Blinded Investigator Research Articles

Pregnancy outcomes in ANCA-associated vasculitis patients: A systematic review and meta-analysis

ObjectiveAntineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV), namely granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis and microscopic polyangiitis constitute a group of rare systemic vasculitides, affecting small vessels. Genders are equally affected, with symptoms most commonly presenting during and/or after the fifth decade of life, but AAV may also present in younger individuals. As advanced maternal age is becoming common and safe over the last decades, it is now more feasible for middle-aged women suffering from AAV to get pregnant. Although adverse pregnancy outcomes have been thoroughly investigated in other systemic diseases, the exact prevalence of pregnancy complications and unfavorable outcomes in pregnant women with AAV has not been systematically evaluated. MethodsWe researched PubMed, Scopus, Cochrane Library and Cinahl databases until September, 2022. Three blinded investigators extracted data and assessed the risk of bias. A random effects model was used for the analysis. The outcomes studied were pre-term delivery, intrauterine growth restriction (IUGR) neonates and disease flare. ResultsWe included six studies with 92 pregnancies in patients with AAV. The prevalence of pre-term delivery, IUGR neonates and disease flare were 18% (CI: 0.10–0.30, P=non-significant), 20% (CI: 0.11–0.33, P=non-significant) and 28% (CI: 0.09–0.59, P<0.01), respectively. ConclusionThe analysis demonstrated higher occurrence of adverse outcomes in pregnant women suffering from AAV accompanied by an increased risk of disease flare during pregnancy. These findings underline the importance of preconception counseling and the necessity of close monitoring in these patients similarly to other systemic inflammatory diseases.

Ameliorative potential of stem cells from human exfoliated deciduous teeth (SHED) in preclinical studies: A meta-analysis

The preclinical and clinical role of mesenchymal stem cells from various adult sources is extensively investigated and established in regenerative medicine. However, the comprehensive exploration of the therapeutic potential of Stem cells from human exfoliated deciduous teeth (SHED) is inadequate. Therefore, we performed a systematic meta-analysis of preclinical animal model studies in several diseases to provide insight into SHED's efficacy and therapeutic potential. Two blinded and independent investigators searched the available online databases and scrutinized the included studies. Meta-analysis was performed to evaluate the pooled effect estimate of intervention of SHED by Review Manager 5.4.1. To investigate the therapeutic efficacy of SHED intervention, we also analyzed the test of heterogeneity (I2), overall effect (Z), sensitivity, and publication bias. Among the 2156 scrutinized studies, 40 were included and evaluated as per inclusion and exclusion criteria. The intervention of SHED and its derivatives in several diseases depicted statistically significant therapeutic effects in periodontitis, pulpitis, spinal cord injury, parkinson's disease, alzheimer's disease, focal cerebral ischemia, peripheral nerve injury, and retinal pigmentosa. SHED also improved levels of alanine aminotransferase, aspartate aminotransferase, and bilirubin in liver fibrosis . In autoimmune diseases also, values were significant. SHED also showed a statistically significant reduction of wound healing area and new bone formation in bone defects. The pooled effect estimates of included preclinical studies demonstrated a statistically significant therapeutic effect of SHED in numerous diseases. Based on our data, it is suggested that the potential of SHED may be implemented in clinical trials after conducting a few more preclinical studies.

Association of statin use and lipid levels with cerebral microbleeds and intracranial hemorrhage in patients with atrial fibrillation: A prospective cohort study.

An increased risk of intracranial hemorrhage (ICH) associated with statins has been reported, but data on the relationship between statin use and cerebral microbleeds (CMBs) in patients with atrial fibrillation (AF), a population at high bleeding and cardiovascular risk, are lacking. To explore the association between statin use and blood lipid levels with the prevalence and progression of CMBs in patients with AF with a particular focus on anticoagulated patients. Data of Swiss-AF, a prospective cohort of patients with established AF, were analyzed. Statin use was assessed during baseline and throughout follow-up. Lipid values were measured at baseline. CMBs were assessed using magnetic resonance imagining (MRI) at baseline and at 2 years follow-up. Imaging data were centrally assessed by blinded investigators. Associations of statin use and low-density lipoprotein (LDL) levels with CMB prevalence at baseline or CMB progression (at least one additional or new CMB on follow-up MRI at 2 years compared with baseline) were assessed using logistic regression models; the association with ICH was assessed using flexible parametric survival models. Models were adjusted for hypertension, smoking, body mass index, diabetes, stroke/transient ischemic attack, coronary heart disease, antiplatelet use, anticoagulant use, and education. Of the 1693 patients with CMB data at baseline MRI (mean ± SD age 72.5 ± 8.4 years, 27.6% women, 90.1% on oral anticoagulants), 802 patients (47.4%) were statin users. The multivariable adjusted odds ratio (adjOR) for CMBs prevalence at baseline for statin users was 1.10 (95% CI = 0.83-1.45). AdjOR for 1 unit increase in LDL levels was 0.95 (95% CI = 0.82-1.10). At 2 years, 1188 patients had follow-up MRI. CMBs progression was observed in 44 (8.0%) statin users and 47 (7.4%) non-statin users. Of these patients, 64 (70.3%) developed a single new CMB, 14 (15.4%) developed 2 CMBs, and 13 developed more than 3 CMBs. The multivariable adjOR for statin users was 1.09 (95% CI = 0.66-1.80). There was no association between LDL levels and CMB progression (adjOR 1.02, 95% CI = 0.79-1.32). At follow-up 14 (1.2%) statin users had ICH versus 16 (1.3%) non-users. The age and sex adjusted hazard ratio (adjHR) was 0.75 (95% CI = 0.36-1.55). The results remained robust in sensitivity analyses excluding participants without anticoagulants. In this prospective cohort of patients with AF, a population at increased hemorrhagic risk due to anticoagulation, the use of statins was not associated with an increased risk of CMBs.

