weekly for 8 weeks, while the other arm was a wait-list control group receiving only standard care. Primary outcome was pain intensity and interference over the past week using the Brief Pain Inventory at the end of the intervention. Secondary outcomes included clinical assessment (CTCAE [Common Toxicity Criteria for Adverse Events] grading and Total Neuropathy Score–Clinical Version) and nerve conduction studies; and patient-reported outcome measures (Functional Assessment of Cancer Therapy–Gynecologic Oncology Group–Neurotoxicity Quality of Life scale and Symptom Distress Scale) assessed at baseline, end of treatment (8 weeks), week 14, and week 20 from the beginning of treatment. Results: Eighty-seven patients were randomized to the experimental arm (n = 44) and to the standard care wait-list control arm (n = 43). Significant changes at 8 weeks were detected in relation to primary outcome (pain), the clinical neurological assessment, quality of life domains, and symptom distress (all P < .05). Improvements in pain interference, neurotoxicity-related symptoms, and functional aspects of quality of life were sustained in the 14-week assessment (P < .05), as were physical and functional well-being at the 20-week assessment (P < .05). Conclusions: Acupuncture is an effective intervention for treating chemotherapy-induced peripheral neuropathy and improving patients’ quality of life and experience with neurotoxicity-related symptoms with longer term effects evident.

Role of Microtearing Turbulence in DIII-D High Bootstrap Current Fraction Plasmas

We report on the first direct comparisons of microtearing turbulence simulations to experimental measurements in a representative high bootstrap current fraction (f_{BS}) plasma. Previous studies of high f_{BS} plasmas carried out in DIII-D with large radius internal transport barriers (ITBs) have found that, while the ion energy transport is accurately reproduced by neoclassical theory, the electron transport remains anomalous and not well described by existing quasilinear transport models. A key feature of these plasmas is the large value of the normalized pressure gradient, which is shown to completely stabilize conventional drift-wave and kinetic ballooning mode instabilities in the ITB, but destabilizes the microtearing mode. Nonlinear gyrokinetic simulations of the ITB region performed with the cgyro code demonstrate that the microtearing modes are robustly unstable and capable of driving electron energy transport levels comparable to experimental levels for input parameters consistent with the experimental measurements. These simulations uniformly predict that the microtearing mode fluctuation and flux spectra extend to significantly shorter wavelengths than the range of linear instability, representing significantly different nonlinear dynamics and saturation mechanisms than conventional drift-wave turbulence, which is also consistent with the fundamental tearing nature of the instability. The predicted transport levels are found to be most sensitive to the magnetic shear, rather than the temperature gradients more typically identified as driving turbulent plasma transport.

Platelets loaded with liposome-encapsulated thrombin have increased coagulability

Essentials Platelet transfusions can have limited efficacy during hemorrhage associated with coagulopathy. Thrombin can be shielded by encapsulation into nanoliposomes and delivered to platelets ex vivo. Loading platelets with liposomal thrombin improved several aspects of platelet coagulability. Platelets loaded with liposomal thrombin can overcome some coagulopathic deficiencies in vitro.

SUMMARY

Background Platelets are integral to clot formation and are often transfused to stop or prevent bleeding. However, transfusions of platelets are not always effective, particularly in the most severe cases of hemorrhage. Nanoparticle systems have been developed to mimic platelets but inherently lack important aspects of platelet function, which limits their potential effectiveness. Objectives Increasing the natural coagulability of transfusable platelets could increase their efficacy during treatment of severe hemorrhage. Thrombin is a potent platelet agonist that currently cannot be used intravenously because of the risk of thrombosis. We hypothesized that delivery of thrombin to ex vivo platelets via liposomal encapsulation would enable transfusable platelets to become more coagulable in response to platelet agonists. Methods Thrombin was encapsulated into nanoliposomes and delivered to platelets ex vivo. Platelet coagulability was measured by monitoring platelet activation, clot contraction, clot time and clot stability in several in vitro assays. These parameters were also measured under conditions where coagulation is compromised, including during acidosis, antiplatelet drugs, hemophilia A and trauma-induced coagulopathy. Results Liposomal thrombin was endocytosed and used by platelets ex vivo but was not secreted upon activation. These modified platelets became more sensitive and responsive to agonists and improved clotting time even under conditions that normally cause platelet dysfunction or have impaired coagulation. Conclusions Several aspects of platelet function were enhanced by ex vivo delivery of liposomal thrombin.

