Early Volume Research Articles

The Thin Light of Freedom: The Civil War and Emancipation in the Heart of America

The Thin Light of Freedom is the long-awaited sequel to Edward L. Ayers's Bancroft Prize–winning In the Presence of Mine Enemies: The Civil War in the Heart of America, 1859–1863 (2003). The book opens with the Confederate army's invasion of Pennsylvania in July 1863 and concludes with the return of Virginia into the Union in January 1870, reflecting the author's point that “Reconstruction was not the mere aftermath of the Civil War, but the culmination of the fundamental struggles of the Civil War” (p. 281). Like the earlier volume, it centers on two counties in the Great Valley separated by the Mason-Dixon line (Augusta in Virginia and Franklin in Pennsylvania) and is based on the pioneering digital archive Valley of the Shadow, a storehouse of records generated by both communities during the Civil War era. These records include several newspapers, a few fantastically rich personal diaries, and a good amount of government papers. A master storyteller, Ayers weaves from these sources a nuanced, sophisticated, and eminently readable narrative about the upheaval of the 1860s in the lives of individuals and in the life of the nation. The wartime chapters will speak even to readers allergic to military history—though both counties were often focal points of intense military action, Ayers avoids traditional battlefield narratives for a close look at the visceral realities of daily life in a war zone. The Reconstruction chapters depict a reality mostly familiar to specialists, but the author's ability to read the minds of white southerners provides a uniquely intimate look at those who experienced emancipation as a catastrophe and will appeal to anyone with an interest in southern history or in cultures of defeat.

Intravenous fibrinolysis plus endovascular thrombectomy versus direct endovascular thrombectomy for anterior circulation acute ischemic stroke: clinical and infarct volume results

Backgroundendovascular therapy (ET) is the standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). The role of adjunctive intravenous thrombolysis (IVT) in these patients remains unclear. The present study aims to investigate whether IVT followed by ET (CoT, combined therapy) provides additional benefits over direct ET for anterior circulation AIS with LVO.Methodswe achieved a single center retrospective study of patients with AIS caused by anterior circulation LVO, referred to our center between January 2014 and January 2017 and treated with ET. Functional recovery (modified Rankin at 3-months follow-up), recanalization rate (thrombolysis in cerebral infarction [TICI] score) and time, early follow-up brain CT scan infarct volume (EFIV) (for recanalized patients only), symptomatic intracerebral hemorrhage (sICH) and 3-month mortality were the outcomes of interests. Independent predictors of the outcomes were explored with multivariable logistic regression.Results145 subjects were included in the study, of whom 70 underwent direct ET and 75 were treated with CoT. Functional independence at 3-months was more frequent in CoT subjects compared to patients who received direct ET (mRS score 0–1: 48.5% vs 18.6%; P < 0.001. mRS score 0–2: 67.1% vs 37.3%; P < 0.001); CoT patients had also higher first-pass success rate (62.7% vs 38.6%, P < 0.05), higher recanalization rate (84.3% vs 65.3%; P = 0.009) and, in recanalized subjects, smaller EFIV (16.4 ml vs 62.3 ml; P = 0.003). Mortality and intracranial bleeding did not differ between the two groups. In multivariable regression analysis, low baseline NIHSS score (P < 0.05), vessel recanalization (P = 0.05) and CoT (P = 0.03) were independent predictors of favorable outcome at three months.ConclusionsCoT appears more effective than ET alone for anterior circulation AIS with LVO, with similar safety profile.

BNP Levels as a Predictive Marker for Preterm Birth in Women With Hypertensive Disorders in Pregnancy [10A

INTRODUCTION: Few tests are able to determine the risk of preterm birth (PTB) in women with hypertensive disorders in pregnancy. B-type natriuretic peptide (BNP) is a sensitive marker discerning early cardiac dysfunction and volume expansion in these women. The primary purpose of this study is to evaluate BNP levels in pregnant women with hypertensive disorders as a predictor of medically indicated PTB. METHODS: Pregnant women who presented at Touro Infirmary, New Orleans, LA, between April 2015 and May 2017 for hypertension evaluation were eligible for enrollment. BNP values were collected prior to and at delivery. A BNP level of >100 was considered elevated. All obstetrical and neonatal outcomes were recorded. Fisher's test was used to compare the proportion of patients with elevated BNP levels for women with versus without indicated PTB and for women with versus without newborn requiring neonatal intensive care unit (NICU) stay. Neonatal weight and Apgar scores were compared using the Wilcoxon rank sum test. RESULTS: Of 52 women with hypertensive disorders as an indication for PTB, 34.6% had an elevated BNP, as compared to 12.5% of those with hypertensive disorders that delivered at term (p=0.004). Of 41 women whose newborn required NICU stay, 34.2% had an elevated BNP, as compared to 15.4% of those whose newborn did not require NICU stay (p=0.021). Neonatal weight and Apgar scores were not different (p>0.05) for those with elevated maternal BNP levels. CONCLUSION: BNP measurement may be helpful in determining which women with hypertensive disorders are at higher risk for medically indicated PTB.

Outcomes of large vestibular schwannomas following subtotal resection: early post-operative volume regression and facial nerve function.