Restoration of the native tibial joint line obliquity in total knee arthroplasty with inverse kinematic alignment does not increase knee adduction moments.

Patient-specific alignment in total knee arthroplasty (TKA) has shown promising patient-reported outcome measures; however, the clinical and biomechanical effects of restoring the native knee anatomy remain debated. The purpose of this study was to compare the gait pattern between a mechanically aligned TKA cohort (adjusted mechanical alignment-aMA) and a patient-specific alignment TKA cohort (inverse kinematic alignment-iKA). At two years postoperatively, the aMA and iKA groups, each with 15 patients, were analyzed in a retrospective case-control study. All patients underwent TKA with robotic assistance (Mako, Stryker) through an identical perioperative protocol. The patients' demographics were identical. The control group comprised 15 healthy participants matched for age and gender. Gait analysis was performed with a 3D motion capture system (VICON). Data collection was conducted by a blinded investigator. The primary outcomes were knee flexion during walking, knee adduction moment during walking and spatiotemporal parameters (STPs). The secondary outcomes were the Oxford Knee Score (OKS) and Forgotten Joint Score (FJS). During walking, the maximum knee flexion did not differ between the iKA group (53.0°) and the control group (55.1°), whereas the aMA group showed lower amplitudes of sagittal motion (47.4°). In addition, the native limb alignment in the iKA group was better restored, and although more in varus, the knee adduction moments in the iKA group were not increased (225Nmm/kg) compared to aMA group (276Nmm/kg). No significant differences in STPs were observed between patients receiving iKA and healthy controls. Six of 7 STPs differed significantly between patients receiving aMA and healthy controls. The OKS was significantly better in patients receiving iKA than aMA: 45.4 vs. 40.9; p = 0.05. The FJS was significantly better in patients receiving iKA than aMA: 84.8 vs. 55.5; p = 0.002. At two years postoperatively, the gait pattern showed greater resemblance to that in healthy controls in patients receiving iKA rather than aMA. The restoration of the native coronal limb alignment does not lead to increased knee adduction moments due to the restoration of the native tibial joint line obliquity. Level III.

Ovary Dissection Is a Sensitive Measure of Sterility in Anopheles gambiae Exposed to the Insect Growth Regulator Pyriproxyfen.

Pyriproxyfen (PPF) is an insect growth regulator used in the co-treatment of long-lasting insecticidal nets for its ability to sterilize female mosquitoes. To evaluate the efficacy of PPF-treated nets on mosquito reproductivity, most studies observe oviposition (egg-laying) rates in the laboratory. This technique has several technical disadvantages. Our study assessed if ovarial dissection could serve as an effective proxy for evaluating sterility in Anopheles gambiae mosquitoes. Blood-fed females were exposed to untreated or PPF-treated nets in cylinder assays and followed over several days to observe oviposition rates or egg development by dissection. For identifying PPF-exposed mosquitoes, both techniques demonstrated high sensitivity (oviposition: 99.1%; dissection: 100.0%), but for identifying non-exposed mosquitoes, specificity was significantly higher in the dissection group (52.5% vs. 18.9%). To assess whether dissection could be applied to nets treated with a pyrethroid or co-treated with a pyrethroid and PPF in tunnel tests, a blinded investigator performed dissections to predict the PPF exposure status across different treatment groups. The exposure status of dissected females was predicted with >90% accuracy. We report that dissection is a sensitive technique to assess sterility in female Anopheles gambiae mosquitoes and can be used as a predictor of PPF exposure.

