Risk factors for persistent abnormality on chest radiographs at 12-weeks post hospitalisation with PCR confirmed COVID-19.

BACKGROUND: The long-term consequences of COVID-19 remain unclear. There is concern a proportion of patients will progress to develop pulmonary fibrosis. We aimed to assess the temporal change in CXR infiltrates in a cohort of patients following hospitalisation for COVID-19. METHODS: We conducted a single-centre prospective cohort study of patients admitted to University Hospital Southampton with confirmed SARS-CoV2 infection between 20th March and 3rd June 2020. Patients were approached for standard-of-care follow-up 12-weeks after hospitalisation. Inpatient and follow-up CXRs were scored by the assessing clinician for extent of pulmonary infiltrates; 0-4 per lung (Nil = 0, < 25% = 1, 25-50% = 2, 51-75% = 3, > 75% = 4). RESULTS: 101 patients with paired CXRs were included. Demographics: 53% male with a median (IQR) age 53.0 (45-63) years and length of stay 9 (5-17.5) days. The median CXR follow-up interval was 82 (77-86) days with median baseline and follow-up CXR scores of 4.0 (3-5) and 0.0 (0-1) respectively. 32% of patients had persistent CXR abnormality at 12-weeks. In multivariate analysis length of stay (LOS), smoking-status and obesity were identified as independent risk factors for persistent CXR abnormality. Serum LDH was significantly higher at baseline and at follow-up in patients with CXR abnormalities compared to those with resolution. A 5-point composite risk score (1-point each; LOS ≥ 15 days, Level 2/3 admission, LDH > 750 U/L, obesity and smoking-status) strongly predicted risk of persistent radiograph abnormality (0.81). CONCLUSION: Persistent CXR abnormality 12-weeks post COVID-19 was common in this cohort. LOS, obesity, increased serum LDH, and smoking-status were risk factors for radiograph abnormality. These findings require further prospective validation.

Inflammatory phenotyping predicts clinical outcome in COVID-19.

BACKGROUND: The COVID-19 pandemic has led to more than 760,000 deaths worldwide (correct as of 16th August 2020). Studies suggest a hyperinflammatory response is a major cause of disease severity and death. Identitfying COVID-19 patients with hyperinflammation may identify subgroups who could benefit from targeted immunomodulatory treatments. Analysis of cytokine levels at the point of diagnosis of SARS-CoV-2 infection can identify patients at risk of deterioration. METHODS: We used a multiplex cytokine assay to measure serum IL-6, IL-8, TNF, IL-1ß, GM-CSF, IL-10, IL-33 and IFN-γ in 100 hospitalised patients with confirmed COVID-19 at admission to University Hospital Southampton (UK). Demographic, clinical and outcome data were collected for analysis. RESULTS: Age > 70 years was the strongest predictor of death (OR 28, 95% CI 5.94, 139.45). IL-6, IL-8, TNF, IL-1ß and IL-33 were significantly associated with adverse outcome. Clinical parameters were predictive of poor outcome (AUROC 0.71), addition of a combined cytokine panel significantly improved the predictability (AUROC 0.85). In those ≤70 years, IL-33 and TNF were predictive of poor outcome (AUROC 0.83 and 0.84), addition of a combined cytokine panel demonstrated greater predictability of poor outcome than clinical parameters alone (AUROC 0.92 vs 0.77). CONCLUSIONS: A combined cytokine panel improves the accuracy of the predictive value for adverse outcome beyond standard clinical data alone. Identification of specific cytokines may help to stratify patients towards trials of specific immunomodulatory treatments to improve outcomes in COVID-19.

Spatially dependent electromagnetically induced transparency.

Recent years have seen vast progress in the generation and detection of structured light, with potential applications in high capacity optical data storage and continuous variable quantum technologies. Here we measure the transmission of structured light through cold rubidium atoms and observe regions of electromagnetically induced transparency (EIT), using the phase profile as control parameter for the atomic opacity. With q plates we generate a probe beam with azimuthally varying phase and polarization structure, and its right and left circular polarization components provide the probe and control of an EIT transition. We observe an azimuthal modulation of the absorption profile that is dictated by the phase and polarization structure of the probe laser. Conventional EIT systems do not exhibit phase sensitivity. We show, however, that a weak transverse magnetic field closes the EIT transitions, thereby generating phase-dependent dark states which in turn lead to phase-dependent transparency, in agreement with our measurements.