Subtotal resection (STR) of vestibular schwannoma (VS) tumors remains controversial and little is known regarding post-operative volume changes. Authors retrospective reviewed the medical records from January 1st 2002 toJanuary 1st2018, for all patients who had undergone primary STR of large VS at a single tertiary academic institution. Our series consists of 34 patients with a mean age of 53.9 (median 53; range 21-87) years that had STR of their VS tumor. The mean pre-operative tumor diameter and volume was 3.9cm (median 3.0cm; range 1.6-6.0cm) and 11.7cm3 (median 9.6cm3; range 2.8-44.3cm3), respectively, with a mean extent of resection of 86% (median 90%; range 53-99%). The mean radiographic and clinical follow-up was 40months (range 6-120months) and 51months (range 7-141months), respectively. 85% of patients had optimal House-Brackmann (HB) scores (Grade 1 & 2) immediately post-operatively, and 91% at 1year; 94% of patients had normal (HB 1) at last follow-up. There was significant regression of residual tumor volume at 1year (p = 0.006) and 2years (p = 0.02), but not at 3years (p = 0.08), when compared to the prior year. There was significant regression of size over time, with a mean slope estimate of - 0.70 units per year (p < 0.001). Excellent clinical facial nerve outcomes can be obtained with STR of large VS tumors. Maximal reduction in tumor size occurs at 2-year post-operatively. Thus, in patients undergoing surgery for large VS, STR and a "watch and wait" strategy is a reasonable treatment option that may optimize facial nerve outcomes.

Neuronal Plasticity in the Mushroom-Body Calyx of Bumble Bee Workers During Early Adult Development.

Division of labor among workers is a key feature of social insects and frequently characterized by an age-related transition between tasks, which is accompanied by considerable structural changes in higher brain centers. Bumble bees (Bombus terrestris), in contrast, exhibit a size-related rather than an age-related task allocation, and thus workers may already start foraging at two days of age. We ask how this early behavioral maturation and distinct size variation are represented at the neuronal level and focused our analysis on the mushroom bodies (MBs), brain centers associated with sensory integration, learning and memory. To test for structural neuronal changes related to age, light exposure, and body size, whole-mount brains of age-marked workers were dissected for synapsin immunolabeling. MB calyx volumes, densities, and absolute numbers of olfactory and visual projection neuron (PN) boutons were determined by confocal laser scanning microscopy and three-dimensional image analyses. Dark-reared bumble bee workers showed an early age-related volume increase in olfactory and visual calyx subcompartments together with a decrease in PN-bouton density during the first three days of adult life. A 12:12 h light-dark cycle did not affect structural organization of the MB calyces compared to dark-reared individuals. MB calyx volumes and bouton numbers positively correlated with body size, whereas bouton density was lower in larger workers. We conclude that, in comparison to the closely related honey bees, neuronal maturation in bumble bees is completed at a much earlier stage, suggesting a strong correlation between neuronal maturation time and lifestyle in both species.

Incremental Maxillomandibular Advancement: The Relationship Between Skeletal Advancement and Airway Volume

IntroductionObstructive sleep apnea (OSA) is characterized by repetitive episodes of supra‐laryngeal airway collapse during sleep, causing increased airflow resistance and reduced respiration. Obstruction and reduced volume mainly occurs in the retropalatal (RPS) and/or retroglossal space (RGS). The most effective surgical treatment (save tracheostomy) is maxillomandibular advancement (MMA). During MMA, the skeletal framework is modified, thereby reducing airway collapse upon inspiration. A clear mechanistic understanding of MMA surgery describing airway dimensions and resulting volumetric increases does not yet exist. The primary objective of the study was to define volume changes during incremental MMA. The secondary objective was to measure where maximal airway tissue movement occurs.MethodsAn oral surgeon performed MMA on three fresh cadaveric heads (n=3). The mandible and maxilla were advanced by four implanted distraction devices (KLS Martin Inc.). The devices were bilaterally advanced by 2mm increments to 14mm to encompass the full range of clinical advancements. Computerized tomography (CT) scans, (0.6 mm isotropic, Siemens, O‐arm), were taken at baseline (no advancement) and each advancement level (2, 4, 6, 8, 10, 12, 14mm). For the primary objective, total airway volume and linear anteroposterior (AP) and lateral (LAT) 2D dimensions of the RPS and RGS were analyzed at each incremental advancement using Amira™ (Thermo Fisher Scientific). To address the secondary objective, translation of airway tissues, radiopaque microbeads (800 μm, Ortech) were implanted at borders of the RPS and RGS using a syringe and endoscope and their movement was tracked through each advancement.ResultsDuring incremental MMA, airway volume increased at each increment compared to baseline. For 0–2, 2–4 &amp; 4–6mm, normalized volume increases were incrementally larger with each advancement [mean0–2mm = 20.3 ± 22.8%; mean2–4mm = 34.9 ± 13.8%; mean4–6mm = 62.4 ± 17.2%]. Consistent volumetric increases occurred during the advancements from 6mm to 10mm [mean6–8mm = 50.8 ± 27.0%; mean8–10mm = 45.6 ± 28.7%]. Preliminary analysis (n=1) shows that during early MMA (2mm–6mm), lateral dimensions increased at a greater magnitude compared to later advancements (8–14mm). Microbead migration supports these findings while highlighting airway wall movement.ConclusionWhile volumetric increases occur at each advancement, the greatest relative change occurs at the advancement from 4–6mm. Relative volumetric increases show a consistent increase in airway volume with each incremental advancement throughout 6–10mm. Lateral wall widening is the chief mechanism for early volume change, at advancements between 2–6mm, while AP dimensions are affected at 8–14mm advancements. The relationships between 2D (AP/LAT) changes and 3D (volume) demonstrate that volume change in initial advancements are primarily due to lateral enlargement. Depending on OSA severity, clinicians may exploit these relationships when performing MMA.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Experimental Study on Volume Deformation of Iron Tailing-steel Slag Aggregate Concrete

