Comparisons of Sustainability Behaviors Pre- and Early Pandemic Among Botanical Garden Members

The COVID-19 outbreak drastically altered the behaviors of millions of Americans in 2020, including behaviors that contribute to carbon emissions. As many Americans stayed home midyear, environmental groups noted the decrease in driving and transportation-related pollution, theorizing that the pandemic could have a positive impact on the environment by decreasing individuals' carbon emissions. However, it is dubious that individuals will behave in a more eco-friendly manner under the uncertain and stressful conditions of a global pandemic simply because they are more likely to be confined to their homes. We examined sustainability behaviors in 2018 and in the early pandemic in 2020 among a sample of members of a U.S., botanical garden. We surveyed members in May–July 2018, asking whether they had or had not done 11 sustainability behaviors (e.g., used alternative transportation, took shorter showers) in the past month. We resurveyed members about their engagement in those behaviors in April 2020 as well as to recall their engagement in those behaviors pre-pandemic in February 2020. We examined differences in self-reported behaviors among respondents who had taken both the May–July 2018 and April 2020 surveys (matched group n = 227), and then among respondents who had taken either the May–July (n = 1057) or the April 2020 survey (n = 881), but not both. Respondents in the matched group were more likely to report recycling, reducing red meat consumption, eating a plant-based diet, and reducing food waste in April 2020 compared to May–July 2018; they were less likely to compost, check the air in their tires, and use a smart thermostat. However, these differences also emerged when examining recalled behavior in February 2020, suggesting that matched group respondents' self-reports may reflect changes in behavior over time rather than due to the pandemic. The unmatched group was more likely to reduce food waste but less likely to use alternative transportation to commute, check the air in their tires for fuel efficiency, and recycle in April 2020 compared to May–July 2018. Thus, few changes in sustainability behaviors can be attributed to the pandemic, but those that do involve personal travel or home confinement.

The Effect of Sex-Mismatched Red Blood Cell Transfusion on Endothelial Cell Activation in Critically Ill Patients

<b><i>Background:</i></b> Observational studies suggest that sex-mismatched transfusion is associated with increased mortality. Mechanisms driving mortality are not known but may include endothelial activation. The aim of this study is to investigate the effects of sex-mismatched red blood cell (RBC) transfusions on endothelial cell activation markers in critically ill patients. <b><i>Study Design and Methods:</i></b> In patients admitted to the intensive care unit who received a single RBC unit, blood samples were drawn before (T₀), 1 h after (T₁), and 24 h after transfusion (T₂₄) for analysis of soluble syndecan-1, soluble intercellular adhesion molecule-1, soluble thrombomodulin (sTM), von Willebrand factor antigen, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNFα). Changes in the levels of these factors were compared between sex-matched and sex-mismatched groups. <b><i>Results:</i></b> Of 69 included patients, 32 patients were in the sex-matched and 37 patients were in the sex-mismatched group. Compared to baseline, sex-matched transfusion was associated with significant reduction in sTM level (<i>p</i> value = 0.03). Between-group comparison showed that levels of syndecan-1 and sTM were significantly higher in the sex-mismatched group compared to the sex-matched group at T₂₄ (<i>p</i> value = 0.04 and 0.01, respectively). Also, TNFα and IL-6 levels showed a statistically marginal significant increase compared to baseline in the sex-mismatched group at T₂₄ (<i>p</i> value = 0.06 and 0.05, respectively), but not in the sex-matched group. <b><i>Discussion:</i></b> Transfusion of a single sex-mismatched RBC unit was associated with higher syndecan-1 and sTM levels compared to transfusion of sex-matched RBC unit. These findings may suggest that sex-mismatched RBC transfusion is associated with endothelial activation.