High speed switching between arbitrary spatial light profiles.

Complex images, inscribed into the spatial profile of a laser beam or even a single photon, offer a highly efficient method of data encoding. Here we present a prototype system which can quickly modulate between arbitrary images. We display an array of holograms, each defined by its phase and intensity profile, on a spatial light modulator. The input beam is then steered by an acousto-optic modulator to one of these holograms, where it is converted into the desired light mode. We demonstrate switching between characters within three separate alphabets at a switching rate of up to10 kHz. This rate is limited by our detection system, and we anticipate that the system is capable of far higher rates. Furthermore our system is not limited in efficiency by channel number, making it ideal for quantum communication applications.

Rapid syndromic PCR testing in patients with respiratory tract infections reduces time to results and improves microbial yield.

Lack of rapid and comprehensive microbiological diagnosis in patients with community acquired pneumonia (CAP) hampers appropriate antimicrobial therapy. This study evaluates the real-world performance of the BioFire FilmArray Pneumonia panel plus (FAP plus) and explores the feasibility of evaluation in a randomised controlled trial. Patients presenting to hospital with suspected CAP were recruited in a prospective feasibility study. An induced sputum or an endotracheal aspirate was obtained from all participants. The FAP plus turnaround time (TAT) and microbiological yield were compared with standard diagnostic methods (SDs). 96/104 (92%) enrolled patients had a respiratory tract infection (RTI); 72 CAP and 24 other RTIs. Median TAT was shorter for the FAP plus, compared with in-house PCR (2.6 vs 24.1 h, p < 0.001) and sputum cultures (2.6 vs 57.5 h, p < 0.001). The total microbiological yield by the FAP plus was higher compared to SDs (91% (162/179) vs 55% (99/179), p < 0.0001). Haemophilus influenzae, Streptococcus pneumoniae and influenza A virus were the most frequent pathogens. In conclusion, molecular panel testing in adults with CAP was associated with a significant reduction in time to actionable results and increased microbiological yield. The impact on antibiotic use and patient outcome should be assessed in randomised controlled trials.

Prevention of stress gastritis with tissue preservation solution.

Stress gastritis frequently occurs in association with shock or sepsis. Gastric mucosal ischemia appears to be a key feature in these critically ill patients. The University of Wisconsin cold preservation solution (UWS) is an isoosmolar, nonglucose-based perfusate that minimizes hypothermia-induced cell swelling and prevents intracellular acidosis and oxygen-free radical injury, while providing high energy substrates for donor organs. In a prospective, single-blind study, 18 similar Sprague-Dawley rats were randomly divided to receive only 5 per cent dextrose and water (D5W) (Group 1) or a 50 per cent solution of D5W+UWS (Group 2) for 72 hours. At the end of 72 hours the animals were stressed by the cold-restraint model. The mean number of ulcers for Group 2 was nearly half that of Group 1. Also, Group 2 had a significantly lower mean total ulcer length (P less than 0.005) and ulcer index (P less than 0.05). Most of Group 2 had mild gastritis changes (grade 0 to 1), while more than half of Group 1 had severe gastritis (grade 3). Gastric mucosal pH was similar for both groups. Topically applied UWS appears to reduce the severity and incidence of stress gastritis in this experimental model. Because mucosal pH values were similar, it is thought that UWS may alter the effects of gastric mucosal ischemia at a cellular level.

Occult ankle fracture detected by an ankle effusion on plain radiography: a case report.