Utilization in building materials is one of the main technical ideas for realizing large-scale, high added value recycling of industrial solid wastes such as iron tailings and steel slags. It is common to use only iron tailings or steel slags instead of ordinary sands or stones as concrete aggregates, but using them at the same time and combining their performance advantages to improve the mechanical properties and durability of concrete has not yet appeared. Therefore, sands were replaced by iron tailings as fine aggregates and stones were replaced by steel slags as coarse aggregates to prepare iron tailing-steel slag concrete in this research. And the strength, early crack resistance and long-term volume deformation of iron tailing-steel slag concrete were tested. The results show that iron tailings have negative effect on concrete strength when used as fine aggregates and steel slags are beneficial to concrete strength with a small adding amount. In addition, iron tailings with proper adding amount can inhibit the deformation of concrete caused by steel slags, in consequence of which early crack resistance and volume stability of concrete are improved.

The Associations of Early Sport Specialization and Training Volume with Injury Rates in NCAA Division I Athletes

Objectives: Sixty million United States youth ages 6-18 participate in organized athletics, with large increases in both sport participation and specialization in the past two decades. This study seeks to determine whether early specialization in a single sport and high training volume is associated with an increased risk of injury and surgery in NCAA Division I athletes. A secondary aim is to assess whether sport specialization and high training volume is associated with elite athletic status (i.e. being recruited and/or receiving athletic scholarships). Methods: All NCAA Division I athletes at a single institution were sent a voluntary survey by email. Athletes were surveyed regarding demographics, scholarship status, reasons for sport specialization, age of specialization, training volume, and injury/surgical history. A total of 232 out of 652 athletes completed some portion of the survey. 30 surveys were excluded due to incomplete or incorrect survey completion, leaving 202 surveys available for analysis. Injuries were defined as those which precluded sport participation for &gt; 1 week. Early sport specialization was defined as narrowing participation to one primary sport prior to age 14. High training volume was defined as greater than 28 hours per week during pre-high school years. Exclusion criteria included incomplete surveys and individuals less than age 18. Chi-square, Fisher’s Exact, and Mann-Whitney U tests were performed to establish significant differences. Results: Individuals who specialized in their varsity sport prior to age 14 were more likely to report a history of injury (86.9 vs. 74.0%, X = 4.7, p = .03), multiple injuries (64.6 vs. 49.4%, X = 4.2, p = .04), multiple college injuries (17.2 vs. 6.5%, X = 4.5, p = .03), total injuries (2 vs. 1, U = 3035, p = .02), and total time out for injury (15.2 vs. 7.0 weeks, U = 3150, p = .05). Early specializers were more likely to be recruited (92.9 vs. 83.1%, X = 4.1, p = .04) and receive a scholarship in their varsity sport (82.8 vs. 67.5%, X = 5.6, p =.02). Full scholarship athletes were more likely to report multiple surgical injuries (11.7 vs. 3.5%, X = 5.0, p =.03). Those with a scholarships greater than 50% were more likely to report a surgical injury (34.1 vs. 18.3%, X = 6.5, p = .01). Individuals who trained for greater than 28 hours per week in their varsity sport prior to high school were more likely to report multiple injuries (90.0 vs. 56.7%, X = 4.3, p = .04) multiple college injuries (40.0% vs. 14.0%, p = .05), a surgical injury (60.0 vs. 21.7%, p = .01), multiple surgical injuries (30.0 vs. 4.5%, p = .02), and greater total time out for injury (36.5 vs. 11.0 weeks, U = 424, p = .02). Individuals with a pre-high school training volume greater than 28 hours/week in their varsity sport were not more likely to be recruited (90.0 vs. 89.8%, p = 1.0) or receive a scholarship (80.0 vs. 74.5%, p = 1.0). Those in non-contact varsity sports were more likely to report multiple college injuries than those in limited and full contact sports, respectively (20.4 vs. 6.4 vs. 8.8%, X = 7.0, p = .03). Those in individual sports were more likely to report a college injury (55.3 vs. 38.9%, X = 5.1, p = .02) and multiple college injuries (25.0 vs. 7.1%, X = 12.7, p &amp;lt .001). Conclusion: NCAA Division I athletes who specialized in their varsity sport prior to age 14 were more likely to be recruited and receive an athletic scholarship. However, these individuals, as well as those with high training volume prior to high school, had increased rates of injury and injuries requiring surgery.