Factors affecting electrogram sensing in an insertable cardiac monitor: Insights from surface electrocardiogram mapping analysis

Fidelity of electrogram sensing may reduce false alerts from an insertable cardiac monitor (ICM). The purpose of this study was to assess the effect of vector length, implant angle, and patient factors on electrogram sensing using surface electrocardiogram (EKG) mapping. Twelve separate precordial single-lead surface EKGs were acquired from 150 participants at 2 interelectrode distances (75 and 45 mm), at 3 vector angles (vertical, oblique, and horizontal), and in 2 postures (upright and supine). A subset of 50 patients also received a clinically indicated ICM implant in 1:1 ratio (Reveal LINQ [Medtronic, Minneapolis, MN]/BIOMONITOR III [Biotronik, Berlin, Germany]). All EKGs and ICM electrograms were analyzed by blinded investigators using DigitizeIt software (V2.3.3, Braunschweig, Germany). The P-wave visibility threshold was set at >0.015 mV. Logistic regression was used to identify factors affecting P-wave amplitude. A total of 1800 tracings from 150 participants (44.5% female; median 59 years) were assessed. Median P and R waves were 45% and 53% larger with vector lengths of 75 and 45 mm, respectively (P < .001 for both). The oblique orientation yielded the best P- and R-wave sensing, while posture change did not affect P-wave amplitude. Mixed effects modeling found that visible P waves occur more frequently with a vector length of 75 mm than with 45 mm (86% vs 75%, respectively; P < .0001). A longer vector length improved both P-wave amplitude and visibility in all body mass index categories. There was a moderate correlation of P and R waves from the ICM electrograms to those from surface EKG recordings (ICC 0.74 and 0.80, respectively). Longer vector length and oblique implant angle yielded the best electrogram sensing and are relevant considerations for ICM implantation procedures.

Effects of advance care planning in care dependent community-dwelling older persons (STADPLAN): A cluster-randomised controlled trial

Background: Most randomised controlled trials on advance care planning were conducted in people with advanced, life-limiting illnesses or in institutional settings. There are few studies on its effect in older people living in the community. Aim: To determine the effects of advance care planning in older community dwelling people. Design: The STADPLAN study was a cluster-randomised trial with 12 months follow-up. The complex intervention comprised a 2-days training for nurse facilitators that delivered a formal advance care planning counselling and a written information brochure. Patients in the control group received optimised usual care, that is, provision of a short information brochure. Setting/participants: Home care services in three regions of Germany were randomised using concealed allocation. Care dependent clients of participating home care services, aged 60 years or older, and rated to have a life-expectancy of at least 4 weeks were included. Primary outcome was active participation in care at 12 months, assessed by blinded investigators using the Patient Activation Measure (PAM-13). Results: Twenty-seven home care services and 380 patients took part. Three hundred seventy-three patients were included in the primary analysis (n = 206 in the intervention and n = 167 in the control group). There was no statistically significant difference between the intervention and control group with regard to the PAM-13 after 12 months (75.7 vs 78.4; p = 0.13). No differences in quality of life, anxiety and depression, advance care planning engagement, and in proportion of participants with advance directives were found between groups. Conclusions: The intervention showed no relevant effects on patient activation or quality of life in community dwelling older persons, possibly indicating the need for more tailored interventions. However, results are limited by a lack of statistical power. Trial registration: German Clinical Trials Register: DRKS00016886

Just-in-time procedural training for pediatric emergency medicine trainees: A randomized educational interventional trial.

Pediatric requirements include procedural skills training such as peripheral intravenous (PIV) catheter placement and bag-mask ventilation (BMV). Clinical experiences may be limited and temporally remote from scheduled teaching. Just-in-time (JIT) training prior to utilization can promote skill development and mitigate learning decay. Our objective was to assess the impact of JIT training on pediatric residents' procedural performance, knowledge, and confidence with PIV placement and BMV. Residents received standardized baseline training in both PIV placement and BMV during scheduled educational programming. Between 3 and 6 months later, participants were randomized and received JIT training for either PIV placement or BMV. JIT training included a brief video and coached practice, totaling <5 min. Each participant was videotaped performing both procedures on skills trainers. Blinded investigators scored performance using skills checklists. Pre- and postintervention knowledge was assessed using multiple-choice and short-answer items, and confidence was reported using Likert scores. Seventy-two residents completed baseline training sessions: 36 were randomized to receive JIT training for PIV and 36 for BMV. Thirty-five residents in each cohort completed the curriculum. There were no significant differences between the cohorts with regard to demographics, baseline knowledge, or prior simulation experience. JIT training was associated with improved procedural performance for PIV (median 87% vs. 70%, p < 0.001) and for BMV (mean 83% vs. 57%, p < 0.001). Results remained significant after using regression models to adjust for differences in prior clinical experience. Improvements in knowledge or confidence were not associated with JIT training in either cohort. JIT training resulted in a significant improvement in resident procedural performance with PIV placement and BMV in a simulated environment. There were no differences in outcome with regard to knowledge or confidence. Future work might explore how the demonstrated benefit translates into the clinical setting.