Towards Developing the Piece-Wise Linear Neural Network Algorithm for Rule Extraction

This paper discusses development and application of a decomposition neural network rule extraction algorithm for nonlinear regression problems. The algorithm is called the piece-wise linear artificial neural network or PWL-ANN algorithm. The objective of the algorithm is to “open up” the black box of a neural network model so that rules in the form of linear equations are generated by approximating the sigmoid activation functions of the hidden neurons in an artificial neural network (ANN). The preliminary results showed that the algorithm gives high fidelity and satisfactory results on sixteen of the nineteen tested datasets. By analyzing the values of R2 given by the PWL approximation on the hidden neurons and the overall output, it is evident that in addition to accurate approximation of each individual node of a given ANN model, there are more factors affecting the fidelity of the PWL-ANN algorithm Nevertheless, the algorithm shows promising potential for domains when better understanding about the problem is needed.

Transition of Children with Medical Complexity To Adult Care: A Survey of Current Canadian Practices

BACKGROUND: Children with medical complexity (CMC), among the most medically fragile and resource-intensive patients, are an ever-growing population. Unique barriers exist for successful transition of CMC to adult care. Transition care specific to CMC has not been previously studied.

OBJECTIVES: To describe transition policy and procedures used by Canadian pediatricians who care for CMC, and whether this is consistent with core elements of transition according to nationalguidelines. To identify pediatricians'; perceived barriers to successful transition of CMC.

DESIGN/METHODS: We conducted a 29-item online survey using REDCap of Canadian general pediatricians who provide transition care to CMC. Use of core elements of transition as per Canadian Paediatric Society (CPS) and American Academy of Pediatrics (AAP) statements, and perceived barriers to transition were measured using 5-point Likert scales. Descriptive analysis was performed using SAS 9.3.

RESULTS: The response rate was 30% (77/). 19% of pediatricians reported feeling satisfied with their success in transitioning CMC to adult care. 51% and 40% have read the CPS and AAP policy statements on transition, respectively. 22% have a specified set of procedures on transition for CMC at their institution. 23% performed assessments for transition readiness. In transition planning for capable CMC, 69% assessed knowledge of own medical condition and 54% assessed preparedness to navigate adult services independently. For CMC with neurocognitive disabilities, 65% discussed capacity and 53% reviewed care directives. 2% felt the legal process regarding capacity was easy to navigate for families, and 52% provided no legal resources to families during transition. 59% did not have existing relationships with adult practitioners willing to take on care coordination of CMC. 86% communicated with receiving adult practitioners upon transfer of care. Pediatricians' major perceived barriers to successful transition are listed in Table 1.

A Matched-Paired Comparative Analysis of the Hemodynamics of the Trifecta and Perimount Aortic Bioprostheses

BACKGROUND AND AIM OF THE STUDY

Current cohort studies comparing the Trifecta valve to alternative pericardial bioprostheses are limited by selection bias. The study aim was to determine if hemodynamics are improved after the aortic valve implantation of a Trifecta valve as compared to a standard pericardial valve, when evaluated using strict paired matching for specific key relevant confounders.

METHODS

Valve hemodynamics were compared in patients undergoing implantation with a Trifecta or Perimount valve matched for left ventricular outflow tract (LVOT) diameter, gender, age, body size, and days since surgery, using a 1:1 matched-paired cohort analysis (n = 20 per group).

RESULTS

Patients receiving a Trifecta valve had a larger increase in indexed stroke volume (SVi) relative to baseline compared to the Perimount patients (p = 0.013), in whom SVi was decreased. The mean transvalvular pressure gradient was lower in Trifecta patients despite the larger SVi (p = 0.02). The effective orifice area (EOA) and indexed EOA (EOAi) were significantly larger in Trifecta patients compared to Perimount patients (2.04 +/- 0.46 versus 1.77 +/- 0.45 cm2, p = 0.049; 1.10 +/- 0.22 versus 0.95 +/- 0.06 cm2/m2, p = 0.027, respectively), and there was a greater increase in EOA and EOAi from baseline (p = 0.010 for both). Severe prosthesis-patient mismatch (PPM) (EOAi < or = 0.65 cm2/m2) was seen in two (10%) of the Perimount cases, but in none of the patients with the Trifecta valve (p = 0.072).

CONCLUSION

Trifecta valve implantation is associated with a significant improvement in EOA and a decreased incidence of PPM as compared to the Perimount valve. The superior hemodynamic outcomes observed support consideration of this valve for aortic valve replacement, particularly in patients with a small LVOT at risk for PPM.

Continuous detection of trace level concentration of oil droplets in water using microfluidic AC electroosmosis (ACEO)

A novel design for high throughput detection of oil micro-droplets in water which is important to environmental oil spill monitoring agencies.

Do interventions by allied health professionals discussing adherence to insulin improve this adherence?

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