Association between Delayed Lactogenesis Ⅱ and Early Milk Volume among Mothers of Preterm Infants

PurposeThis study aimed to evaluate the effect of delayed lactogenesis Ⅱ on early milk volume in mothers expressing milk for their preterm infants. Methods142 mothers with preterm infants participated in a longitudinal cohort study, the milk volumes over 14 days postpartum between mothers with delayed lactogenesis Ⅱ (≥ 72 hours) and mothers with non-delayed lactogenesis Ⅱ(< 72 hours) were compared using Wilcoxon's rank sum tests. ResultsThe prevalence of delayed lactogenesisⅡ among mothers of preterm infants was 36.0% (36/100). There existed negative correlations between the onset of lactogenesis Ⅱ and the daily milk volumes( rs = −0.525∼−0.354, p = .002 ∼ p < .001). The milk volumes in every 24-hour of the 14 days postpartum in delayed group were significantly less than that in non-delayed group (p = .002 ∼ p < .001). After controlling for the covariates, pregnancy-induced hypertension syndrome, delayed expression initiation, shorter daily sleeping time were found to be the risk factors for delayed lactogenesis Ⅱ. ConclusionDelayed lactogenesis Ⅱ was associated with lower milk volume in early postpartum period. Women who were at risk for delayed lactogenesis Ⅱ need targeted interventions and additional support during pregnancy and postpartum.

Abstract P4-01-21: Multiplexed targeted digital sequencing of circulating tumor DNA to detect minimal residual disease in early and locally advanced breast cancer

Abstract Background: Circulating tumor DNA (ctDNA) analysis holds potential for minimal residual disease (MRD) detection in early stage breast cancer. However, sensitivity for MRD is limited due to low ctDNA levels in early stage patients and limited blood volumes. Loss of input DNA during library preparation, limited multiplexing or low sensitivity of current molecular methods further limit accuracy. To address this gap, we have developed TARgeted DIgital Sequencing (TARDIS), a novel method for simultaneous analysis of multiple patient-specific mutations in plasma DNA. Methods: Using tumor exome sequencing, we identify and prioritize somatic founder mutations, design nested primers and evaluate them for multiplex performance. Using 5-10 ng input plasma DNA, we perform 1) targeted linear pre-amplification to improve downstream molecular conversion, 2) single-stranded adapter ligation to incorporate unique molecular identifiers (UMIs) and 3) targeted PCR to prepare sequencing-ready libraries. The resulting sequencing reads have fixed target-specific ends and variable ligation ends. We utilize fragment size and UMIs to group sequencing reads into read families. To ensure specificity, we require targeted mutations are supported by 2 or more read families. Results: To assess analytical performance, we targeted 8 mutations in cell-free DNA reference samples with 0.25%-2% mutation allele fractions (AFs). Precision across 7-16 replicates at each AF level agreed with expectations of Poisson distribution, demonstrating effective analysis of ˜70% of input DNA. At 2%, 1%, 0.5% and 0.25% AFs, variant-level sensitivity was 96.4%, 96.4%, 91.1% and 65.8%, approaching the theoretical limit given input DNA. At 0.25% AF, 3-7 mutations were detected per sample, achieving 100% sample-level sensitivity. In 16 wild-type replicates, no targeted mutations were called (100% specificity). Averaging multiple mutations improved precision in sample-level AF estimates. Mean AFs from 8 mutations for the 2% sample were 2.34%-2.80% (5.8% CV). In 6 patients with breast cancer treated with neoadjuvant therapy (NAT), we analyzed 8-18 patient-specific mutations (mean 11.8). Before treatment, ctDNA was detected in 5/6 patients at mean AFs of 0.02%-1.19% (mean 0.40%), supported by 2-10 mutations (mean 5.6). Of these 5 patients, 4 had residual disease after NAT and ctDNA was detected pre-operatively or during NAT in 3/4 patients. 1 patient achieved pathological Complete Response and ctDNA was undetectable after NAT. Conclusions: Preliminary results suggest TARDIS enables accurate MRD detection after neoadjuvant therapy in patients with early stage breast cancer. On-going work is expanding this analysis to include additional patients and investigate the clinical validity of peri-operative ctDNA monitoring. Summary of clinical resultsPatientPre-NAT Stage (TNM)SubtypeNo. of Mutations TargetedBaseline ctDNA (AF%, No. of Mutations)ctDNA after or during NAT (AF%, No. of Mutations)Residual Tumor (TNM)1T3 N1ER+ PR+ HER2-8+ (0.02%, 2)-T2 N12T3 N0TNBC12+ (0.29%, 6)+ (0.01%, 1)T1a N03T2 N1TNBC18+ (1.19%, 10)+ (0.01%, 1)T1mi N04T3 N1TNBC10+ (0.02%, 3)+ (0.05%, 3)T3 N15T2 N0TNBC9+ (0.46%, 7)-pathCR6T1c N1TNBC14--pathCR Citation Format: McDonald BR, Contente-Cuomo T, Sammut S-J, Ernst B, Odenheimer-Bergman A, Perdigones N, Chin S-F, Farooq M, Cronin PA, Anderson KS, Kosiorek H, Northfelt D, McCullough A, Patel B, Caldas C, Pockaj B, Murtaza M. Multiplexed targeted digital sequencing of circulating tumor DNA to detect minimal residual disease in early and locally advanced breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-01-21.