A Blinded Investigation: Accentuated NK Lymphocyte CD335 (NKp46) Expression Predicts Pregnancy Failures.

NKp46 is an NK cell receptor uniquely expressed by NK cells and a small subset of innate lymphoid cells. In our previous studies, we suggested a tight connection between the activity of NK cells and the expression of NKp46 and supported the clinical significance of NKp46 expression in NK cells in women with reproductive failures. In this study, we investigated the expression of NKp46 in NK cells in the peripheral blood of women in early pregnancy and analyzed its association with pregnancy loss. In a blinded study, we examined blood samples and analyzed the subsequent pregnancy outcomes from 98 early pregnant women (5th-7th week of gestation-w.g.) and 66 women in the 11th-13th week of pregnancy who served as controls. We studied the expression of NKp46 and the levels of anti-cardiolipin antibodies (aCL). The results of aCL were shared with the clinic, while the expression of NKp46 was blinded and not analyzed until the end of the study. A misbalance in the NKp46+NK cells subpopulations was associated with an unfavorable ongoing pregnancy. A decreased level of NKp46high cells (<14%) was strongly associated with miscarriage. A decreased level of the double-bright subpopulation (NKp46hightCD56++) also was a negative prognostic factor for the pregnancy course, but its increased level (>4%) was strongly associated with a successful pregnancy course. Our results showed that accentuated levels of NKp46+NK cells lead to a negative prognosis for early pregnancy courses in women.

Positive effect of leptin substitution on mood and behaviour in patients with congenital leptin deficiency.

States of starvation are characterized by reduced physical activity and social withdrawal. This has been suggested to be mediated at least in part via reduced leptin concentrations. We therefore aimed to ascertain if leptin substitution in patients with congenital leptin deficiency (CLD) can improve physical activity and mood. Seven patients with CLD were filmed prior to and after short- and long-term substitution (2-21 days; 3-4 months) in a play situation. Six independent, blinded investigators ranked each video according to specifically developed scales concerning motor activity, social interaction, emotionality, and mood with higher scores representing improvements. Short term metreleptin substitution significantly increased mean total score from 17.7 ± 4.1 to 22.6 ± 6.6 (p = 0.039), and mean scores for motor activity (4.1 ± 1.1 to 5.1 ± 1.5, p = 0.023) and social interaction (4.6 ± 1.1 to 6.2 ± 1.7, p = 0.016). After long term substitution means of all four single scales and of total score were even higher than at short-term follow-up. During a treatment pause of 3 months in two children, all four scale scores fell below substitution levels and rose again after restart. Metreleptin substitution improved indices of physical activity and psychological wellbeing in patients with CLD. This suggests that reduced leptin concentrations might be in part responsible for emotional and behavioural changes seen during starvation.

Reproducible target transfer from electroanatomic mapping to radiotherapy planning systems for cardiac radioablation - cross-validation for the RAVENTA trial

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): RAVENTA is part of the EU-Horizon-2020 STOPSTORM project. Background Ventricular arrhythmias are a leading cause of morbidity and mortality in patients with structural heart disease. Non-invasive stereotactic single-fraction arrhythmia radioablation (STAR) with 25 Gy has been proposed as a bail-out strategy in patients where catheter-based ablation is either not feasible or has previously failed to control the arrhythmia. Defining the exact radiotherapy target, however, presents unique challenges, and manual transfer of locations from the electroanatomic map (EAM) into the cardiac CT results in a high degree of uncertainty. Different workflows have been developed to register EAM with the cardiac CT and allow for target definition in EAM space with semi-automated transfer of the target structure to CT coordinates. Validation of these approaches is presently lacking. Here we report the initial cross-validation results of two conceptually different software solutions for target transfer quality assurance in STAR. Methods Clinical case data of patients treated with STAR (EAM data, cardiac CT and screenshots of the map with marked target region) were collected retrospectively from centres participating in the RAdiosurgery for VENtricular TAchycardia (RAVENTA) trial. Two blinded investigators independently created a target volume in the cardiac CT based on the marked target region using either a 3D-3D registration approach (3D Slicer / EAMapReader) or a 2D-3D registration (CARDIO-RT), as described previously. The resulting target structures were analysed in a core lab for overlap and similarity by means of surface distance metrics and conformity. Results Three clinical data sets were analysed, one for each mapping system in widespread clinical use. Agreement between structures created with both approaches was good, with DICE coefficients of 0.88, 0.69 and 0.506 and median surface distances of 0 mm, 1.2 mm and 2.2 mm, respectively. The least agreement was seen in a case where no additional structures were mapped besides the LV, whereas additional anchor points such as the ascending aorta seem to reduce registration ambiguity. Conclusion Using two conceptually different approaches for the target transfer from EAM to cardiac CT we were able to show good agreement between both methods. Both techniques thus can be used for quality assurance and analysis in STAR. Further study in a larger sample of patient data sets is warranted to elucidate differences between transfer methods and predictors for improved registration.

