Stable iron (58Fe) isotopic measurements in Kenyan toddlers during 3 months of iron supplementation demonstrate that half of the iron absorbed is lost

Increased iron loss may reduce the effectiveness of iron supplementation. The objective of this study was to determine if daily oral iron supplementation increases iron loss, measured using a stable isotope of iron (58Fe). We enrolled and dewormed 24 iron-depleted Kenyan children, 24-27 months of age, whose body iron was enriched and equilibrated with 58Fe given at least 1 year earlier. Over 3 months of supplementation (6 mg iron/kg body weight [BW]/day), mean (±SD) iron absorption was 1.10 (±0.28) mg/day. During supplementation, 0.55 (±0.36) mg iron/day was lost, equal to half of the amount of absorbed iron. Supplementation did not increase faecal haem/porphyrin or biomarkers of enterocyte damage and gut or systemic inflammation. Using individual patient data, we examined iron dose, absorption and loss among all available long-term iron isotopic studies of supplementation. Expressed in terms of body weight, daily iron loss was correlated significantly with iron absorption (Pearson's r = 0.66 [95% confidence interval 0.48-0.78]) but not with iron dose (r = 0.16 [95% CI -0.10-0.40]). The results of this study indicate that iron loss is increased with daily oral iron supplementation and may blunt the efficacy of iron supplements in children. This study was registered at ClinicalTrials.gov as NCT04721964.

Pediatric oncology provider perspectives and patient/family perceptions of chemotherapy-induced nausea and vomiting management: Experiences at an academic medical center

BACKGROUND

Chemotherapy-induced nausea and vomiting (CINV) is common in children undergoing cancer treatment, and significantly impacts quality of life. Clinical practice guidelines (CPGs) have been developed to guide CINV management, though many patients do not receive guideline-concordant care. Few studies have examined provider perspectives on CINV management or preferred improvement approaches, or pediatric patient perception of CINV control.

METHODS

A cross-sectional study of pediatric oncology providers was conducted at a large freestanding children's hospital. Providers completed an anonymous online survey about CINV control in patients admitted for scheduled chemotherapy, and their knowledge and utilization of CINV CPGs. A survey of English and Spanish-speaking pediatric oncology patients admitted for scheduled chemotherapy was conducted to assess CINV management, with key demographics used to understand association with perceptions and adherence to antiemetic guidelines.

RESULTS

For providers, 75% of respondents felt CINV management could be moderately or extremely improved, significantly more so by chemotherapy prescribers and pediatric medical residents than nurses. Over half of respondents did not have awareness of CINV CPGs, particularly pediatric medical residents. For patients, nausea was reported to be extremely well controlled in 44% of cases, and vomiting extremely well controlled in 50% of cases. There were no significant differences in patient-reported CINV across demographics, when considering emetogenicity of chemotherapy received, or concordance to guidelines.

CONCLUSIONS

Implementing education in this area may help to improve provider comfort, and ultimately, the patient experience. Future studies will expand upon this novel patient perception, and develop and evaluate CINV management interventions.

Evaluation of ChatGPT-generated medical responses: A systematic review and meta-analysis

OBJECTIVE

Large language models (LLMs) such as ChatGPT are increasingly explored in medical domains. However, the absence of standard guidelines for performance evaluation has led to methodological inconsistencies. This study aims to summarize the available evidence on evaluating ChatGPT's performance in answering medical questions and provide direction for future research.

METHODS

An extensive literature search was conducted on June 15, 2023, across ten medical databases. The keyword used was "ChatGPT," without restrictions on publication type, language, or date. Studies evaluating ChatGPT's performance in answering medical questions were included. Exclusions comprised review articles, comments, patents, non-medical evaluations of ChatGPT, and preprint studies. Data was extracted on general study characteristics, question sources, conversation processes, assessment metrics, and performance of ChatGPT. An evaluation framework for LLM in medical inquiries was proposed by integrating insights from selected literature. This study is registered with PROSPERO, CRD42023456327.

RESULTS

A total of 3520 articles were identified, of which 60 were reviewed and summarized in this paper and 17 were included in the meta-analysis. ChatGPT displayed an overall integrated accuracy of 56 % (95 % CI: 51 %-60 %, I2 = 87 %) in addressing medical queries. However, the studies varied in question resource, question-asking process, and evaluation metrics. As per our proposed evaluation framework, many studies failed to report methodological details, such as the date of inquiry, version of ChatGPT, and inter-rater consistency.

CONCLUSION

This review reveals ChatGPT's potential in addressing medical inquiries, but the heterogeneity of the study design and insufficient reporting might affect the results' reliability. Our proposed evaluation framework provides insights for the future study design and transparent reporting of LLM in responding to medical questions.

Aortic Arch Plaques and the Long-Term Risk of Stroke and Cardiovascular Events in the Statin Era

BACKGROUND

Aortic arch plaques are associated with an increased risk of ischemic stroke in patients with cryptogenic stroke or prior embolic events. However, this relationship is unclear in the community. We investigated (1) the long-term risk of stroke and cardiovascular events associated with arch plaques and (2) whether statin therapy prescribed for any indication modified the association.

METHODS

A total of 934 stroke-free participants (72±9 years; 37% men) from the CABL study (Cardiovascular Abnormalities and Brain Lesion) were evaluated. Arch plaques were assessed by suprasternal transthoracic echocardiography; plaques ≥4 mm in thickness were classified as large plaques. The primary outcome was ischemic stroke; the secondary outcome was combined cardiovascular events (ischemic stroke, myocardial infarction, and cardiovascular death). The plaque-related risk of outcomes was also analyzed according to the presence of statin treatment. No plaque was used as a reference.

RESULTS

Aortic arch plaques were present in 645 participants (69.1%), with large plaques in 114 (12.2%). During a mean follow-up of 11.3±3.6 years, 236 (25.3%) cardiovascular events occurred (76 ischemic strokes, 27 myocardial infarctions, and 133 cardiovascular deaths). Large arch plaques were independently associated with combined events (adjusted hazard ratio, 2.19 [95% CI, 1.40-3.43]) but not stroke alone (adjusted hazard ratio, 1.09 [95% CI, 0.50-2.38]). The association between large plaques and cardiovascular events was significant in participants receiving statins (adjusted hazard ratio, 2.57 [95% CI, 1.52-4.37]) but not in others; however, participants on statin treatment also had a worse risk profile (higher body mass index, greater frequencies of hypertension, diabetes, and coronary artery disease).

CONCLUSIONS

Aortic arch plaques may be a marker of cardiovascular risk rather than a direct embolic stroke source in older adults without prior stroke. The efficacy of broader cardiovascular risk factors control, beyond cholesterol levels alone, for primary prevention of cardiovascular events in individuals with aortic arch plaques may require further investigation.

Iron Deficiency in Chronic Pediatric Heart Failure: Overall Assessment and Outcomes in Dilated Cardiomyopathy

OBJECTIVE

To evaluate the frequency of iron status assessment in pediatric heart failure and the prevalence and adverse effects of absolute iron deficiency in dilated cardiomyopathy-induced heart failure.

STUDY DESIGN

We retrospectively reviewed records of children with chronic heart failure at our center between 2010 and 2020. In children with dilated cardiomyopathy, we analyzed baseline cardiac function, hemoglobin level, and subsequent risk of composite adverse events (CAE), including death, heart transplant, ventricular assist device (VAD) placement, and transplant registry listing. Absolute iron deficiency and iron sufficiency were defined as transferrin saturations <20% and ≥30%, respectively; and indeterminant iron status as 20%-29%.

RESULTS

Of 799 patients with chronic heart failure, 471 (59%) had no iron-related laboratory measurements. Of 68 children with dilated cardiomyopathy, baseline transferrin saturation, and quantitative left ventricular ejection fraction (LVEF), 33 (49%) and 14 (21%) were iron deficient and sufficient, respectively, and 21 (31%) indeterminant. LVEF was reduced to 23.6 ± 12.1% from 32.9 ± 16.8% in iron deficiency and sufficiency, respectively (P = .04), without a significant difference in hemoglobin. After stratification by New York Heart Association classification, in advanced class IV, hemoglobin was reduced to 10.9 ± 1.3 g/dL vs 12.7 ± 2.0 g/dL in iron deficiency and sufficiency, respectively (P = .01), without a significant difference in LVEF.