Subtle ankle fractures may escape detection on plain radiography. These occult fractures can cause prolonged disability and pain. We present a case of blunt ankle trauma where plain radiography failed to reveal any bony abnormalities. The recognition of an ankle effusion on plain radiographs prompted us to perform a computed tomography (CT) scan of the ankle. The CT scan demonstrated an anterior plafond fracture of the distal tibia, which required surgical fixation. Had the fracture not been identified, our patient would have been treated inappropriately for a ligament sprain. An occult fracture should be suspected if an ankle is grossly swollen after blunt trauma, and plain radiography demonstrates an effusion. In this circumstance, performance of further imaging studies, such as conventional or CT, are advised to rule out an occult ankle fracture.

Percutaneous placement of an implantable arm port through an internal mammary venous pathway: Case report.

Current chemotherapeutic regimens often require long-term central venous access for their administration. Obtaining a durable form of vascular access in patients with recurrent cancer can be a challenge due to direct tumor involvement and prior surgical, chemotherapeutic or radiation therapy. We describe a case of a peripherally inserted access port in a patient with recurrent head and neck cancer, in whom radiation therapy planned for metastatic mediastinal disease prevented placement of a chest port. At the time of port implantation, venography revealed central venous occlusion. Using mediastinal venography, a collateral pathway to the superior vena cava was identified between the left and right internal mammary veins. By employing this technique, an arm port system was successfully navigated through the collateral pathway percutaneously with the tip of the port tubing placed at the cavoatrial junction. This case illustrates technical nuances and emphasizes the importance of thorough venography when attempting to achieve difficult vascular access.

Percutaneous drainage of aortic aneurysm sac abscesses following endovascular aneurysm repair.

PURPOSE: To report preliminary experiences with the treatment of aortic aneurysm sac abscesses following prior endovascular aortic aneurysm repair (EVAR) using computerized tomography (CT)-guided percutaneous drainage. CASE REPORTS: Three patients aged 73 to 78 years with aortic aneurysm sac infections following prior EVAR, 2 of which were associated with aortoduodenal fistula, underwent CT-guided percutaneous drainage and catheter placement. One patient had complete resolution of the aortic aneurysm sac abscess following percutaneous drainage; 1 patient was stabilized to eventual extraanatomic bypass, graft explantation, and fistula repair; and 1 patient was temporized to debridement and fistula repair with endograft preservation. CONCLUSION: CT-guided percutaneous drainage may be a helpful therapy in selected patients for the treatment of aortic aneurysm sac infections following EVAR.

A randomised, partially observer blind, multicentre, head-to-head comparison of a two-dose regimen of Baxter and GlaxoSmithKline H1N1 pandemic vaccines, administered 21 days apart.