Abstract WP61: Union of Ischemic Core and Hypoperfusion Volume Correlates With 24-hour Infarct Size in DEFUSE 3

Background and Purpose: Accurate prediction of 24-hour infarct volume early after stroke onset helps determine appropriate interventions and prognosis. In the Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke (DEFUSE 3) trial, we evaluated the accuracy of early ischemic core and hypoperfusion volumes for predicting infarct volume 24 hours after randomization to endovascular thrombectomy vs. medical management. We also assessed if the volume of persistent hypoperfusion at 24 hours predicts infarct volume. Methods: Patients in DEFUSE 3 with CT or MRI DWI/perfusion imaging acquired at baseline and at 24 hours after randomization were included. Ischemic core and Tmax&gt;6s hypoperfusion volumes at baseline and 24 hours were calculated using RAPID software and compared with the 24-hour infarct volumes. Patients were stratified by reperfusion status for analyses. Results: Of 125 eligible patients, 59 patients with &gt;90% reperfusion had a strong correlation between baseline ischemic core volumes and 24-hour infarct volume (r = 0.83; p &lt; 0.0001), and 14 patients with &lt;10% reperfusion had a strong correlation between baseline Tmax&gt;6s volume and 24-hour infarct volume (r = 0.77; p &lt; 0.001). In the 52 patients with 10-90% reperfusion, as well as in all 125 patients, the union of the baseline ischemic core and the Tmax&gt;6s perfusion volume at 24 hours was highly correlated with 24-hour infarct volume (for N=125, r = 0.83; p &lt; 0.0001), with a median absolute difference of 21.3 ml between observed and predicted infarct volumes. Conclusions: The union of the irreversibly injured ischemic core and critically hypoperfused tissue volumes, as identified by CT perfusion or MR DWI/perfusion, predicted infarct volume at 24 hours in DEFUSE 3 patients. Clinical Trial Registration - URL: http://www.clinicaltrials.gov. Unique identifier: NCT02586415

The Swan Maiden by Raymond H. Thompson

Reviewed by: The Swan Maiden by Raymond H. Thompson Norris J. Lacy raymond h. thompson, The Swan Maiden. Series: The Striking Hawk, vol. 7. A Blue Dragon/Dragonfly Book, 2017. Pp. 506. isbn: 1973935694. $18.75. In addition to his distinguished scholarly contributions to Arthurian studies, Raymond Thompson is the author of seven science fiction novels constituting a cycle titled The Striking Hawk. Only the most recent contribution, The Swan Maiden, is published on paper between covers. The earlier volumes are available in electronic editions at very modest cost. The previous novels are Project Excalibur (2014), The Sword in the Stone (2015), Grail (2015), The Wild Hunt (2016), The Blue Dragon (2016), and The Grand Tournament (2016). All are Blue Dragon / Dragonfly books. The central character (or at least the usual center of consciousness) of this novel is Rory Maelduin, who is surrounded by an astonishing cast. There are his wife (Heather Sheridan), his children, grandchildren, adopted and foster children, and a cast—literally—of thousands. Incidentally, the first volume of the cycle, Project Excalibur, explains Maelduin’s involvement in these adventures. He is recruited because he is a retired Canadian professor of medieval literature, specifically an expert in things Arthurian and, especially, in the Merlin story. (A hint of autobiography, perhaps.) The titles of Thompson’s previous novels firmly establish the Arthurianism of the series, but readers of The Swan Maiden must exercise some patience in order to comprehend fully its Arthur/Grail character. The two main adult characters are Rory and Heather—hardly traditional Arthurian names. The novel offers a complex series of adventures pitting Rory and his friends and allies against various enemies, the goal being to break a geis placed on a remarkable young girl named Elise. As is often the case with Arthurian narratives, there are three primary challenges, and ultimately, after many peregrinations and adventures, Rory et al. are successful, an outcome we never doubted. The geis is broken, and Elise is accepted as a member of Maelduin’s family. But what about all of this is Arthurian, other than the geis and, conceivably, the three goals to be accomplished through various adventures? In fact, for a time this connection is indicated mainly by a number of Arthurian names and frequent passing references to the Grail Lance (p. 27 and passim), the Castle Perilous (p. 30), and other familiar motifs. Any number of times, we find observations about characteristics of [End Page 164] Arthurian legend; for example, ‘Knights of the Round Table were always wandering all over the place in search of adventure. They were easily distracted’ (p. 337). (And earlier, near the end of volume 3 [Grail], Thompson had offered us a quite faithful account of the traditional Grail ceremony.) Concerning names, the son-in-law of Maelduin is Gawain, and Arthurian or near-Arthurian names are frequent. Maelduin’s extended family includes, for example, twins Owein and Morag; a girl Rhiannon; and a major figure, perhaps surprisingly, Lohengrin, a youth whose duties as the champion of Elise are a single aspect of the obvious attraction that each feels for the other. (The author’s note concluding the volume [p. 505] points out correctly that Arthurian compositions regularly imported characters and names from other texts or traditions, and Lohengrin should not materially disorient us. In addition, Thompson reminds readers that the Swan Maiden herself is not attached—except here—to Arthurian legend.) But there is much more. It happens that Maelduin is an avatar of Merlin, and he, like many other characters, has shape-shifting powers: he is often a merlin, the bird suggested by his Arthurian name. Among his allies and adversaries are dragons, dragonflies, selkies, dolphins, iguanas, slugs, and other life forms, and many of those are able to converse together and modify their shapes. We learn, for example, that dragonflies can become hornets, and dragons transform to parrots (p. 252) and other birds. And of course Elise is the Swan Maiden, who, despite her youth and relative inexperience, is able to transform herself into a swan. One of the most striking shape-shifters is the Prydwen, ‘ . . . a Grail vessel capable of traveling between worlds’ (p. 55). The ship, traditionally Arthur...