CONCLUSIONS

In this single-center study, iron deficiency was not monitored in most children with chronic heart failure. In pediatric dilated cardiomyopathy-induced heart failure, absolute iron deficiency was prevalent and associated with clinically consequential and possibly correctable decreases in cardiac function and hemoglobin concentration.

Left Atrial Strain and Incident Atrial Fibrillation in Older Adults

Atrial fibrillation (AF) is frequent in older adults and associated with left atrial (LA) dysfunction. LA strain (LAε) and LA strain rate (LASR) may detect subclinical LA disease. We investigated whether reduced LAε and LASR predict new-onset AF in older adults without history of AF or stroke. LAε and LASR were assessed by speckle-tracking echocardiography in 824 participants from the community-based Cardiovascular Abnormalities and Brain Lesions study. Positive longitudinal LAε and LASR during ventricular systole, LASR during early ventricular diastole, and LASR during LA contraction were measured. Cause-specific hazards regression model evaluated the association of LAε and LASR with incident AF, adjusting for pertinent covariates. The mean age was 71.1 ± 9.2 years (313 men, 511 women). During a mean follow-up of 10.9 years, new-onset AF occurred in 105 participants (12.7%). Lower LAε and LASR at baseline were observed in patients with new-onset AF (all p <0.01). In multivariable analysis, positive longitudinal LAε (adjusted hazard ratio [HR] per SD decrease 2.05, confidence interval [CI] 1.24 to 3.36) and LASR during LA contraction (HR per SD increase 2.24, CI 1.37 to 3.65) remained associated with new-onset AF, independently of LA volumes and left ventricular function. Along with positive longitudinal LAε, reduced LASR during ventricular systole predicted AF in participants with LA volume below the median value (HR 2.54, CI 1.10 to 6.09), whereas reduced LASR during LA contraction predicted AF in participants with larger LA (HR 2.35, CI 1.31 to 4.23). In conclusion, reduced positive longitudinal LAε and LASR predict new-onset AF in older adults regardless of LA size and may improve AF risk stratification.

Morin protects chicks with T-2 toxin poisoning by decreasing heterophil extracellular traps, oxidative stress and inflammatory response

1. Fusarium tritici widely exists in a variety of grain feeds. The T-2 toxin is the main hazardous component produced by Fusarium tritici, making a serious hazard to poultry industry. Morin, belonging to the flavonoid family, can be extracted from mulberry plants and possesses anticancer, antioxidant and anti-inflammatory compounds, but whether morin protects chicks with T-2 toxin poisoning remains unclear. This experiment firstly established a chick model of T-2 toxin poisoning and then investigated the protective effects and mechanism of morin against T-2 toxin in chicks.2. The function of liver and kidney was measured by corresponding alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), blood urea nitrogen (BUN), creatinine (Cre) and uric acid (UA) kits. Histopathological changes were observed by haematoxylin-eosin staining. The status of oxidative stress was measured by MDA, SOD, CAT, GSH and GSH-PX kits. The mRNA levels of TNF-α, COX-2, IL-1β, IL-6, caspase-1, caspase-3 and caspase-11 were measured by quantitative real-time PCR. Heterophil extracellular trap (HET) release was analysed by immunofluorescence and fluorescence microplate.3. The model with T-2 toxin poisoning in chicks was successfully established. Morin significantly decreased T-2 toxin-induced ALT, AST, ALP, BUN, Cre and UA, and improved T-2 toxin-induced liver cell rupture, liver cord disorder and kidney interstitial oedema. Oxidative stress analysis showed that morin ameliorated T-2 toxin-induced damage by reducing malondialdehyde (MDA), increasing superoxide dismutase (SOD), catalase (CAT), glutathione (GSH) and glutathione peroxidase (GSH-PX). The qRT-PCR analysis showed that morin reduced T-2 toxin-induced mRNA expressions of TNF-α, COX-2, IL-1β, IL-6, caspase-1, caspase-3 and caspase-11. Moreover, morin significantly reduced the release of T-2 toxin-induced HET in vitro and in vivo.4. Morin can protect chicks from T-2 toxin poisoning by decreasing HETs, oxidative stress and inflammatory responses, which make it a useful compound against T-2 toxin poisoning in poultry feed.

Tailored magnetic resonance fingerprinting of post-operative pediatric brain tumor patients

PURPOSE

Brain and spinal cord tumors are the second most common cancer in children and account for one out of four cancers diagnosed. However, the long acquisition times associated with acquiring both data types prohibit using quantitative MR (qMR) in pediatric imaging protocols. This study aims to demonstrate the tailored magnetic resonance fingerprinting's (TMRF) ability to simultaneously provide quantitative maps (T1, T2) and multi-contrast qualitative images (T1 weighted, T1 FLAIR, T2 weighted) rapidly in pediatric brain tumor patients.

METHODS

In this work, we imaged five pediatric patients with brain tumors (resected/residual) using TMRF at 3 T. We compared the TMRF-derived T2 weighted images with those from the vendor-supplied sequence (as the gold standard, GS) for healthy and pathological tissue signal intensities. The relaxometric maps from TMRF were subjected to a region of interest (ROI) analysis to differentiate between healthy and pathological tissues. We performed the Wilcoxon rank sum test to check for significant differences between the two tissue types.

RESULTS

We found significant differences (p < 0.05) in both T1 and T2 ROI values between the two tissue types. A strong correlation was found between the TMRF-based T2 weighted and GS signal intensities for the healthy (correlation coefficient, r = 0.99) and pathological tissues (r = 0.88).

CONCLUSION

The TMRF implementation provides the two relaxometric maps and can potentially save ~2 min if it replaces the T2-weighted imaging in the current protocol.

Magnetic resonance fingerprinting based thermometry (MRFT): application toex vivoimaging near DBS leads

The purpose of this study is to demonstrate the first work ofT1-based magnetic resonance thermometry using magnetic resonance fingerprinting (dubbed MRFT). We compared temperature estimation of MRFT with proton resonance frequency shift (PRFS) thermometry onex vivobovine muscle. We demonstrated MRFT's feasibility in predicting temperature onex vivobovine muscles with deep brain stimulation (DBS) lead.B0maps generated from MRFT were compared with gold standardB0maps near the DBS lead. MRFT and PRFS estimated temperatures were compared in the presence of motion. All experiments were performed on a 3 Tesla whole-body GE Premier system with a 21-channel receive head coil (GE Healthcare, Milwaukee, WI). Four fluoroptic probes were used to measure the temperature at the center of a cold muscle (probe 1), the room temperature water bottle (probe 2), and the center and periphery of the heated muscle (probes 3 and 4). We selected regions of interest (ROIs) around the location of the probes and used simple linear regression to generate the temperature sensitivity calibration equations that convertT1maps and Δsmaps to temperature maps. We then repeated the same setup and compared MRFT and PRFS thermometry temperature estimation with gold standard probe measurements. For the MRFT experiment on DBS lead, we taped the probe to the tip of the DBS lead and used a turbo spin echo sequence to induce heating near the lead. We selected ROIs around the tip of the lead to compare MRFT temperature estimation with probe measurements and compared with PRFS temperature estimation. Vendor-suppliedB0mapping sequence was acquired to compare with MRFT-generatedB0maps. We found strong linear relationships (R2> 0.958) betweenT1and temperature and Δsand temperatures in our temperature sensitivity calibration experiment. MRFT and PRFS thermometry both accurately predict temperature (RMSE < 1.55 °C) compared to probe measurements. MRFT estimated temperature near DBS lead has a similar trend as the probe temperature. BothB0maps show inhomogeneities around the lead. MRFT estimated temperature is less sensitive to motion.