OBJECTIVES: To evaluate the immunogenicity of a two-dose schedule of Baxter cell-cultured, non-adjuvanted, whole-virion H1N1 vaccine, and GlaxoSmithKline AS03(A)-adjuvanted split-virion H1N1 vaccine with respect to the EU Committee for Medicinal Products for Human Use (CHMP) and the US Food and Drug Administration (FDA) licensing criteria. DESIGN: An age-stratified, randomised, observer-blind, parallel-group, multicentre controlled trial was carried out in volunteers aged ≥ 18-44, ≥ 45-64 and ≥ 65 years. SETTING: Three teaching hospitals in the UK (Leicester Royal Infirmary, Leicester; Nottingham City Hospital, Nottingham; and Royal Hallamshire Hospital, Sheffield). PARTICIPANTS: Three hundred and forty-seven subjects were identified and randomised to AS03(A)-adjuvanted split-virion H1N1 vaccine or whole-virion (WV) vaccine in age groups [≥ 18-44 years (n = 140), ≥ 45-64 years (n = 136) and ≥ 65 years (n = 71)]. INTERVENTIONS: Vaccine was administered by intramuscular injection into the deltoid muscle of the non-dominant arm. One hundred and seventy-five randomised subjects were allocated AS03(A)-adjuvanted split H1N1 vaccine; one hundred and sixty-nine subjects had a second dose of the same vaccine 21 days later. One hundred and seventy-two subjects were allocated WV vaccine; one hundred and seventy-one subjects had a second dose of the same vaccine 21 days later. Serum samples for antibody measurements were collected on days 0 (before the first vaccination), 7, 14, 21 (before the second vaccination), 28, 35, 42 and 180. Subjects were observed for local and systemic reactions for 30 minutes after each injection, and for the next 7 days they recorded, in self-completed diaries, the severity of solicited local (pain, bruising, erythema and swelling) and systemic symptoms (chills, malaise, muscle aches, nausea and headache), oral temperature and use of analgesic medications. MAIN OUTCOME MEASURES: Vaccine immunogenicity using the CHMP and the FDA licensing criteria. Antibody titres were measured using haemagglutination inhibition (HI) and microneutralisation (MN) assays at baseline and 7, 14 and 21 days after each vaccination and at day 180. The three immunogenicity criteria end points were the seroprotection rate, the seroconversion rate and the mean-fold titre elevation. RESULTS: Both vaccine doses were given in 340 subjects (98%). Data from 680 (99%) of 687 issued diary cards were returned. Sera were obtained from 340 (98.0%), 333 (96.0%), 341 (98.3%), 331 (95.4%), 329 (94.8%) and 332 (95.7%) subjects on days 7, 14, 21, 28, 35 and 42, respectively. Three hundred and forty-six and 345 subjects were included in the safety and immunogenicity analyses, respectively. Prevaccination antibody was detected by HI (titre ≥ 1 : 8) and MN (titre ≥ 1 : 10) in 14% and 31% of subjects, respectively. Among the 298 (85.9%) subjects without baseline antibody on HI assay, a titre of ≥ 1 : 40 (seroprotection) was achieved after a single dose of AS03(A)-adjuvanted vaccine and WV vaccine by day 21 in 93.0% and 65.5%, respectively, of subjects between 18 and 44 years, 76.4% and 36.1% of subjects between 45 and 64 years, and 53.1% and 30.0% of subjects ≥ 65 years. Among all 347 subjects, a titre of ≥ 1 : 40 was achieved after a single dose of AS03(A)-adjuvanted vaccine and WV vaccine by day 21 in 94.0% and 71.4%, respectively, of subjects between 18 and 44 years, 77.3% and 38.8% of subjects between 45 and 64 years, and 51.4% and 32.4% of subjects ≥ 65 years. The age-adjusted odds ratio (OR) for adjuvanted compared with WV vaccine, in terms of seroprotection, was 4.42 [95% confidence interval (CI) 2.63 to 7.44, p < 0.001]. On day 42, among subjects without baseline antibody on HI assay, a titre of ≥ 1 : 40 was achieved after the second dose of AS03(A)-adjuvanted vaccine and WV vaccine by 100% and 67.9%, respectively, of subjects between 18 and 44 years, 89.3% and 41% of subjects between 45 and 64 years, and 76.5% and 34.5% of subjects ≥ 65 years. Among all 347 subjects, a titre of ≥ 1 : 40 was achieved on day 42 after the second dose of AS03(A)-adjuvanted vaccine and WV vaccine in 100% and 73.1%, respectively, of subjects between 18 and 44 years, 90.8% and 43.9% of subjects between 45 and 64 years, and 75.7% and 36.4% of subjects ≥ 65 years. The age-adjusted OR for adjuvanted vaccine compared with WV vaccine, in terms of seroprotection, was 11.21 (95% CI 5.80 to 21.64, p < 0.001). Age-related decline in antibody response occurred after both doses of both vaccines. WV vaccine was associated with fewer local and systemic reactions and lower immune responses than was AS03(A)-adjuvanted vaccine. The most frequent solicited local event was pain, reported by 28% and 76% of subjects after either dose of WV or adjuvanted vaccine, respectively (OR 7.71, 95% CI 4.48 to 13.24, p < 0.0001). The most common systemic event was myalgia, reported by 24% and 49% of subjects after either dose of WV or adjuvanted vaccine (OR 2.99, 95% CI 1.86 to 4.80, p < 0.0001). CONCLUSIONS: AS03(A)-adjuvanted 2009 H1N1 vaccine is more immunogenic and provides greater antigen-sparing capacity than WV 2009 H1N1 vaccine. TRIAL REGISTRATION: Current Controlled Trials ISRCTN92328241. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 14, No. 55. See the HTA programme website for further project information.