Predictive Value of Cervical Shear Wave Elastography in the Induction of Labor in Late-Term Pregnancy Nulliparous Women: Preliminary Results.

The prediction of induction of labor continues to be a paradigm nowadays. Bishop Score is the traditional widely spread method but with a low reliability. Ultrasound cervical assessment has been proposed as an instrument of measurement. Shear wave elastography (SWE) should be a promising tool in the prediction of the success of labor induction in nulliparous late-term pregnancies. Ninety-two women with nulliparous late-term pregnancies who were going to be induced were included in the study. A shear wave measurement of the cervix divided into six regions (inner, middle and outer in both cervical lips), cervical length and fetal biometry was performed by blinded investigators prior to routine hand cervical assessment (Bishop Score (BS)) and induction of labor. The primary outcome was success of induction. Sixty-three women achieved labor. Nine women did not, and they underwent a cesarean section due to failure to induce labor. SWE was significantly higher in the inner part of the posterior cervix (p < 0.0001). SWE showed an area under the curve (AUC): 0.809 (0.677-0.941) in the inner posterior part. For CL, AUC was 0.816 (0.692-0.984). BS AUC was 0.467 (0.283-0.651). The ICC of inter-observer reproducibility was ≥0.83 in each region of interest (ROI). The cervix elastic gradient seems to be confirmed. The inner part of the posterior cervical lip is the most reliable region to predict induction of labor results in SWE terms. In addition, cervical length seems to be one of the most important procedures in the prediction of induction. Both methods combined could replace the Bishop Score.

Evaluation of the dislodgement force of splinted restorations with engaging conical abutments over multiple nonparallel implants (in-vitro study)

BackgroundSplinted multiunit cement-retained restorations with screw access channels over engaging abutments are viable implant prosthetic options. However, information regarding the maximum degree of divergence between multiple implants is lacking. The purpose of this in vitro study was to determine the maximum degree of divergence between 2 adjacent implants with conical connections that allows insertion and removal of splinted restorations with engaging preparable abutments or titanium base abutments.MethodsTwo implants were aligned in a stone base, one straight and the other at an angle ranging from 0 to 20 degrees. The implants represented an implant system that had an internal conical connection and a hexed abutment engaging the base of the connection. Two straight preparable engaging cement retained abutments were screwed onto the implants and splinted together using acrylic resin. A total of 11 angles were tested, with 7 specimens for every angle. Evaluation of dislodging force was performed by pulling out the splinted abutments after unscrewing them. This was performed subjectively by 3 blinded investigators who applied a tactile pulling force. A scale of 0–10 was used to estimate the pulling force. Objectively the dislodging force was measured in Newtons using a universal testing machine. A statistical correlation was made between the subjective and objective dislodging force values using Spearman’s rank correlation coefficient.ResultsThe mean subjective values increased gradually from 0 to 16 degrees. A sudden rise was noticed at 18 degrees (9.71 ± 0.23) and, at 20 degrees, the investigators were not able to remove the splinted abutments from the implants. The mean objective dislodgement force values increased gradually from 0 to16 degrees and abruptly from 16 degrees (13.57 ± 0.45 N) to 18 degrees (25.40 ± 0.66 N) and 20 degrees (35.22 ± 0.64). The correlation between the subjective and the objective evaluations assessed using the Spearman’s rank correlation coefficient was 0.98 indicating a statistically significant correlation (P < .001). As the objective dislodging force increased, the subjective dislodgement difficulty increased.ConclusionsSplinting cement retained restorations with screw access channels on engaging abutments is possible when multiple implants with conical connections having an internal flare angle of 8 degrees are used, with implant divergence of up to 16 degrees.

Neoclitoral location may affect sexual function in transgender women: a preliminary pelvic MRI study.