Subclinical Left Ventricular Dysfunction and Ventricular Arrhythmias in Older Adults With Normal Ejection Fraction

Background Premature ventricular contractions (PVCs) and nonsustained ventricular tachycardia (NSVT) are known to be associated with reduced left ventricular (LV) ejection fraction and adverse outcomes in patients with structural heart disease. The relationship between subclinical LV dysfunction and ventricular arrhythmias in the general population is not established. Methods and Results Participants in the SAFARIS (Subclinical Atrial Fibrillation and Risk of Ischemic Stroke) study with normal left ventricular ejection fraction (n=503; mean age 77 years, 63% women) underwent 14-day electrocardiographic monitoring and 2-dimensional echocardiography. Frequent PVCs were defined as PVCs >500 per 24 hours and NSVT as ≥4 consecutive ventricular ectopic beats. Reduced LV global longitudinal strain (GLS) was used as an indicator of subclinical LV dysfunction. Seventy-six participants (15.1%) had PVCs >500/d, 117 (23.3%) had NSVT episodes. LV GLS was significantly reduced in both frequent PVCs and NSVT groups (P<0.01). In multivariable analyses, lower LV GLS was associated with frequent PVCs (adjusted odds ratio [aOR], 1.19 [95% CI, 1.09-1.30 per unit reduction]; P<0.001) and NSVT (aOR, 1.09 [95% CI, 1.01-1.17]; P=0.036) independently of established risk factors and other echocardiographic parameters. Abnormal LV GLS (>-15.8%) carried a 2-fold increase in risk of ventricular arrhythmias (aOR, 2.18, P=0.029 for PVCs; aOR, 2.09, P=0.026 for NSVT). Conclusions PVCs and NSVT episodes were frequent in this community-based elderly cohort with normal left ventricular ejection fraction and were independently associated with lower LV GLS. The association between LV dysfunction and ventricular arrhythmias is present at an early, subclinical stage, an observation that carries possible preventative implications.

Long term aortic arch plaque progression in older adults

Background and aims

The presence of aortic arch plaques (AAP) is significantly associated with increased cardiovascular morbidity and mortality. Few studies have examined the incidence of AAP progression and factors which may contribute to it using transthoracic echocardiography (TTE). The objective of this study was to utilize sequential imaging of the aortic arch using TTE to examine the rate of AAP progression and its risk factors in a cohort of older adults.

Methods

Participants enrolled in both the Cardiovascular Abnormalities and Brain Lesion study (years 2005-2010) and the Subclinical Atrial Fibrillation and Risk of Ischemic Stroke study (2014-2019) who underwent TTE with assessment of aortic arch plaques at both time points represent the study cohort.

Results

300 participants were included in the study. Mean age was 67.8 ± 7.5 years at baseline, and 76.7 ± 6.8 years at follow-up; 197 (65.7%) were women. At baseline, 87 (29%) had no significant AAP, 182 (60.7%) had evidence of small AAP (2.0-3.9 mm) and 31 (10.3%) had evidence of large (≥4 mm) AAP. At the time of follow-up assessment, 157 (52.3%) of participants exhibited progression of AAP with 70 (23.3%) having mild progression and 87 (29%) having severe progression. There were no significant demographic or clinical predictors of AAP progression except baseline plaque thickness itself which was significantly lower in the group with AAP progression.

Conclusions

Our study demonstrates a high prevalence of AAP on TTE exam in a population-based cohort of older adults with a high incidence of AAP progression. TTE is a useful test for baseline and follow up imaging of AAP, even in subjects with no or little AAP at baseline.

Accelerated MRI using intelligent protocolling and subject-specific denoising applied to Alzheimer's disease imaging

Magnetic Resonance Imaging (MR Imaging) is routinely employed in diagnosing Alzheimer's Disease (AD), which accounts for up to 60-80% of dementia cases. However, it is time-consuming, and protocol optimization to accelerate MR Imaging requires local expertise since each pulse sequence involves multiple configurable parameters that need optimization for contrast, acquisition time, and signal-to-noise ratio (SNR). The lack of this expertise contributes to the highly inefficient utilization of MRI services diminishing their clinical value. In this work, we extend our previous effort and demonstrate accelerated MRI via intelligent protocolling of the modified brain screen protocol, referred to as the Gold Standard (GS) protocol. We leverage deep learning-based contrast-specific image-denoising to improve the image quality of data acquired using the accelerated protocol. Since the SNR of MR acquisitions depends on the volume of the object being imaged, we demonstrate subject-specific (SS) image-denoising. The accelerated protocol resulted in a 1.94 × gain in imaging throughput. This translated to a 72.51% increase in MR Value-defined in this work as the ratio of the sum of median object-masked local SNR values across all contrasts to the protocol's acquisition duration. We also computed PSNR, local SNR, MS-SSIM, and variance of the Laplacian values for image quality evaluation on 25 retrospective datasets. The minimum/maximum PSNR gains (measured in dB) were 1.18/11.68 and 1.04/13.15, from the baseline and SS image-denoising models, respectively. MS-SSIM gains were: 0.003/0.065 and 0.01/0.066; variance of the Laplacian (lower is better): 0.104/-0.135 and 0.13/-0.143. The GS protocol constitutes 44.44% of the comprehensive AD imaging protocol defined by the European Prevention of Alzheimer's Disease project. Therefore, we also demonstrate the potential for AD-imaging via automated volumetry of relevant brain anatomies. We performed statistical analysis on these volumetric measurements of the hippocampus and amygdala from the GS and accelerated protocols, and found that 27 locations were in excellent agreement. In conclusion, accelerated brain imaging with the potential for AD imaging was demonstrated, and image quality was recovered post-acquisition using DL-based image denoising models.

Factors associated with the progression of aortic valve calcification in older adults

BACKGROUND

Aortic valve calcification (AVC) is a common valvular abnormality that predisposes to stenosis; AVC progression and factors associated with it remain unclear. We investigated the association of clinical factors and serum biomarkers with AVC progression in a population-based cohort of older adults.

METHODS

Participants enrolled in both the Cardiovascular Abnormalities and Brain Lesion study (CABL; years 2005-2010) and the Subclinical Atrial Fibrillation And Risk of Ischemic Stroke study (SAFARIS;2014-2019) represent the study cohort. AVC was defined as bright dense echoes >1 mm in size on ≥1 cusps; each cusp was graded on a scale of 0 (normal) to 3 (severe calcification) at baseline and follow up. Serum biomarkers were measured at the time of follow-up assessment.

RESULTS

373 participants (mean 68.1 ± 7.6 years of age, 146 M/ 227F) were included. 139 (37%) had AVC progression;93 (25%) had mild progression (1 grade), and 46 (12%) had moderate-severe progression (≥2 grades). The only significant clinical predictor of any progression was the use of anti-hypertensive medication which was associated with older age, higher BMI and more frequent hypertension, diabetes and hyperlipidemia. In multivariable analysis including biomarkers, transforming growth factor beta 1 (TGF-β1) was significantly associated with both all and moderate-severe AVC progression.

CONCLUSIONS

A significant number of elderly subjects with AVC show progression of their valve disease; individual vascular risk factors are not associated with AVC progression, although a combined effect may exist. Higher levels of TGF-β1 are observed in individuals with AVC progression.

Association of Left Atrial Strain With Ischemic Stroke Risk in Older Adults

Importance

The risk of ischemic stroke is higher among patients with left atrial (LA) enlargement. Left atrial strain (LAε) and LA strain rate (LASR) may indicate LA dysfunction when LA volumes are still normal. The association of LAε with incident ischemic stroke in the general population is not well established.

Objective

To investigate whether LAε and LASR are associated with new-onset ischemic stroke among older adults.

Design

The Cardiovascular Abnormalities and Brain Lesions study was conducted from September 29, 2005, to July 6, 2010, to investigate cardiovascular factors associated with subclinical cerebrovascular disease. A total of 806 participants in the Northern Manhattan Study who were aged 55 years or older without history of prior stroke or atrial fibrillation (AF) were included, and annual follow-up telephone interviews were completed May 22, 2022. Statistical analysis was performed from June through November 2022.

Exposures

Left atrial strain and LASR were assessed by speckle-tracking echocardiography. Global peak positive longitudinal LAε and positive longitudinal LASR during ventricular systole, global peak negative longitudinal LASR during early ventricular diastole, and global peak negative longitudinal LASR during LA contraction were measured. Brain magnetic resonance imaging was used to detect silent brain infarcts and white matter hyperintensities at baseline.

Main Outcomes and Measures

Risk analysis with cause-specific Cox proportional hazards regression modeling was used to assess the association of positive longitudinal LAε and positive longitudinal LASR with incident ischemic stroke, adjusting for other stroke risk factors, including incident AF.

Results

The study included 806 participants (501 women [62.2%]) with a mean (SD) age of 71.0 (9.2) years; 119 participants (14.8%) were Black, 567 (70.3%) were Hispanic, and 105 (13.0%) were White. During a mean (SD) follow-up of 10.9 (3.7) years, new-onset ischemic stroke occurred in 53 participants (6.6%); incident AF was observed in 103 participants (12.8%). Compared with individuals who did not develop ischemic stroke, participants with ischemic stroke had lower positive longitudinal LAε and negative longitudinal LASR at baseline. In multivariable analysis, the lowest (ie, closest to zero) vs all other quintiles of positive longitudinal LAε (adjusted hazard ratio [HR], 3.12; 95% CI, 1.56-6.24) and negative longitudinal LASR during LA contraction (HR, 2.89; 95% CI, 1.44-5.80) were associated with incident ischemic stroke, independent of left ventricular global longitudinal strain and incident AF. Among participants with a normal LA size, the lowest vs all other quintiles of positive longitudinal LAε (HR, 4.64; 95% CI, 1.55-13.89) and negative longitudinal LASR during LA contraction (HR, 11.02; 95% CI 3.51-34.62) remained independently associated with incident ischemic stroke.