Endovascular stenting in superior vena cava syndrome: utility of a through-and-through guidewire technique.

OBJECTIVE: To describe an ancillary technique when a conventional femoral approach to superior vena cava (SVC) stent placement is not feasible because of buckling of balloon catheters or stent-deployment systems during device advancement. PATIENTS AND METHODS: Three patients in whom device advancement across the SVC lesion from a femoral or axillary approach was unsuccessful were managed by accessing the right jugular vein; SVC lesions were crossed from an antegrade direction, and the jugular guidewire was secured at the femoral access site to create a through-and-through guidewire. RESULTS: Countertraction on the through-and-through guidewire during stent placement and dilation permitted unhindered advancement of stent delivery systems and catheters across the SVC. Technical and clinical success was achieved in each patient with relief of SVC syndrome within 24-72 hours. Survival ranged from 26 to 137 days. CONCLUSION: A through-and-through guidewire technique is useful when stenting a highly stenotic or thrombosed SVC in patients with superior vena cava syndrome.

Thrombin injection for treatment of brachial artery pseudoaneurysm at the site of a hemodialysis fistula: report of two patients.

We report two patients with arteriovenous hemodialysis fistulas that were complicated by brachial artery pseudoaneurysms. Each pseudoaneurysm was percutaneously thrombosed with an injection of thrombin, using techniques to prevent escape of thrombin into the native brachial artery. In one patient, an angioplasty balloon was inflated across the neck of the aneurysm during thrombin injection. In the second patient, thrombin was injected during ultrasound-guided compression of the neck of the pseudoaneurysm. Complete thrombosis of each pseudoaneurysm was achieved within 30 sec. No ischemic or embolic events occurred. This technique may be useful in treating pseudoaneurysms of smaller peripheral arteries.

Cine phase-contrast MR to assess portal blood flow in a 10-year-old girl with abdominal aortic coarctation: a case report.

We report the case of a 10-year-old girl with repaired abdominal aortic coarctation in whom chronic mesenteric ischemia was clinically suspected. Cine phase-contrast magnetic resonance (MR) was used to determine the difference between fasting and postprandial portal blood flow. Fasting flow rates in the portal vein were normal. After a meal, blood flow in the portal vein increased 226% over the fasting state, showing normal augmentation. To the best of our knowledge, this is the first application of this technique to a pediatric setting.

Tobacco use among Massachusetts youth: is tobacco control working?

BACKGROUND: This paper examines whether the Massachusetts Tobacco Control Program is affecting the rates of smoking and smokeless tobacco use among Massachusetts' youth. METHODS: School survey data from the Massachusetts Prevalence Study were analyzed to estimate differences between 1993 and 1996 rates of youth cigarette and smokeless tobacco use, attitudes toward smoking, and awareness of cigarette ads and promotions of antismoking messages. RESULTS: Lifetime and Current Smoking rates declined significantly among middle school males, contrasting with stable national trends. Among girls in this age group, Lifetime and Current Smoking did not change significantly. Hispanic middle school students exhibited a significant decline in Lifetime Use. There were no significant changes in Lifetime or Current Smoking rates among high school students. Lifetime use of smokeless tobacco declined among middle school students while Current Use declined among both middle and high school students. Students reported declines in awareness of cigarette ads or promotions and increases in awareness of antismoking messages. CONCLUSIONS: These results provide evidence for cautious optimism regarding the impact of tobacco control, but indicate that these efforts should begin earlier and that additional research is needed to understand and address the problems of tobacco use by girls.

Stent placement of gastroenteric anastomoses formed by magnetic compression.