Impact of Left Bundle Branch Block on Left Atrial Dyssynchrony and Its Relationship to Left Ventricular Diastolic Function in Patients with Heart Failure and Dilated Cardiomyopathy.

Background and ObjectivesThe impact of left bundle branch block (LBBB) on left atrial (LA) dyssynchrony in heart failure (HF) patients with non-ischemic dilated cardiomyopathy (DCM) has not been clearly elucidated.MethodsEighty consecutive symptomatic HF patients with non-ischemic DCM (left ventricular ejection fraction, LVEF<35%) were included. LBBB was defined on electrocardiography. Left ventricular (LV) systolic and diastolic dyssynchrony index and LA dyssynchrony index were obtained by color-coded tissue Doppler imaging.ResultsThere was no significant difference in LV size, LVEF, LV global longitudinal strain, peak atrial longitudinal strain and LA volume between patients with LBBB (n=38) and no LBBB (n=42). There was a significant difference in LV systolic dyssynchrony index (p=0.014) and there was a mild difference in LV diastolic synchronicity index (p=0.045) between patients with LBBB and no LBBB. However, there was no difference in LA dyssynchrony index between the 2 groups (p=0.60). LA dyssynchrony index was not related to LV systolic and diastolic dyssynchrony indexes, but it was related to the deceleration time of mitral early diastolic velocity (E), the ratio of E to mitral annular early diastolic velocity (E/e′) and LA volume. E/e′ was most related to LA dyssynchrony index (r2=0.325, p=0.002).ConclusionsLBBB influences both LV systolic and diastolic dyssynchrony, but not LA dyssynchrony. LA dyssynchrony was related to LV diastolic function regardless of the presence of LBBB in in patients with non-ischemic DCM.

Pre-clinical study protocol: Blood transfusion in endotoxaemic shock

The Surviving Sepsis Campaign (SCC) and the American College of Critical Care Medicine (ACCM) guidelines recommend blood transfusion in sepsis when the haemoglobin concentration drops below 7.0 g/dL and 10.0 g/dL respectively, while the World Health Organisation (WHO) guideline recommends transfusion in septic shock ‘if intravenous (IV) fluids do not maintain adequate circulation’, as a supportive measure of last resort. Volume expansion using crystalloid and colloid fluid boluses for haemodynamic resuscitation in severe illness/sepsis, has been associated with adverse outcomes in recent literature. However, the volume expansion effect(s) following blood transfusion for haemodynamic circulatory support, in severe illness remain unclear with most previous studies having focused on evaluating effects of either different RBC storage durations (short versus long duration) or haemoglobin thresholds (low versus high threshold) pre-transfusion.•We describe the protocol for a pre-clinical randomised controlled trial designed to examine haemodynamic effect(s) of early volume expansion using packed RBCs (PRBCs) transfusion (before any crystalloids or colloids) in a validated ovine-model of hyperdynamic endotoxaemic shock.•Additional exploration of mechanisms underlying any physiological, haemodynamic, haematological, immunologic and tissue specific-effects of blood transfusion will be undertaken including comparison of effects of short (≤5 days) versus long (≥30 days) storage duration of PRBCs prior to transfusion.

First trimester 3D ultrasound placental volume for predicting preeclampsia and/or intrauterine growth restriction

The objective of the study was to determine the sensitivity of the placental volume for predicting preeclampsia and/or intrauterine growth restriction (IUGR) in the first trimester. A prospective observational study was conducted in pregnant women with a gestational age of 11 to 13+6 weeks. A 3 D transabdominal placental volume measurement was performed at the time of first-trimester aneuploidy screening. The predictive values of this test were calculated. The data from 360 pregnant women was analysed. Seventeen cases developed preeclampsia and/or IUGR. The 10th percentile of placental volume was used as the cut-off level. The sensitivity, specificity, positive predictive value and negative predictive value of placental volume less than the 10th percentile for prediction of preeclampsia and/or IUGR were 23.5%, 90.7%, 11.1% and 96%, respectively. The sensitivity, specificity, positive predictive value and negative predictive value for prediction of early onset preeclampsia were 50%, 90.7%, 3.0% and 99.7%, respectively. This study demonstrated that the placental volume was lower in the cases with preeclampsia and/or IUGR. It was not an effective screening tool for preeclampsia and/or IUGR in the first trimester.IMPACT STATEMENTWhat is already known on this subject? Placental volume may reflect trophoblast invasion, but much earlier, in the first trimester. The estimation of a smaller early placental volume has been shown to be significantly associated with preeclampsia and IUGR.What do the results of this study add? The placental volume was lower in the cases with preeclampsia and/or IUGR. It was not an effective screening tool for preeclampsia and/or IUGR in the first trimester. But it might be used for predicting early onset preeclampsia.What are the implications of these findings for clinical practice and/or further research? Further research of placental volume in the first trimester for predicting an early onset preeclampsia should be conducted.