Conclusions and Relevance

This cohort study suggests that reduced positive longitudinal LAε and negative longitudinal LASR are independently associated with ischemic stroke in older adults. Assessment of LAε and LASR by speckle-tracking echocardiography may improve stroke risk stratification in elderly individuals.

Subclinical left ventricular systolic dysfunction and incident stroke in the elderly: long-term findings from Cardiovascular Abnormalities and Brain Lesions

AIMS

Heart disease is associated with an increased risk for ischaemic stroke. However, the predictive value of reduced left ventricular ejection fraction (LVEF) for stroke is controversial and only observed in patients with severe reduction. LV global longitudinal strain (LV GLS) can detect subclinical LV systolic impairment when LVEF is normal. We investigated the prognostic role of LV GLS for incident stroke in a predominantly elderly cohort.

METHODS AND RESULTS

Two-dimensional echocardiography with speckle tracking was performed in the Cardiac Abnormalities and Brain Lesions (CABL) study. Among 708 stroke-free participants (mean age 71.4 ± 9.4 years, 60.9% women), abnormal LV GLS (>-14.7%: 95% percentile of the subgroup without risk factors) was detected in 133 (18.8%). During a mean follow-up of 10.8 ± 3.9 years, 47 participants (6.6%) experienced an ischaemic stroke (26 cardioembolic or cryptogenic, 21 other subtypes). The cumulative incidence of ischaemic stroke was significantly higher in participants with abnormal LV GLS than with normal LV GLS (P < 0.001). In multivariate stepwise logistic regression analysis, abnormal LV GLS was associated with ischaemic stroke independently of cardiovascular risk factors including LVEF, LV mass, left atrial volume, subclinical cerebrovascular disease at baseline, and incident atrial fibrillation [hazard ratio (HR): 2.69, 95% confidence interval (CI): 1.47-4.92; P = 0.001]. Abnormal LV GLS independently predicted cardioembolic or cryptogenic stroke (adjusted HR: 3.57, 95% CI: 1.51-8.43; P = 0.004) but not other subtypes.

CONCLUSION

LV GLS was a strong independent predictor of ischaemic stroke in a predominantly elderly stroke-free cohort. Our findings provide insights into the brain-heart interaction and may help improve stroke primary prevention strategies.

Long-term Outcome of Body Composition, Ectopic Lipid, and Insulin Resistance Changes With Surgical Treatment of Acromegaly

Context

Acromegaly presents a unique pattern of lower adiposity and insulin resistance in active disease but reduction in insulin resistance despite a rise in adiposity after surgery. Depot-specific adipose tissue masses and ectopic lipid are important predictors of insulin resistance in other populations, but whether they are in acromegaly is unknown. Long-term persistence of body composition changes after surgery is unknown.

Objective

To determine how depot-specific body composition and ectopic lipid relate to insulin resistance in active acromegaly and whether their changes with surgery are sustained long-term.

Methods

Cross-sectional study in patients with active acromegaly and longitudinal study in newly diagnosed patients studied before and in long-term follow-up, 3 (1-8) years (median, range), after surgery. Seventy-one patients with active acromegaly studied cross-sectionally and 28 with newly diagnosed acromegaly studied longitudinally. Main outcome measures were visceral (VAT), subcutaneous (SAT), and intermuscular adipose tissue masses by whole-body magnetic resonance imaging; intrahepatic lipid (IHL) by proton magnetic resonance spectroscopy; insulin resistance measures derived from fasting; and oral glucose tolerance test insulin and glucose levels.

Results

SAT and insulin-like growth factor 1 level, but not VAT or IHL, were independent predictors of insulin resistance in active acromegaly. VAT, SAT, and IHL gains were sustained long-term after surgery. VAT mass rise with surgery correlated inversely with rise in QUICKI while SAT rise correlated with fall in the Homeostatic Model Assessment score.

Conclusion

SAT and disease activity are important predictors of insulin resistance in active acromegaly. Adiposity gains are sustained long-term after surgical treatment and impact on the accompanying improvement in insulin resistance.

Neuropsychiatric Symptoms and Trajectories of Dependence and Cognition in a Sample of Community-dwelling Older Adults with Dementia

BACKGROUND AND OBJECTIVES

Neuropsychiatric symptoms (NPS), including psychotic symptoms (hallucinations, illusions, delusions), agitation/aggression, and depressed mood, are common in individuals with Alzheimer's disease (AD) and predict poorer outcomes, including faster disease progression. We aimed to evaluate associations between NPS and cognition and dependence in a multi-ethnic sample of community-dwelling older adults with AD.

METHODS

Predictors 3 (P3) is a cohort study of AD disease courses recruiting older adults aged 65 and above residing in upper Manhattan. A total of 138 of 293 participants had probable AD at the study baseline. We fit linear mixed models to examine longitudinal associations of time-varying NPS (psychotic symptoms, agitation/aggression, and depressed mood) with dependence and cognition, adjusted for race-ethnicity, sex, education, age, clinical dementia rating score, APOE-ε4, and comorbidity burden; separate interaction models were fit for age, Hispanic ethnicity, and sex.

RESULTS

Psychotic symptoms were associated with faster rates of increasing dependence and declining cognition over time, agitation/aggression with faster rates of declining cognition, and depressed mood with faster rates of increasing dependence. Among psychotic symptoms, delusions, but not hallucinations or illusions, were associated with worse outcome trajectories. Depressed mood predicted an accelerated increase in dependence in males but not females.

CONCLUSION

Our results confirm and extend prior results in clinic-based samples. The presence of NPS was associated with worse trajectories of dependence and cognition in this muti-ethnic sample of older adults with AD. Importantly, sex modified the association between depressed mood and dependence. Our results on NPS as predictors of differential AD progression in a community-dwelling, ethnically diverse sample serve to better inform the clinical care of patients and the future development of AD therapies.

Acute chest syndrome, airway inflammation and lung function in sickle cell disease

BACKGROUND

Acute chest syndrome (ACS) is an acute complication in SCD but its effects on lung function are not well understood. Inflammation is a key component of SCD pathophysiology but with an unclear association with lung function. We hypothesized that children with ACS had worse lung function than children without ACS and aimed to investigate the association of lung function deficits with inflammatory cytokines.

METHODS

Patients enrolled in a previous 2-year randomized clinical trial who had consented to future data use, were enrolled for the present exploratory study. Patients were categorized into ACS and non-ACS groups. Demographic and clinical information were collected. Serum samples were used for quantification of serum cytokines and leukotriene B4 levels and pulmonary function tests (PFTs) were assessed.

RESULTS

Children with ACS had lower total lung capacity (TLC) at baseline and at 2 years, with a significant decline in forced expiratory volume in 1 sec (FEV1) and mid-maximal expiratory flow rate (FEF25-75%) in the 2 year period (p = 0.015 and p = 0.039 respectively). For children with ACS, serum cytokines IL-5, and IL-13 were higher at baseline and at 2 years compared to children with no ACS. IP-10 and IL-6 were negatively correlated with PFT markers. In multivariable regression using generalized estimating equation approach for factors predicting lung function, age was significantly associated FEV1 (p = 0.047) and ratio of FEV1 and forced vital capacity (FVC)- FEV1/FVC ratio (p = 0.006); males had lower FEV1/FVC (p = 0.035) and higher TLC (p = 0.031). Asthma status was associated with FEV1 (p = 0.017) and FVC (p = 0.022); history of ACS was significantly associated with TLC (p = 0.027).

CONCLUSION

Pulmonary function abnormalities were more common and inflammatory markers were elevated in patients with ACS, compared with those without ACS. These findings suggest airway inflammation is present in children with SCD and ACS, which could be contributing to impaired pulmonary function.

Validation of a Multivariate Prediction Model of the Clinical Progression of Alzheimer's Disease in a Community-Dwelling Multiethnic Cohort

BACKGROUND

The major aims of the three Predictors Studies have been to further our understanding of Alzheimer's disease (AD) progression sufficiently to predict the length of time from disease onset to major disease outcomes in individual patients with AD.