A Two-Minute Walking Test With a Smartphone App for Persons With Multiple Sclerosis: Validation Study

Background Walking disturbances are a common dysfunction in persons with multiple sclerosis (MS). The 2-Minute Walking Test (2MWT) is widely used to quantify walking speed. We implemented a smartphone-based 2MWT (s2MWT) in MS sherpa, an app for persons with MS. When performing the s2MWT, users of the app are instructed to walk as fast as safely possible for 2 minutes in the open air, while the app records their movement and calculates the distance walked. Objective The aim of this study is to investigate the concurrent validity and test-retest reliability of the MS sherpa s2MWT. Methods We performed a validation study on 25 persons with relapsing-remitting MS and 79 healthy control (HC) participants. In the HC group, 21 participants were matched to the persons with MS based on age, gender, and education and these followed the same assessment schedule as the persons with MS (the HC-matched group), whereas 58 participants had a less intense assessment schedule to determine reference values (the HC-normative group). Intraclass correlation coefficients (ICCs) were determined between the distance measured by the s2MWT and the distance measured using distance markers on the pavement during these s2MWT assessments. ICCs were also determined for test-retest reliability and derived from 10 smartphone tests per study participant, with 3 days in between each test. We interviewed 7 study participants with MS regarding their experiences with the s2MWT. Results In total, 755 s2MWTs were completed. The adherence rate for the persons with MS and the participants in the HC-matched group was 92.4% (425/460). The calculated distance walked on the s2MWT was, on average, 8.43 m or 5% (SD 18.9 m or 11%) higher than the distance measured using distance markers (n=43). An ICC of 0.817 was found for the concurrent validity of the s2MWT in the combined analysis of persons with MS and HC participants. Average ICCs of 9 test-retest reliability analyses of the s2MWT for persons with MS and the participants in the HC-matched group were 0.648 (SD 0.150) and 0.600 (SD 0.090), respectively, whereas the average ICC of 2 test-retest reliability analyses of the s2MWT for the participants in the HC-normative group was 0.700 (SD 0.029). The interviewed study participants found the s2MWT easy to perform, but they also expressed that the test results can be confronting and that a pressure to reach a certain distance can be experienced. Conclusions The high correlation between s2MWT distance and the conventional 2MWT distance indicates a good concurrent validity. Similarly, high correlations underpin a good test-retest reliability of the s2MWT. We conclude that the s2MWT can be used to measure the distance that the persons with MS walk in 2 minutes outdoors near their home, from which both clinical studies and clinical practice can benefit.

Single HLA Class I Mismatches with High Peptide Divergence in the Graft-Versus-Host Direction Are Associated with Inferior Survival after 9/10 HLA-Matched UD-HCT: A Retrospective Study from the CIBMTR