1049: Fully automated placental volume quantification from 3DUS for prediction of small-for-gestational age infants

Early placental volume (PV) is associated with small-for-gestational age infants born under the 10thor 5thcentiles (SGA10 and SGA5). However, 3DUS requires time-intensive, manual or semi-automated segmentation. For PV to become useful in a clinical setting, a fully automated segmentation method is needed. 3DUS images obtained at 11-14 weeks were put through our novel, fully automated pipeline (Figure 1), which starts by training a convolutional neural network (CNN) from a disjoint set of 47 manually annotated 3DUS images. This model is used to segment the study images. The results are fed into a joint label fusion (JLF) step as initialization. The results are combined via a second-tier random forest (RF) model to obtain final segmentations. Fig. 1b shows typical segmentation results. The study images were also segmented using the semi-automated VOCAL (GE Healthcare) method. The PV obtained with either method was used to train a logistic regression classifier for SGA10 and SGA5 outcomes. We either use the raw PV, or the normalized placental quotient (PQ=PV/gestational age at the time of US). A 5-fold stratified cross-validation setup is used, with 10 different seeds per fold. 341 subjects were included, with 35 (10.3%) and 19 (5.6%) delivering SGA10 and SGA5 infants, respectively. The mean gestational age at delivery was 39±1.7wks. There was a high correlation between the PV values obtained by each method (R2=0.78); although the mean PV was lower for VOCAL compared to CNN/JLF (66.2±18.1cc vs. 81.3± 21.2cc; p<1e-5), consistent with our prior observation that VOCAL underestimates PV. Figure 2 shows the ROC curves for predicting SGA10 and SGA5 outcomes with our CNN/JLF method and with VOCAL, averaged over the folds. The differences in AUC did not reach statistical significance. Our fully automated segmentation method successfully yields PV measurements at 11-14 weeks that are significantly associated with SGA, but with no manual user input required. This paves the way for exploring such a tool in a clinical setting as part of a multivariable prediction model for risk stratification and patient counseling. Moreover, it can allow a more rigorous investigation of placental shape and morphometry as potentially relevant markers of placental development.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Can SCUBE1 be used to predict the early diagnosis, lesion volume and prognosis of acute ischemic stroke?

Abstract Objective SCUBE1 [signal peptide-CUB (complement C1r/C1 s)-EGF (epidermal growth factor)-like domain-containing protein 1] is a novel biochemical marker. SCUBE1 is thought to play roles both in platelet activation and inflammation, which are important stages for the development of acute ischemic stroke (AIS).The purpose of our study was to determine the diagnostic and prognostic values and temporal change of plasma SCUBE1 levels in AIS patients. Materials and methods Thirty-five patients diagnosed with AIS at the Cumhuriyet University Faculty of Medicine Neurology Department, between June and December 2017, and a control group of 35 healthy volunteers were included. Results Median first day SCUBE1 value in the patient group was 97.51 ng/mL, and the median 7th day SCUBE1 value was 32.72 ng/mL. Median control group SCUBE1 value was 27.51 ng/mL. The first day SCUBE1 levels were significantly higher than the 7th day and the control group SCUBE1 levels (p=0.001, p&lt;0.001, respectively). The ROC analysis showed that SCUBE1 levels above 68.8 ng/mL can be used as an indicator with high sensitivity and specificity for AIS diagnosis. Multivariate analysis revealed that the first day SCUBE1 had significant independent effects on development of AIS. In correlation analysis, plasma SCUBE1 levels showed a significantly positive correlation with lesion volume, NIHSS and MRS values (p&lt;0.01). Conclusion First day plasma SCUBE1 values in AIS patients rised at significant levels compared to the control group. SCUBE1 could use both in the early diagnosis and prediction of prognosis and lesion volume of AIS patients.