OBJECTIVES

To validate a longitudinal Grade of Membership (L-GoM) prediction algorithm developed using clinic-based, mainly white patients from the Predictors 2 Study in a statistically representative community-based sample of Hispanic (N = 211) and non-Hispanic (N = 62) older adults (with 60 males and 213 females) from the Predictors 3 Study and extend the algorithm to mild cognitive impairment (MCI).

METHODS

The L-GoM model was applied to data collected at the initial Predictors 3 visit for 150 subjects with AD and 123 with MCI. Participants were followed annually for up to seven years. Observed rates of survival and need for full-time care (FTC) were compared to those predicted by the algorithm.

RESULTS

Initial MCI/AD severity in Predictors 3 was substantially higher than among clinic-based AD patients enrolled at the specialized Alzheimer's centers in Predictors 2. The observed survival and need for FTC followed the L-GoM model trajectories in individuals with MCI or AD, except for N = 32 subjects who were initially diagnosed with AD but reverted to a non-AD diagnosis on follow-up.

CONCLUSION

These findings indicate that the L-GoM model is applicable to community-dwelling, multiethnic older adults with AD. They extend the use of the model to the prediction of outcomes for MCI. They also justify release of our L-GoM calculator at this time.

Circulating IgA antibodies against the Fusobacterium nucleatum adhesin FadA are a potential biomarker for colorectal neoplasia

Fusobacterium nucleatum (Fn) is a gram-negative oral anaerobe and prevalent in colorectal cancer (CRC). Fn encodes a unique amyloid-like adhesin, FadAc, consisting of intact pre-FadA and cleaved mature FadA (mFadA), to promote CRC tumorigenesis. We aimed to evaluate circulating anti-FadAc antibody levels as a biomarker for CRC. Circulating anti-FadAc IgA and IgG levels were measured by ELISA in two study populations. In Study 1, plasma samples from CRC patients (n=25) and matched healthy controls (n=25) were obtained from University Hospitals Cleveland Medical Center. Plasma levels of anti-FadAc IgA were significantly increased in CRC patients (n=25; mean ± SD: 1.48±1.07 ug/ml) compared to matched healthy controls (n=25; 0.71±0.36 ug/ml) (p= 0.001). The increase was significant in both early (stages I & II) and advanced (stages III & IV) CRC. In Study 2, sera from 50 CRC patients and 50 patients with advanced colorectal adenomas were obtained from the Weill Cornell biobank. Anti-FadAc antibody titers were stratified according to the tumor stage and location. Similar as Study 1, serum levels of anti-FadAc IgA were significantly increased in CRC patients (n=50; 2.06±1.47 ug/ml) compared to patients with colorectal adenomas (n=50; 1.49±0.99 ug/ml; p= 0.025). Significant increase was limited to proximal cancers, but not distal tumors. Anti-FadAc IgG was not increased in either study population, suggesting that Fn likely translocates through the gastrointestinal tract and interact with colonic mucosa. Anti-FadAc IgA, but not IgG, is a potential biomarker for early diagnosis of colorectal neoplasia, especially for proximal tumors.

Retraction Note: Combination therapy with metformin and IL-12 to inhibit the growth of hepatic carcinoma by promoting apoptosis and autophagy in HepG2-bearing mice

The article "Combination therapy with metformin and IL-12 to inhibit the growth of hepatic carcinoma by promoting apoptosis and autophagy in HepG2-bearing mice, by Z. Jin, B.-X. Jia, L.-D. Tan, Q.-M. Chen, Y.-H. Liu, published in Eur Rev Med Pharmacol Sci 2020; 24 (23): 12368-12379-DOI: 10.26355/eurrev_202012_24031-PMID: 33336757" has been retracted by the authors as they cannot ensure the reliability of the manuscript due to inaccuracies in the conclusions and in the experiment (the cell migration and invasion assay along with the cell cycle arrest assay are missing). The Publisher apologizes for any inconvenience this may cause https://www.europeanreview.org/article/24031.

Pediatric hematology providers' contraceptive practices for female adolescents and young adults with sickle cell disease: A national survey

BACKGROUND

Adolescent and young adult (AYA) women with sickle cell disease (SCD) have increased pregnancy-related health risks and are prescribed potentially teratogenic medications, yet limited data are available regarding pediatric SCD provider contraceptive practices. We aimed to assess pediatric hematology providers' beliefs, practices, motivators, and barriers for providing contraceptive care to female AYAs with SCD.

METHODS

Guided by the Health Belief Model (HBM), we developed a 25-question, web-based survey to assess practices. Survey links were distributed nationwide to pediatric SCD and/or general hematology providers through their publicly available emails and by request to directors of U.S.-accredited Pediatric Hematology-Oncology fellowship programs for distribution to their SCD providers. Data analysis included descriptive statistics, chi-square analysis, and logistic regression.

RESULTS

Of 177 respondents, 160 surveys meeting inclusion criteria were analyzed. Most providers reported counseling (77.5%) and referring female AYA patients for contraception (90.8%), but fewer reported prescribing contraception (41.8%). Proportionally fewer trainees provided counseling compared with established providers (54% vs. 85%, p < .001), with a similar trend for prescribing (p = .05). Prescription practices did not differ significantly by provider beliefs regarding potential teratogenicity of hydroxyurea. Key motivators included patient request and disclosure of sexual activity. Key barriers included inadequate provider training, limited visit time, and perceived patient/parent interest.

CONCLUSION

Provider contraceptive practices for female AYAs with SCD varied, especially by provider status. Health beliefs regarding teratogenic potential of hydroxyurea did not correlate with contraceptive practices. Clinical guidelines, provider training, and patient/parent decision-making tools may be tested to assess whether provider contraceptive practices could be improved.

Health literacy screening in pediatric oncology and stem cell transplant caregivers: A cross-sectional cohort study

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Background: Despite advances in childhood cancer outcomes, disparities among socially vulnerable populations persist. Associations between educational attainment, English proficiency and outcomes suggest that factors impacting communication and comprehension may contribute. Health literacy (HL) is the degree to which individuals can process and act on health information. It is reported that up to 35% of adults in the U.S. have limited HL, with prevalence rising to 50% in those from low-income households. While studies from medical oncology report associations between limited HL and inferior outcomes, there remains a paucity of data on HL rates and associated outcomes in pediatric oncology and stem cell transplant (SCT) populations. We evaluated HL rates in a group of pediatric oncology and SCT parents/caregivers at a large academic medical center, and explored associations with self-reported demographics. Methods: English or Spanish-speaking parents of children (1 – 18 years) receiving chemotherapy or SCT were eligible. Self-reported sociodemographics were collected via survey, and HL was measured via bilingual interview using the Newest Vital Sign screening tool. Scores indicating likelihood of limited (0 – 1), moderate (2 – 3) and high (4 – 6) literacy were calculated and associations between HL, demographics, social determinants of health, and clinical characteristics were explored. Results: In total, 48 caregivers had evaluable HL and demographic data; 33% were Hispanic, 27% were non-Hispanic Black, and 25% were Spanish speaking only; 53% had public insurance, and 12% did not complete high school. Forty-four patients (90%) had cancer, 51% of whom had leukemia or lymphoma. Mean HL score was 3.27 (+/- 1.90). Nine caregivers (18%) had limited HL, 18 (37%) had moderate HL, and 21 (43%) had high HL. When comparing the limited/moderate HL group to the high HL group in univariate analysis, a significantly higher proportion of those in the limited/moderate group were Spanish speaking only (p = 0.035), received less than a high school education (p = 0.002), were unemployed (p = 0.038), and endorsed material hardship (e.g., food insecurity) (p = 0.001). Across all participants, 69% sought information about their child’s diagnosis from providers, and 55% sought information from the internet. Conclusions: Among this diverse population of pediatric oncology and SCT caregivers, over 50% are at risk of limited HL. Univariate models indicate that limited literacy is associated with Spanish language preference, low educational attainment, and material hardship, however larger patient numbers are needed to evaluate adjusted associations. Analyses measuring the contribution of HL to clinical outcomes are ongoing, with early results indicating that interventions addressing both material hardship and limited literacy are urgently needed.