Assigned female at birth with anorgasmia possess a smaller clitoral glans and clitoral components farther from the vagina lumen than women with normal orgasmic function. There are no studies evaluating this correlation in operated transgender women. We evaluated whether differences in MRI measurements of neoclitoris volume and distance between the neoclitoris and the neovagina were correlated with differences in sexual function. We recruited for a prospective survey study 40 operated male to female patients (oMtF) who had undergone genital gender affirming surgery and postoperative pelvic MRI. Individual pelvic MRIs were reviewed by two blinded investigators, the three axes of the neoclitoris were measured and the volume was calculated using the ellipsoid formula. The distance between the neoclitoris and the neovagina was also measured. Sexual functioning was assessed using the Female Sexual Function Index (FSFI) and the operated Male to Female Sexual Function Index (oMtFSFI). Mean scores differences in FSFI, oMtFSFI were examined; associations with clitoral size, location, sexual functioning and demographical variables were investigated as well. The response rate was 55%, 11 MtFs operated with pubic neoclitoris technique (PNT) and 11 with neo-urethroclitoroplasty according to Petrović (NCP). The NCP group presented a neoclitoris mean volume of 1.04 (SD 0.39) cc vs 1.31 (SD 0.78) cc of the other group (p = 0.55). The mean distance between neoclitoris and neovagina was 4.20 (SD 0.57) cm in the PNT group and 2.55 (SD 0.45) in the NCP group (p < 0.001). Patients who had undergone NCP achieved a higher FSFI and oMtFSFI mean Total Score than those operated with the previous technique (FSFI 25.81 SD 3.02 vs 18.62 SD 9.92 p = 0.08; oMtFSFI 37.63 SD 8.28 vs 43.36 SD 13.02 p = 0.23). According to pelvic MRI measurements, this study suggests a correlation between neoclitoral location and oMtF sexual satisfaction.

Fetal echocardiographic features associated with bicuspid aortic valve.

Prenatal diagnosis of bicuspid aortic valve is challenging. Bicuspid aortic valve is often associated with aortic dilation. Fetuses with postnatally confirmed bicuspid aortic valve were gestational age-matched with normal controls. Complex lesions were excluded. Aortic valve and arch measurements by two blinded investigators were compared. We identified 27 cases and 27 controls. Estimated fetal weight percentile was lower in cases than controls. Seven cases had one or more significant lesions including perimembranous ventricular septal defects (n = 2), isolated annular hypoplasia (n = 2), and/or arch hypoplasia/coarctation (n = 4). Fetuses with bicuspid aortic valves had significantly smaller median z-scores of the aortic annulus (-1.60 versus -0.53, p < 0.001) and root (-1.10 versus -0.53, p = 0.040), and larger ratios of root to annulus (1.32 versus 1.21, p < 0.001), sinotubular junction to annulus (1.07 versus 0.99, p < 0.001), ascending aorta to annulus (1.29 versus 1.18, p < 0.001), and transverse aorta to annulus (1.04 versus 0.96, p = 0.023). Leaflets were "doming" in 11 cases (41%) and 0 controls (p = 0.010), "thickened" in 10 cases (37%) and 0 controls (p = 0.002). We noted similar findings in the subgroup without significant additional cardiac defects. The appearance of doming or thickened aortic valve leaflets on fetal echocardiogram is associated with bicuspid aortic valve. Compared to controls, fetuses with bicuspid aortic valve had smaller aortic annulus sizes (possibly related to smaller fetal size) without proportionally smaller aortic measurements, resulting in larger aortic dimension to annulus ratios. Despite inherent challenges of diagnosing bicuspid aortic valve prenatally, these findings may increase suspicion and prompt appropriate postnatal follow-up.

Brief Report: Safety and Antitumor Activity of Durvalumab Plus Tremelimumab in Programmed Cell Death-(Ligand)1–Monotherapy Pretreated, Advanced NSCLC: Results From a Phase 1b Clinical Trial

IntroductionAlthough first-line immunotherapy approaches are standard, in patients with non-small cell lung cancer (NSCLC) previously treated with programmed cell death protein-1 or programmed death-(ligand)1 (PD-[L]1) inhibitors, the activity of combined CTLA-4 plus PD-(L)1 inhibition is unknown. This phase 1b study evaluated the safety and efficacy of durvalumab plus tremelimumab in adults with advanced NSCLC who received anti–PD-(L)1 monotherapy as their most recent line of therapy. MethodsPatients with PD-(L)1–relapsed or refractory NSCLC were enrolled between October 25, 2013, and September 17, 2019. Durvalumab 20 mg/kg plus tremelimumab 1 mg/kg was administered intravenously every 4 weeks for four doses, followed by up to nine doses of durvalumab monotherapy every 4 weeks for up to 12 months of treatment or disease progression. Primary end points included safety and objective response rate (ORR) on the basis of Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST v1.1) per blinded independent central review; secondary end points were ORR on the basis of RECIST v1.1 per investigator; duration of response, disease control, and progression-free survival on the basis of RECIST v1.1 per blinded independent central review and investigator; and overall survival. ClinicalTrials.gov identifier: NCT02000947. ResultsPD-(L)1–refractory (n = 38) and PD-(L)1–relapsed (n = 40) patients were treated. The most common treatment-related adverse events were fatigue (26.3%, PD-(L)1–refractory patients) and diarrhea (27.5%, PD-(L)1–relapsed patients). Grade 3 to 4 treatment-related adverse events occurred in 22 patients. Median follow-up duration was 43.6 months for PD-(L)1–refractory patients and 41.2 months for PD-(L)1–relapsed patients. The ORR was 5.3% for PD-(L)1–refractory patients (one complete response, one partial response) and 0% for PD-(L)1–relapsed patients. ConclusionsDurvalumab plus tremelimumab had a manageable safety profile, but the combination did not have efficacy after PD-(L)1 treatment failure.