1098. Clinical Features and Outcomes of United States Marine Corps Recruits Hospitalized With Shiga Toxin-Producing Escherichia coli Infection and Hemolytic–Uremic Syndrome

BackgroundShiga toxin-producing Escherichia coli (STEC) is associated with potentially life-threatening dysentery, along with its most feared complication, the hemolytic–uremic syndrome (HUS), occurring in up to 20% of STEC-infected patients. 10–30% of patients may experience chronic renovascular and neurologic sequelae after acute resolution. We describe clinical features and outcomes of a young, male military recruit population hospitalized for STEC infection and HUS in 2017.MethodsBetween October and November 2017, an STEC outbreak occurred at Marine Corps Recruit Depot San Diego (MCRD-SD) affecting 244 recruits, including 30 who required hospitalization. Polymerase chain reaction and pulsed-field gel electrophoresis of stool culture isolates demonstrated stx2-positive E. coli O157:H7. Thirty recruits required hospitalization; the remaining 214 underwent daily clinical evaluation and laboratory testing at MCRD with daily crystalloid volume expansion until the resolution of dysentery.Results50% (15/30) of hospitalized recruits developed HUS and were initially managed with volume expansion until the onset of oliguria. Five recruits with severe HUS required hemodialysis; six required intensive critical care unit (ICU) admission; and three suffered from respiratory failure requiring mechanical ventilation. Average length of hospitalization was 10 days. Patients requiring hemodialysis received an average 7.4 days of renal replacement. Three patients experienced encephalopathy with seizures and were managed with levetiracetam and corticosteroids for Stx-induced cerebral edema. One patient received eculizumab, a terminal complement inhibitor approved for atypical HUS, with resolution of seizures and return to his neurocognitive baseline but with persistent electroencephalographic abnormalities. There were no deaths, and all recruits had recovery of renal function.ConclusionThis case series represents the largest STEC-HUS outbreak affecting a military population. Rates of HUS and mortality were lower than seen in prior outbreaks, in part due to a high level of baseline health and early detection and management of suspect cases. Early volume expansion and close monitoring of cases may have reduced the risk for HUS progression and long-term renal sequelae.Disclosures All authors: No reported disclosures.

Aggressive Resuscitation Is Associated with the Development of Acute Kidney Injury in Acute Pancreatitis.

The association between early resuscitation volume and clinical outcomes remains controversial in acute pancreatitis. In the present study, we aimed to identify the association between resuscitation volume and the development of acute kidney injury (AKI) and other clinical outcome metrics. Patients admitted to our center with moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP) from January 2009 to December 2013 were reviewed retrospectively. Patients were stratified into two groups on the basis of the volume of fluid infused during the first 24h. The primary clinical endpoint was incidence of AKI. Moreover, AKI lasting time, utilization of continuous renal replacement therapy and lasting time, creatinine increase, and other clinical metrics were also compared. The potential risk factors of new-onset AKI were also analyzed. A total of 179 patients were included, and aggressive fluid resuscitation (≥ 4l) was associated with increased incidence of AKI compared with nonaggressive group (53.12% vs. 25.64%, p = 0.008), longer AKI lasting time (p = 0.038), and increased creatinine increase (p < 0.001) during hospitalization. Moreover, utilization of continuous renal replacement therapy was more frequent in aggressive group (40.63% vs. 24.36%, p = 0.108), and the lasting time of continuous renal replacement therapy was also longer (p = 0.181), though both not statistically different. Moreover, in multivariate analysis, aggressive resuscitation [OR 4.36 (1.52-13.62); p = 0.001] and chloride exposure [OR 2.53 (1.26-5.21); p = 0.012] in the first 24h were risk factors of new-onset AKI. In patients with MSAP and SAP, aggressive fluid resuscitation was associated with increased incidence and longer duration of AKI. Moreover, aggressive resuscitation and chloride exposure in the first 24h were risk factors of new-onset AKI.

105. An interesting case of relation between placenta volume, uterine artery PI in early pregnancy and the prognosis of pregnancy

Objective We reported an association between placenta volume in early pregnancy and birth weight. We report our experience with an interesting case to support it. Methods During pregnancy 11–14 weeks, the placenta volume was measured using Vocal mode manual trace of Voluson730/E8. The index of the placenta volume is PQ (placental quotient: placental volume/crow-rump length, normal 0.997 ) The normal of the PQ was measured from 270 cases that we experienced in our department. Results Case is in 34 years old, first pregnancy was established by timing. She was admitted because of hypertensive disorder of pregnancy from pregnancy 24 weeks, in 26–3 weeks her fetus was death intra-uterine, and it was delivered in 564 g (−2.6SD) girl. PQ was 0.632 at 11–2 weeks, UA-PI was 1.21 in pregnancy 20 weeks. Second pregnancy, 37 years old, pregnancy was established in IVF-ET, and she was delivery by a cesarean section because of breech presentation 2,498 g (−0.7SD) boy in 37–0 weeks. PQ was 1.076 at 11–5 weeks, PQ was 0.851 at 13–5 weeks, UA-PI in pregnancy 20 weeks was 0.41. Third pregnancy was established spontaneously, 38 years old. She was admitted because of FGR from pregnancy 30 weeks. An emergency cesarean section was performed due to delivery progressed in 32–2 weeks 1,038 g (−3.1SD) girl. PQ was 0.547 in 12–4 weeks, PQ was 0.412 in 14–4 weeks, UA-PI was 0.39 in pregnancy 20 weeks. Discussions We experienced 1 case 3 delivery to suggest to relation betweeen an early placenta volume, UA-PI and the birth weight. The case that a placenta volume in early pregnancy was small and UA-PI was high needed management as a high risk of FGR and hypertensive disorder in pregnancy.