Body mass index and additional risk factors for cancer in adults with cystic fibrosis

BACKGROUND

Adults with cystic fibrosis (CF) have an increased risk of a variety of cancers, notably gastrointestinal cancers. In CF higher body mass index (BMI) is associated with improved long-term outcomes, yet in the general population high BMI is associated with increased cancer risk. We aimed to delineate associations between BMI and other factors with cancer risk in adults with CF.

METHODS

This was a retrospective cohort study using CF Foundation Patient Registry data from 1992 to 2015. Data were collected on age, sex, CFTR mutation class, pancreatic insufficiency, and annualized data on BMI and FEV1. The primary analysis was the association between BMI and cancer, with secondary analyses focused on BMI trajectory. Multivariable logistic regression was performed, with analyses stratified by history of transplant.

RESULTS

Of 26,199 adults with CF, 446 (1.7%) had cancer diagnosed by histology at a mean age of 40.0 years (SD 12.2), with a higher proportion of transplanted patients developing cancer (137 (3.8%) v 309(1.4%), p < 0.001). Among non-transplanted patients, there was no association between BMI and cancer (p for trend = 0.43). Pancreatic insufficiency (p < 0.01) and higher FEV1 (p < 0.01) were associated with increased cancer risk. In transplanted patients, higher BMI was associated with reduced risk of cancer (p for trend = 0.04). Older age was associated with increased risk in both groups (p < 0.001). BMI trajectories were not associated with cancer risk in either group.

CONCLUSION

Higher BMI is associated with a reduced risk of cancer in transplanted adults with CF. Pancreatic insufficiency is a risk factor for cancer in non-transplanted CF patients.

Clinical Trajectories at the End of Life in Dementia Patients With Alzheimer Disease and Lewy Body Neuropathologic Changes

BACKGROUND AND OBJECTIVES

Evaluating and understanding the heterogeneity in dementia course has important implications for clinical practice, healthcare decision-making, and research. However, inconsistent findings have been reported with regard to the disease courses of the two most common dementias, Alzheimer's disease (AD) and Dementia with Lewy bodies (DLB). Using autopsy-confirmed diagnoses, we aimed to examine the disease trajectories in the years before death among dementia patients with pure AD, pure DLB, or mixed (AD and DLB) pathologies.

METHODS

The current retrospective longitudinal study included 62 participants with autopsy-confirmed diagnoses of pure AD (n=34), mixed AD and DLB (AD+DLB, n = 17), or pure DLB (n=11) from the Predictors 2 Cohort Study, a prospective, clinic-based, cohort of dementia patients. Generalized estimating equation models, with time zero at death, were used to examine the trajectory of cognition (Folstein Mini-Mental State Examination, MMSE), function (Activities of Daily Living, ADL), and dependence scale among patients with different autopsy-confirmed diagnosis (pure AD, AD+DLB, and pure DLB). The models were adjusted for age, sex, education, and baseline features including extrapyramidal signs, MMSE, ADL, and dependence scale.

RESULTS

The participants on average received 9.4±4.6 assessments at 6-month intervals during a mean 5.4±2.9 years of follow-up time. The three groups were similar in both cognition and function status at baseline. Cognition and function were highly correlated among AD+DLB patients but not in pure AD or pure DLB patients at baseline. Patients of the three groups all declined in both cognition and function but had different trajectories of decline. More specifically, the pure DLB patients experienced approximately double the rate of both cognitive decline and functional decline than the pure AD patients, and the mixed pathology group showed double the rate of functional decline as compared to pure AD patients.

DISCUSSION

In this longitudinal study, we found that among patients with dementia, those with Lewy body pathology experienced faster cognitive and functional decline than those with pure AD pathology.

Provider and staff crisis well-being associated with trust in leadership and baseline burnout

BACKGROUND

The impact of the coronavirus 2019 (COVID-19) pandemic on the emotional health of health care workers continues to be an area of active research. However, few studies have focused on those working in pediatrics and its subspecialties, as well as ancillary and non-patient-facing staff. The purpose of this study was to determine the prevalence and associated predictors of burnout and emotional well-being of providers and staff.

METHODS

An anonymous electronic survey was developed evaluating demographics, pandemic experiences, possible predictor variables, and three main outcomes of burnout, psychological distress, and perceived stress. Pediatric hematology oncology (PHO) chiefs and program directors across the country were invited to participate and disseminate the survey to their programs.

RESULTS

A total of 682/1950 (35% of invited) individuals responded to all predictor and outcome variables. Over half reported high levels of burnout and some reported moderate/high levels of distress. Prepandemic burnout and decreased trust in leadership were associated with all three outcomes. Additional predictors included having a child ≤18 years at home, hospital role, and worrying about patient care or relationship with their patients. The majority (n = 444/682, 65.5%) reported that their institution had made COVID-19-related mental health resources available. However, only 6.5% (n = 44/682) reported utilizing these resources.

CONCLUSIONS

While the majority of PHO providers and staff were resilient during the early stages of the COVID-19 pandemic, many reported high levels of burnout, yet few are utilizing institutional resources. This study has highlighted several actionable areas to help identify and address factors that are wearing down the emotional well-being of providers and staff.

ArtifactID: Identifying artifacts in low-field MRI of the brain using deep learning

Low-field MR scanners are more accessible in resource-constrained settings where skilled personnel are scarce. Images acquired in such scenarios are prone to artifacts such as wrap-around and Gibbs ringing. Such artifacts negatively affect the diagnostic quality and may be confused with pathology or reduce the region of interest visibility. As a first step solution, ArtifactID identifies wrap-around and Gibbs ringing in low-field brain MRI. We utilized two datasets: 179 T₁-weighted pathological brain images from a 0.36 T scanner and 581 publicly available T₁-weighted brain images. Individual binary classification models were trained to identify through-plane wrap-around, in-plane wrap-around, and Gibbs ringing. Visual explanations obtained via the GradCAM method helped develop trust in the wrap-around model. The mean precision and recall metrics across the four implemented models were 97.6% and 92.83% respectively. Agreement analysis of the models and the radiologists' labels returned Cohen's kappa values of 0.768 ± 0.062, 1.00 ± 0.000, 0.89 ± 0.085, and 0.878 ± 0.103 for the through-plane wrap-around, in-plane wrap-around, and Gibbs ringing models, respectively.

Tailored Magnetic Resonance Fingerprinting for simultaneous non-synthetic and quantitative imaging: A repeatability study

PURPOSE

The goals of this study include: (a) generating tailored magnetic resonance fingerprinting (TMRF) based non-synthetic imaging; (b) assessing the repeatability of TMRF and deep learning-based mapping of in vitro ISMRM/NIST phantom and in vivo brain data of healthy human subjects.

METHODS

We have acquired qualitative images obtained from the vendor-supplied gold standard, MRF (synthetic), and TMRF (non-synthetic) on one representative healthy human brain. We also acquired thirty datasets on the ISMRM/NIST phantom for the in vitro repeatability study on a GE Discovery 3T MR750w scanner using the TMRF sequence. We compared T₁ and T₂ maps generated from thirty ISMRM/NIST phantom datasets to the spin-echo (SE) based gold standard (GS) method as part of the in vitro repeatability study. R-squared coefficient of determination in a simple linear regression and Bland-Altman analysis were computed for thirty datasets of ISMRM/NIST phantom to assess the accuracy of in vitro quantitative TMRF data. The repeatability of T₁ and T₂ estimates by TMRF was evaluated by calculating the standard deviation (SD) divided by the average of thirty datasets for each sphere, respectively. We acquired ten volunteers for the in vivo repeatability study on the same scanner using the same TMRF sequence. These volunteers were imaged five times with two runs per repetition, resulting in one hundred in vivo datasets. Five contrasts, T₁ and T₂ maps of ten human volunteers acquired over five repetitions, were evaluated in the in vivo repeatability study. We computed the intraclass correlation coefficient (ICC) of the signal-to-noise ratio (SNR), signal intensities, T₁ and T₂ relaxation times in white matter (WM) and gray matter (GM).

RESULTS

The synthetic images generated from MRF show partial volume and flow artifacts compared to non-synthetic images obtained from TMRF images and the gold standard. in vitro studies show that TMRF estimates have less than 5% variations except sphere 14 in the T₂ array (6.36%). TMRF and spin-echo relaxometry measurements were strongly correlated; R² values were 0.9958 and 0.9789 for T₁ and T₂ estimates, respectively. Based on the ICC values, SNR, mean intensity values, and relaxation times of WM and GM for the in vivo studies were consistent. T₁ and T₂ values of WM and GM were similar to previously published values. The mean ± SD of T₁ and T₂ for WM for ten subjects and five repeats are 992 ± 41 ms and 99 ± 6 ms, while the corresponding values for T₁ and T₂ for GM are 1598 ± 73 ms and 152 ± 14 ms.