Establishment of an Intradermal Canine IL-31-Induced Pruritus Model to Evaluate Therapeutic Candidates in Atopic Dermatitis.

Pruritic models in healthy dogs utilizing intravenous administration of interleukin 31 (IL-31) bypass the "natural" itch sensation in AD, which is initiated by pruriceptive primary afferent neurons in the skin. This study aimed to evaluate the immediate/delayed pruritus responses and the pruritic behaviors observed in an intradermal IL-31-induced pruritic model of healthy dogs and the anti-pruritic effect of oclacitinib on said model. In Phase 1, all the dogs were randomized and video-recorded for 300 min after intradermal canine recombinant IL-31 injections (1.75 µg/kg) and vehicle (phosphate-buffered saline) injections. In Phase 2, all the dogs received oral oclacitinib (0.4-0.6 mg/kg, twice daily for 4 consecutive days and once daily on day 5), with the intradermal IL-31 injection performed on day 5. Two blinded investigators reviewed the pruritic behaviors in all the video recordings. Intradermal IL-31 administration to healthy dogs caused a significant increase in the total (p = 0.0052) and local (p = 0.0003) seconds of pruritic behavior compared to the vehicle control. Oral oclacitinib administration significantly reduced the total (p = 0.0011) and local (p = 0.0156) intradermal IL-31-induced pruritic seconds; there was no significant difference in pruritic seconds between the vehicle and oclacitinib within the IL-31 groups. Significant delayed pruritic responses at 150-300 min after IL-31 injections were observed, and intradermal IL-31 failed to induce acute itch (first 30 min). Intradermal injection of IL-31 induces delayed itch responses in dogs that are diminished by the effect of oclacitinib, an oral JAK inhibitor.

AP-452680-1 CLINICAL, ANATOMICAL AND PACING CHARACTERISTICS ASSOCIATED WITH FOLLOW-UP PACING BURDEN OF PROPHYLACTIC PERMANENT PACEMAKER FOR TRANSCATHETER AORTIC VALVE IMPLANTATION PATIENTS

Prophylactic implantation of permanent pacemaker (PPM) prior to transcatheter aortic valve implant (TAVI) is an option for patients at high-risk of atrioventricular block. The long-term follow-up ventricular pacing (VP) burden and associated clinical features of this group are not well known due to pre-existing PPM commonly being excluded by studies assessing TAVI patient outcomes. To identify features associated with longer-term VP in TAVI patients receiving prophylactic PPM. Using our prospectively maintained institutional TAVI database, we identified patients who had a PPM implanted up to 100-days before TAVI (Pre-TAVI), on the TAVI date (Same-day), and up to 30-days after TAVI (Post-TAVI) and evaluated their medical history, clinical parameters and pacing follow-up data up until 31st December 2020. Pre-TAVI patients receiving prophylactic PPM, due to baseline conduction abnormality, also had additional measurement of TAVI implant depth (ID) and membranous septum (MS) length performed by blinded investigators from preprocedural computed tomography (CT) and intraoperative fluoroscopic imaging. Of 681 TAVI procedures, we identified 122 (17.9%) patients (n=79 male; median age 85 [IQR 81-88] years old) who received PPM (including n=47 pre-TAVI), with a total median follow-up after TAVI of 751 days (IQR 323 – 1311). At first PPM check after TAVI (1 day, IQR 1-48 days after TAVI), 32% of patients (34 of 107) had not used VP (<1% burden, “Nil-VP”), with the remaining 73 patients (68% of 107) having used VP (≥1% burden). Nil-VP at first check after TAVI were 6 times more likely to have baseline LBBB (OR 6.79, 95%CI 1.13-40.84, p=.035). At the end of follow-up, there were 27 patients (25% of 107) who did not use VP (<1% burden). Among Pre-TAVI, there were 15 patients with <1% VP burden both before and after TAVI (nil-group), and 13 who had a sudden VP% increase after TAVI (change-group). The nil-group had significantly longer membranous septum ‘MS’ length (5.47 ± 1.7mm vs 2.94 ± 1.28mm, p=.024), shallower implant depth ‘ID’ (1mm [IQR 0-2.5] vs 5mm [IQR 3.5-10], p=.009) and different deltaMSID (4.13 ± 2.50mm vs -3.46 ± 3.69mm p=.007). A quarter of TAVI patients receiving periprocedural PPM did not use VP from their PPM throughout follow-up. The presence of long MS and an intraoperatively measured shallow ID with resultant positive deltaMSID may be features that warrant only periprocedural temporary pacing wire, rather than PPM due to low usage of VP during follow-up.