Introduction Unrelated donor (UD)-recipient disparity for human leukocyte antigen (HLA) class I adversely affects outcome of hematopoietic cell transplantation (UD-HCT). HLA polymorphisms in the peptide antigen binding groove can affect the repertoire of presented peptides. We have recently shown that the degree of peptide divergence between mismatched HLA-DP allotypes is related to T-cell alloreactivity and clinical permissiveness after UD-HCT (Meurer et al Blood 2021). Here, we hypothesized that the clinical tolerability also of HLA class I mismatches in UD-HCT might depend on the divergence of their respective peptide repertoires. Methods We studied 2,562 patients after 9/10 HLA-A, -B, -C, -DRB1, -DQB1-matched UD-HCT for acute myeloid or lymphocytic leukemia, or myelodysplastic syndrome, between 2008 and 2018, and 14,426 10/10 HLA-matched UD-HCT with similar characteristics. Peptide divergence of the mismatched HLA allotypes was predicted based on hierarchical clustering of experimentally determined peptide binding motifs (PBM) (Bassani-Sternberg et al Front Immunol 2018), with 21 different PBM groups identified in 122 HLA class I allotypes (44, 63 and 18 for HLA-A, -B and -C, respectively). The mismatched cohort was stratified into PBM-matches or PBM-mismatches, and within the latter into host-versus-graft (HvG), graft-versus-host (GvH) or bidirectional PBM-mismatches (Figure 1A). The primary study endpoint was overall survival (OS); secondary endpoints included treatment-related mortality (TRM), GVHD and relapse. P-value&lt;0.01 was considered statistically significant. Results The available PBM data allowed us to classify 1,629/2,562 (63.6%) of our pairs. Of these, 386 (23.7%) were PBM-matched and 1,243 (76.3%) were PBM-mismatched, and in the latter, 254 (20.5%), 238 (19.1%) and 751 (60.4%) had HvG, GvH or bidirectional PBM-mismatches, respectively. Transplants were performed mainly with peripheral blood stem cells (78%), myeloablative conditioning (65%) and tacrolimus-based graft-versus-host disease (GvHD) prophylaxis (74%). About half of the 9/10 HLA-matched HCT were performed using in vivo T-cell depletion by anti-thymocyte globulin or Campath, and none used post-transplant cyclophosphamide. Multivariable analyses showed that 10/10 HLA-matched transplants had significantly higher OS, lower TRM and aGvHD 3-4 compared to 9/10 HLA-matched transplants but relapse was similar (Figure 1B,C). There were no significant differences between the PBM-matched and aggregate PBM-mismatched group (Figure 1B). In further analysis, pairs with a bidirectional or only GvH PBM-mismatch had significantly worse OS, compared to pairs in the PBM-matched group or with only a unidirectional HvG (hazards ratio [HR] 0.76, 95% confidence interval [CI] 0.63-0.92, P = 0.0036; Figure 1C). The hazards of TRM and aGvHD 3-4 were lower for the HvG or PBM-matched group compared to the reference (HR 0.78, 95% CI 0.65-0.95, P = 0.0135 and HR 0.79, 95% CI 0.65-0.95, P = 0.0126, respectively), although these were not statistically significant (Figure 1C). Conclusion We show that single HLA class I PBM-mismatches with high peptide divergence in the unidirectional or bidirectional GvH directions are significantly associated with worse survival after 9/10 HLA-matched UD-HCT compared to PBM-matched or unidirectional mismatching in the HvG direction. These data suggest that the mechanistic role of peptide-diversity for T-cell alloreactivity we previously observed for HLA-DPB1 disparity (Meurer et al., Blood 2021), is also a relevant to class I mismatches, providing a new rationale for selecting permissive donors in the setting of 9/10 HLA-matched UD-HCT. Avoiding class I PBM mismatches in the GvH direction is associated with better survival. Figure 1 Figure 1. Disclosures Paczesny: Medical University of South Carolina: Patents & Royalties: inventor on the ST2 bispecific antibody patent application. Lee: Amgen: Research Funding; AstraZeneca: Research Funding; Incyte: Research Funding; Janssen: Other; Kadmon: Research Funding; National Marrow Donor Program: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Research Funding; Syndax: Research Funding; Takeda: Research Funding.

The Application of Magnetic-Controlled Capsule Gastroscopy in Patients Refusing C-EGD: A Single-Center 5-Year Observational Study

Background and Aims. Screening for gastric diseases in symptomatic outpatients with conventional esophagogastroduodenoscopy (C-EGD) is expensive and has poor compliance. We aimed to explore the efficiency and safety of magnetic-controlled capsule gastroscopy (MCCG) in symptomatic outpatients who refused C-EGD. Methods. We performed a retrospective study of 76794 consecutive symptomatic outpatients from January 2014 to October 2019. A total of 2318 adults ( F / M = 1064 / 1254 ) in the MCCG group who refused C-EGD were matched with adults in the C-EGD group using propensity-score matching (PSM). The detection rates of abnormalities were analyzed to explore the application of MCCG in symptomatic patients. Results. Our study demonstrated a prevalence of gastric ulcers (GUs) in patients with functional dyspepsia- (FD-) like symptoms of 8.14%. The detection rate of esophagitis and Barrett’s esophagus was higher in patients with typical gastroesophageal reflux disease (GERD) symptoms than in patients in the other four groups ( P < 0.01 ). The detection rates of gastric ulcers in the five groups (abdominal pain, bloating, heartburn, follow-up, and bleeding) were significantly different ( P = 0.015 ). The total detection rate of gastric ulcers in symptomatic patients was 9.7%. A total of 7 advanced carcinomas were detected by MCCG and confirmed by endoscopic or surgical biopsy. The advanced gastric cancer detection rate was not significantly different between the MCCG group and the C-EGD matched group in terms of nonhematemesis GI bleeding (2 vs. 2, P = 1.00 ). In addition, the overall focal lesion detection rate in the MCCG group was superior to that in the C-EGD matched group (224 vs. 184, P = 0.038 ). MCCG gained a clinically meaningful small bowel diagnostic yield of 54.8% (17/31) out of 31 cases of suspected small bowel bleeding. No patient reported capsule retention at the two-week follow-up. Conclusion. MCCG is well tolerated, safe, and technically feasible and has a considerable diagnostic yield. The overall gastric diagnostic yield of gastric focal lesions with MCCG was comparable to that with C-EGD. MCCG offered a supplementary diagnosis in patients who had a previously undiagnostic C-EGD, indicating that MCCG could play an important role in the routine monitoring and follow-up of outpatient. MCCG shows its safety and efficiency in symptomatic outpatient applications.