CONCLUSION

TMRF and deep learning-based reconstruction produce repeatable, non-synthetic multi-contrast images and parametric maps simultaneously. This article is protected by copyright. All rights reserved.

Bacteremia in Febrile, Non-neutropenic, and Well-appearing Children With Cancer

Fever in a neutropenic pediatric oncology patient requires prompt assessment due to the risk of infectious complications. The appropriate management of fever in non-neutropenic patients, however, is not well-established. We describe the rate of bacteremia in a cohort of non-neutropenic pediatric oncology patients with fever at a large institution. Patients were included if they presented to the emergency department or outpatient clinic between 2009 and 2014 with fever, had a central venous catheter (CVC), and were not neutropenic. Three hundred eighty-six episodes of fever occurring in 159 patients were included in the data analysis. Fifty-nine percent of patients were male, 41% had a diagnosis of acute lymphoblastic leukemia, and 90% had a port-a-cath as CVC. The rate of bacteremia was 3.4%; presence of a port-a-cath was protective against bacteremia whereas a white blood cell count >20,000/mm3 was associated with a higher likelihood of bacteremia. Gram-positive microorganisms were most commonly isolated (64.3%) and frequently resistant to cephalosporins. In summary, in our study, the rate of bacteremia was low among non-neutropenic, well-appearing pediatric cancer patients with a CVC and was not associated with any serious medical complications. Prospective research is needed to determine the most appropriate management of these patients.

Metabolomic Profile Differences Between Demented and Non-Demented APOE4 Carriers in the Long Life Family Study

Rejection of care (RoC) by persons living with dementia (PLWD) has yet to be measured in the hospital setting. Elderspeak communication (i.e., baby talk or infantilization) is an established antecedent to RoC in nursing home dementia care. The purpose of this study was to determine the impact of elderspeak communication by nursing staff on RoC by hospitalized PLWD. Eighty-eight care encounters between 16 PLWD and 53 nursing staff were observed for RoC using the Resistiveness to Care scale in one Midwestern hospital. Audio-recordings of the care encounters were transcribed verbatim and coded for semantic, pragmatic, and prosodic features of elderspeak. Over one-quarter (28.7%) of the duration of nursing staff speech towards PLWD constituted elderspeak and nearly all (96.6%) of the 88 care encounters included some elderspeak. Almost half of the observations (48.9%) included RoC behaviors by PLWD. Rejection of care was modeled as present or absent using a GEE method. Characteristics of the PLWD (e.g., pain, delirium) and the observation (e.g., environmental simulation) were evaluated as potential covariates. After adjusting for pain, length of stay, and gender, a 15-percentage point decrease in the proportion of elderspeak communication by nursing staff reduced the odds of RoC by 62% (OR=0.38, 95% CI=0.21-0.71, p=.002,) and a one unit decrease in pain reduced the odds of RoC by 63% (OR=0.37, 95% CI=0.22-0.63, p<.001). This study identified that pain and elderspeak are two modifiable factors of RoC. Person-centered interventions are needed that address communication practices and approaches to pain management for hospitalized PLWD.

Modeling risks of cardiovascular and cancer mortality following a diagnosis of loco-regional breast cancer

Background

Many women with breast cancer also have a high likelihood of cardiovascular mortality, and while there are several cardiovascular risk prediction models, none have been validated in a cohort of breast cancer patients. We first compared the performance of commonly-used cardiovascular models, and then derived a new model where breast cancer and cardiovascular mortality were modeled simultaneously, to account for the competing risk endpoints and commonality of risk factors between the two events.

Methods

We included 20,462 women diagnosed with stage I–III breast cancer between 2000 and 2010 in Kaiser Permanente Northern California (KPNC) with follow-up through April 30, 2015, and examined the performance of the Framingham, CORE and SCOREOP cardiovascular risk models by area under the receiver operating characteristic curve (AUC), and observed-to -expected (O/E) ratio. We developed a multi-state model based on cause-specific hazards (CSH) to jointly model the causes of mortality.

Results

The extended models including breast cancer characteristics (grade, tumor size, nodal involvement) with CVD risk factors had better discrimination at 5-years with AUCs of 0.85 (95% CI 0.83, 0.86) for cardiovascular death and 0.80 (95% CI 0.78, 0.87) for breast cancer death compared with the existing cardiovascular models evaluated at 5 years AUCs ranging 0.71–0.78. Five-year calibration for breast and cardiovascular mortality from our multi-state model was also excellent (O/E = 1.01, 95% CI 0.91–1.11).

Conclusion

A model incorporating cardiovascular risk factors, breast cancer characteristics, and competing events, outperformed traditional models of cardiovascular disease by simultaneously estimating cancer and cardiovascular mortality risks.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13058-021-01469-w.

Combining tumor deposits with the number of lymph node metastases to improve the prognostic accuracy in stage III colon cancer: a post hoc analysis of the CALGB/SWOG 80702 phase III study (Alliance)☆

BACKGROUND

In colon cancer, tumor deposits (TD) are considered in assigning prognosis and staging only in the absence of lymph node metastasis (i.e. stage III pN1c tumors). We aimed to evaluate the prognostic value of the presence and the number of TD in patients with stage III, node-positive colon cancer.

PATIENTS AND METHODS

All participants from the CALGB/SWOG 80702 phase III trial were included in this post hoc analysis. Pathology reports were reviewed for the presence and the number of TD, lymphovascular and perineural invasion. Associations with disease-free survival (DFS) and overall survival (OS) were evaluated by multivariable Cox models adjusting for sex, treatment arm, T-stage, N-stage, lymphovascular invasion, perineural invasion and lymph node ratio.

RESULTS

Overall, 2028 patients were included with 524 (26%) TD-positive and 1504 (74%) TD-negative tumors. Of the TD-positive patients, 80 (15.4%) were node negative (i.e. pN1c), 239 (46.1%) were pN1a/b (<4 positive lymph nodes) and 200 (38.5%) were pN2 (≥4 positive lymph nodes). The presence of TD was associated with poorer DFS [adjusted hazard ratio (aHR) = 1.63, 95% CI 1.33-1.98] and OS (aHR = 1.59, 95% CI 1.24-2.04). The negative effect of TD was observed for both pN1a/b and pN2 groups. Among TD-positive patients, the number of TD had a linear negative effect on DFS and OS. Combining TD and the number of lymph node metastases, 104 of 1470 (7.1%) pN1 patients were re-staged as pN2, with worse outcomes than patients confirmed as pN1 (3-year DFS rate: 65.4% versus 80.5%, P = 0.0003; 5-year OS rate: 87.9% versus 69.1%, P = <0.0001). DFS was not different between patients re-staged as pN2 and those initially staged as pN2 (3-year DFS rate: 65.4% versus 62.3%, P = 0.4895).

CONCLUSION

Combining the number of TD and the number of lymph node metastases improved the prognostication accuracy of tumor-node-metastasis (TNM) staging.

Office, Central, and Ambulatory Blood Pressure for Predicting First Stroke in Older Adults: A Community-Based Cohort Study

[Figure: see text].

Notoginsenoside R1 protects hypoxia-reoxygenation deprivation-induced injury by upregulation of miR-132 in H9c2 cells

BACKGROUND

Myocardial ischemia/reperfusion injury (IRI) is a common perioperative complication of heart and great vessels surgery, aggravating the original myocardial damage and seriously affecting the postoperative recovery of cardiac function. The aim of this study was to reveal the functional effects and potential mechanisms of notoginsenoside R1 (NG-R1) in myocardial cells injured by hypoxia-reoxygenation (H/R).

METHODS

The rat cardiomyocyte line H9c2 was subjected to H/R with or without NG-R1 treatment. The levels of miR-132 and HBEGF in the cell were altered by microRNA or short-hairpin RNA transfection. Cell viability, apoptosis, lactate dehydrogenase (LDH) and malondialdehyde (MDA) were monitored. Dual luciferin was used to detect the relationship between miR-132 and HBEGF.