The NEB-P2ry1 lung-brainstem axis and the control of breathing in a mouse model of bronchopulmonary dysplasia

Breathing control problems, like apnea of prematurity, are a common complication in preterm infants with bronchopulmonary dysplasia (BPD), but the underlying factors remain incompletely understood. A subpopulation of pulmonary vagal afferent nerve fibers (P2ry1+) innervate CO2 and O2 sensitive clusters of lung neuroendocrine cells (neuroepithelial bodies (NEBs)) located along conducting airways. P2ry1 fibers provide direct sensory input to the brainstem and inhibit breathing upon stimulation. NEBs are hyperplastic in BPD infants and may increase activity of inhibitory P2ry1 vagal fibers. Herein, we sought to determine if the NEB-P2ry1 lung-brainstem axis is altered in association with breathing control in BPD. BPD in mice was induced by exposure to chronic neonatal (postnatal day (P) 0-14) hyperoxia (Hx; 70% O2; n=20) or normoxia (Nx; n=17). Consistent with human BPD, Hx caused alveolar simplification supported by a reduction in alveolar density (p&lt;0.05) and alveoli (p&lt;0.05) in P22 H&amp;E-stained lung sections. Hx mice spent more time apneic at P14 and P17 (p&lt;0.05) in room air and acute hypoxia. Overall (main effect), room air minute ventilation (VE) was reduced in HX mice (p&lt;0.05). Further, VE was reduced during acute hypoxia at P14 and P17 (not P21) with an overall reduction of breathing in Hx mice (p&lt;0.05). From a subset of mice (n=4-5/group) VCO2, VO2, and heat production at rest were greater in P21 Hx mice during room air, suggesting the Hx mice were hypoventilating. Immunofluorescent staining of CGRP (hallmark NEB marker), Ki67 (proliferation), and SEZ6L2 (new NEB cell-membrane marker) in Hx and Nx lungs were imaged and analyzed by a blinded investigator. Consistent with clinical findings, Hx mice had hyperplastic NEBs (8.6 ± 0.45 vs 10.7 ± 1.3 cells/NEB; p&lt;0.05) while only 2 of 143 NEBs expressed Ki67, suggesting no proliferation at P22. CGRP co-localized with SEZ6L2 in both Nx and Hx lungs. A subset of mice received intratracheal delivery of 1ug SEZ6L2-Saporin toxin to lesion NEBs and assess their function. 4 days after SEZ-Saporin treatment breathing frequency was elevated by 11% ± 5% in room air and by 7% ± 5% during acute hypoxia but not in PBS-treated, adult mice (n=3/group) suggesting NEBs have a mild inhibitory influence under normal conditions. Lastly, wireless optogenetic stimulation of P2ry1 vagal fibers in unanesthetized adult control mice (n=3) increased room air breathing by 20% ± 1% and drive to breathe by 36% ± 19% compared to pre-stim breathing. Together, our data demonstrate that hyperoxia-induced BPD alters the control of breathing which may in part be mediated via a unique lung-brainstem axis comprised of hyperplastic NEBs causing greater inhibition of excitatory P2ry1 vagal fibers. The NEB-P2ry1 axis may serve as a novel target for improving breathing in BPD. GCM: Advancing Healthier Wisconsin REAC Award, AHA 20CDA35310121; MRH: HL122358; JLG: DK133121, HL134850, and HL084207; JLS: DK133121 This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Left Ventricular Global Longitudinal Strain as a Parameter of Mild Myocardial Dysfunction in Athletes after COVID-19.

Whether symptoms during COVID-19 contribute to impaired left ventricular (LV) function remains unclear. We determine LV global longitudinal strain (GLS) between athletes with a positive COVID-19 test (PCAt) and healthy control athletes (CON) and relate it to symptoms during COVID-19. GLS is determined in four-, two-, and three-chamber views and assessed offline by a blinded investigator in 88 PCAt (35% women) (training at least three times per week/>20 MET) and 52 CONs from the national or state squad (38% women) at a median of two months after COVID-19. The results show that the GLS is significantly lower (GLS -18.53 ± 1.94% vs. -19.94 ± 1.42%, p < 0.001) and diastolic function significantly reduces (E/A 1.54 ± 0.52 vs. 1.66 ± 0.43, p = 0.020; E/E'l 5.74 ± 1.74 vs. 5.22 ± 1.36, p = 0.024) in PCAt. There is no association between GLS and symptoms like resting or exertional dyspnea, palpitations, chest pain or increased resting heart rate. However, there is a trend toward a lower GLS in PCAt with subjectively perceived performance limitation (p =0.054). A significantly lower GLS and diastolic function in PCAt compared with healthy peers may indicate mild myocardial dysfunction after COVID-19. However, the changes are within the normal range, so that clinical relevance is questionable. Further studies on the effect of lower GLS on performance parameters are necessary.