PURPOSE: To evaluate the use of stents for prolonging the patency of gastroenteric anastomoses (GEA) induced by magnet compression. MATERIALS AND METHODS: Rare earth magnets were inserted perorally and serially in 15 dogs so as to mate across the gastric and jejunal walls. After magnet excretion, the resulting GEA was identified endoscopically, dilated (n = 1), and stented with bare (n = 2) or partially covered (n = 6) flared 10-mm or 12-mm Z stents. The GEA was followed at 2-4-week intervals for patency; malfunctioning shunts were irrigated, or dilated with angioplasty balloons. Gross and histologic examination of the anastomotic tissues was performed in 14 animals. RESULTS: Magnet pairs were excreted in 5-7 days. Of the 19 magnet placements in 15 animals, stent placement was not possible because of early GEA closure (n = 6), failure to locate (n = 2), pancreatic abscess (n = 1), and magnet perforation with peritonitis (n = 1). Estimated duration of GEA patency was 19 days after balloon dilation, 40-64 days with bare Z stents, and 58-147 days (mean, 90 days) with partially covered Z stents. Shunt function was commonly hindered by bezoars. Stent narrowing or occlusion was caused by tissue overgrowth through bare stents (n = 2), between covered stent struts and through partially detached membrane (n = 2). Serious morbidity (n = 2) was due to malpositioned magnets across the pancreas in one animal and gastric perforation in the other. One dog was euthanized because of unsuspected kidney infection. CONCLUSION: Partially covered stents significantly extend the anatomic patency rate of magnetic GEA to 7 weeks or more. Functional patency is frequently impaired by bezoars. Ongoing improvements in covered stent design should provide longer-term GEA patency.

Predictors of long-term patency after femoropopliteal angioplasty: results from the STAR registry.

PURPOSE: To identify variables predictive of long-term patency after femoropopliteal angioplasty. MATERIALS AND METHODS: The primary patency of 219 limbs in 205 patients from a multicenter registry who underwent femoropopliteal angioplasty between January 1, 1992, and December 31, 1994, was prospectively monitored with a combination of angiography, noninvasive hemodynamic testing, and clinical outcome. Patient demographic, angiographic, and hemodynamic variables were examined alone and in combination to determine effect on long-term primary patency. Each limb was graded as Category 1-4 according to the American Heart Association (AHA) criteria for arterial lesions, and differences in outcome for each category were examined. Primary patency and intergroup analysis were determined with use of the Kaplan-Meier method and log-rank test, respectively. Cox proportional hazards models were used to calculate relative risks for predictive variables. RESULTS: Primary patency rates for all limbs (on an intent-to-treat basis) at 12, 24, and 36 months were 87% +/- 3%, 80% +/- 3%, and 69% +/- 5%, respectively. Primary patency at 48 and 60 months was 55% +/- 7%. Poor tibial runoff (single tibial vessel with 50%-99% stenosis or occlusion) was most predictive of occlusion (relative risk 8.5, P <.0001). The presence of diabetes or renal failure was associated with lower long-term patency (relative risk 5.5 and 4.0, P <.0001 and.0002, respectively). Long-term patency was higher with AHA Category 1 lesions (P =.006), and no significant difference in patency was observed between Category 2 and 3 lesions (P =.65). A multivariate Cox proportional hazards model showed only the stratified runoff score and the presence of diabetes to be significant determinants of long-term patency. CONCLUSION: Poor tibial runoff is most predictive of lower long-term patency rates. Diabetes is also independently associated with lower long-term patency rates. The criteria that distinguish Category 2 and 3 lesions do not predict differences in long-term patency, nor do they serve to identify lesions best treated with surgical bypass. This suggests that indications for femoral angioplasty can be extended to include longer and more complex Category 3 lesions.

Vernal pool conservation in connecticut: an assessment and recommendations.

Vernal pools, a variety of ephemeral wetlands, are threatened in many areas of the United States. As habitat fragmentation and degradation increase, some vernal pool amphibian species are declining in numbers. Uneven implementation of state regulations further hampers effective conservation. To prevent further species decline and vernal pool loss, we evaluated alternatives for improving vernal pool conservation. We used transcripts from a recent vernal pool conference, interviews with members of relevant interest groups, and a literature review to determine opportunities for and constraints on improving vernal pool conservation policy. Participants from different interest groups had very diverse views about appropriate protection strategies. We have examined these different perspectives and alternatives and offer policy recommendations on both the state and local level. These recommendations can foster awareness of vernal pools as unique habitats, increase protection of these areas, and expand citizen participation in the vernal pool regulatory process.