RESULTS

NG-R1 (20 μM) had no impact on H9c2 cells, but cell viability was significantly reduced at 80 μM. NG-R1 (20 μM) protected H9c2 cells against H/R-induced cell damage, accompanied by increased cell viability, reduced cell apoptosis, and downregulation of LDH and MDA. Furthermore, the level of miR-132 was decreased in response to H/R exposure but then increased after NG-R1 treatment. When miR-132 was overexpressed, H/R-induced cell damage could be recovered. Downregulation of miR-132 limited the protective effect of NG-R1 on H/R damage. We also found that HBEGF was a direct target of miR-132. The expression of HBEGF was increased upon H/R damage, and this increase was reversed after NG-R1 treatment.

CONCLUSIONS

This study demonstrated that NG-R1 markedly protected H9c2 cells against H/R-induced damage via upregulation of miR-132 and downregulation of its target protein HBEGF.

Validation of a Questionnaire to Identify Respiratory Tract Infections in Children With Sickle Cell Disease

BACKGROUND

No validated questionnaires have been published that are specific for identifying respiratory infections in children with sickle cell disease (SCD).

METHODS

A questionnaire was developed that included 6 respiratory symptoms (difficulty breathing, wheezing, fever, cough, runny or stuffy nose, and sore throat) to identify respiratory events for a clinical trial. The questionnaire results were compared with identification of viral respiratory pathogens from nasal samples by reverse transcriptase polymerase chain reaction.

RESULTS

Eighty questionnaire responses (40 with symptom/s and 40 without) paired with isolation of viral respiratory pathogen from nasal samples were obtained from 53 children with SCD, ages 4 to 18 years over 2 separate periods in different seasons. The questionnaire yielded a sensitivity of 82%, specificity of 72% with an overall accuracy of 76%. The kappa value was 0.53, indicating moderate agreement, and the Fleiss' kappa test statistic was 4.77 with P<0.001, indicating that agreement between the 2 methods was not by chance.

CONCLUSION

These results provide evidence for validity of this 6-symptom respiratory questionnaire in identification of respiratory viral infections for use in SCD-related research.

Factors associated with delayed enteral nutrition in the intensive care unit: a propensity score-matched retrospective cohort study

BACKGROUND

Guidelines recommend enteral nutrition (EN) within 48 h of admission to the medical intensive care unit (ICU) in appropriate patients. However, delayed EN is still common.

OBJECTIVES

This study sought to identify risk factors for delayed EN ordering in the ICU and to examine its association with patient outcomes.

METHODS

This was a retrospective study from 2010-2018. Adult patients were included if they were admitted to the medical ICU for >48 h, were appropriate for EN, and had an order for EN placed within 30 d of admission. The primary outcome was ordering of EN, classified as early if ordered within 48 h of ICU admission and otherwise as delayed. Propensity score matching was used to examine the relation between delayed EN and ICU-free days, and outcomes such as length of ICU admission, length of hospitalization during 30 d of follow-up, and mortality.

RESULTS

A total of 738 (79%) patients received early EN and 196 (21%) received delayed EN. The exposures most strongly associated with delayed EN were order placement by a Doctor of Medicine compared with a dietitian [adjusted OR (aOR): 2.58; 95% CI: 1.57, 4.24] and use of vasopressors within 48 h of ICU admission (aOR: 1.78; 95% CI: 1.22, 2.59). After propensity score matching to balance baseline characteristics, delayed EN ordering was significantly associated with fewer ICU-free days, longer ICU admissions, and longer hospitalizations, but not mortality, compared with early EN.

CONCLUSIONS

Provider-level factors were associated with delayed ordering of EN which itself was associated with worse outcomes. Interventions directed at providers may increase timely EN in the ICU and improve outcomes.

Long non-coding RNA plasmacytoma variant translocation 1 (PVT1) promotes glioblastoma multiforme progression via regulating miR-1301-3p/TMBIM6 axis

OBJECTIVE

To explore whether plasmacytoma variant translocation 1 (PVT1) could regulate glioblastoma multiforme (GBM) progression via microRNA-1301-3p (miR-1301-3p) and transmembrane BAX inhibitor motif containing 6 (TMBIM6) axis.

MATERIALS AND METHODS

Expression patterns of PVT1 and RMBIM6 in GBM patients were analyzed using GEPIA, an online gene expression analysis tool. Levels of PVT1 in GBM cells and normal cells were analyzed with quantitative real-time PCR method. Cell Counting Kit-8 (CCK-8), transwell invasion assay, and flow cytometry assay were applied to detect cell viability and apoptosis. Connections of PVT1 or TMBIM6 with miR-1301-3p were validated with bioinformatic tool and luciferase activity reporter assay.

RESULTS

PVT1 was significantly expressed in GBM tissues and cells. PVT1 promotes GBM cell proliferation and invasion but inhibits apoptosis in vitro. TMBIM6 was significantly expressed in GBM tissues. The knockdown of TMBIM6 reversed the stimulation effects of PVT1 on GBM cell malignancy behaviors with miR-1301-3p as a bridge.

CONCLUSIONS

Collectively, we showed PVT1 elevated TMBIM6 expression mediated by miR-1301-3p and thus to promote GBM progression.

Low CD4 count may be a risk factor for non-tuberculous mycobacteria infection in pediatric hematopoietic cell transplant recipients

BACKGROUND

HCT leaves patients in a relative state of immune deficiency both during their initial transplant admission and for several years following discharge. NTM are generally harmless colonizers of the outside environment, but for immunocompromised patients, they can cause significant disease due to a paucity of T-cell defense. While routine prophylaxis against NTM is recommended for patients with low CD4 counts in certain clinical settings (eg, AIDS), this is not yet established for HCT patients despite their higher risk.

METHODS

Here we build upon our prior work to determine risk factors for NTM in pediatric HCT patients by comparing NTM patient characteristics to matched HCT controls.

RESULTS

We followed 272 patients across a 13-year time period, with 11 cases of NTM. Patients with NTM had a significantly lower CD4 count at Day 365 than matched HCT controls (105.5 ± 97.0 cells/µl vs. 856.2 ± 446.1 cells/µl, respectively; p = .001). No other potential risk factors (eg, CMV, GvHD, disease type) were found to be statistically significant, including use of T-cell depleting agents. This is consistent with an average diagnosis of NTM at Day +323 (ie, outside immediate post-transplant period). All-cause mortality was similar between NTM and control HCT groups, with an NTM attributable mortality of <10%.

CONCLUSION

Since reduced CD4 counts are associated with NTM, and cost and morbidity are high, azithromycin prophylaxis for CD4 count <200 cells/µl in high-risk patients should be considered.

Clinical significance of recurrent gastroesophageal junction intestinal metaplasia after endoscopic eradication of Barrett's esophagus

BACKGROUND AND AIMS

After endoscopic eradication of Barrett's esophagus (BE), recurrence of intestinal metaplasia at the gastroesophageal junction (GEJIM) is common. The clinical significance of this finding is unclear. We assessed whether recurrent GEJIM is associated with increased risk of subsequent dysplasia and whether endoscopic treatment lowers this risk.

METHODS

A retrospective, multicenter, cohort study was performed of treated BE patients who achieved complete eradication of intestinal metaplasia (IM). Postablation follow-up was performed at standard intervals. Recurrent GEJIM was defined as nondysplastic IM on gastroesophageal junction biopsy specimens without endoscopic evidence of BE. Patients were categorized as "never-GEJIM," "GEJIM-observed," or "GEJIM-treated." Endoscopic treatment for recurrent GEJIM was at the endoscopists' discretion. The primary outcome was dysplasia recurrence. Analyses were performed using log-rank tests and Cox proportional hazards modeling.

RESULTS

Six hundred thirty-three patients were analyzed; median follow-up was 47 months (interquartile range, 24-69). Most patients (81%) had high-grade dysplasia or intramucosal adenocarcinoma before treatment. Dysplasia recurrence was 2.2% per year. GEJIM-observed patients had the lowest rate of recurrence (.6%/y) followed by GEJIM-treated (2.2%/y) and never-GEJIM (2.6%/y) (log-rank P = .07). In multivariate analyses, compared with never-GEJIM, the risk of dysplasia recurrence was significantly lower in GEJIM-observed patients (adjusted hazard ratio, .19; 95% confidence interval, .05-.81) and not different in GEJIM-treated patients (adjusted hazard ratio, .81; 95% confidence interval, .39-1.67). Older age and longer initial BE length were independently associated with recurrence.

CONCLUSIONS

Recurrent GEJIM after endoscopic eradication of BE was not associated with an increased risk of subsequent dysplasia. Future studies are warranted to determine if observation is appropriate for this finding.