Observed impact of skin substitutes in lower extremity diabetic ulcers: lessons from the Medicare Database (2015–2018)

Objective: To evaluate large propensity-matched cohorts to assess outcomes in patients receiving advanced treatment (AT) with skin substitutes for lower extremity diabetic ulcers (LEDUs) versus no AT (NAT) for the management of LEDUs. Method: The Medicare Limited Dataset (1 October 2015 through 2 October 2018) were used to retrospectively analyse people receiving care for a LEDU treated with AT or NAT (propensity-matched Group 1). Analysis included major and minor amputations, emergency department (ED) visits and hospital readmissions. In addition, AT following parameters for use (FPFU) was compared with AT not FPFU (propensity-matched Group 2). A paired t-test was used for comparisons of the two groups. For comparisons of three groups, the Kruskal–Wallis test was used. A Bonferroni correction was performed when multiple comparisons were calculated. Results: There were 9,738,760 patients with a diagnosis of diabetes, of whom 909,813 had a LEDU. In propensity-matched Group 1 (12,676 episodes per cohort), AT patients had statistically fewer minor amputations (p=0.0367), major amputations (p<0.0001), ED visits (p<0.0001), and readmissions (p<0.0001) compared with NAT patients. In propensity-matched Group 2 (1131 episodes per cohort), AT FPFU patients had fewer minor amputations (p=0.002) than those in the AT not FPFU group. Conclusion: AT for the management of LEDUs was associated with significant reductions in major and minor amputation, ED use, and hospital readmission compared with LEDUs managed with NAT. Clinics should implement AT in accordance with the highlighted parameters for use to improve outcomes and reduce costs.

Mortality after electroconvulsive therapy

Background There are limited studies examining mortality associated with electroconvulsive therapy (ECT), and many studies do not include a control group or method to identify all patient deaths. Aims We aimed to evaluate the risk of death associated with ECT treatments over 30 days and 1 year. Method We conducted a study analysing electronic medical record data from the Department of Veterans Affairs healthcare system between 2000 and 2017. We compared mortality among patients who received ECT with a matched group of patients created through propensity score matching. Results Our sample included 123 479 individual ECT treatments provided to 8720 patients (including 5157 initial index courses of ECT). Mortality associated with individual ECT treatments was 3.08 per 10 000 treatments over the first 7 days after treatment. When comparing patients who received ECT with a matched group of mental health patients, those receiving ECT had a relative odds of all-cause mortality in the year after their index course of 0.87 (95% CI 0.79–1.11; P = 0.10), and a relative risk of death from causes other than suicide of 0.79 (95% CI 0.66–0.95; P < 0.01). The similar relative odds of all-cause mortality in the first 30 days after ECT was 1.06 (95% CI 0.65–1.73) for all-cause mortality, and 1.02 (95% CI 0.58–1.8) for all-cause mortality excluding suicide deaths. Conclusions There was no evidence of elevated or excess mortality after ECT. There was some indication that mortality may be reduced in patients receiving ECT compared with similar patients who do not receive ECT.

Is There a Futility Discriminant Function Score for Alcoholic Hepatitis?

The treatment for patients with alcoholic hepatitis (AH) who have a discriminant function (DF) score greater than 32 has been steroids. A prior study reported that mortality approaches 100% when the DF score is greater than 54, despite the use of prednisolone. Our aim was to determine if a DF score greater than 54 is associated with high mortality despite steroids. We conducted a retrospective study of 531 first-time inpatient encounters of AH. We compared 30-day mortality between patients with DF 54 or less to those greater than 54 treated with steroids, as well as a matched group not treated with steroids. A total of 531 inpatients diagnosed with AH were identified, of which 124 had a DF greater than 32 and 52 were treated with steroids. Among patients treated with steroids, 30-day mortality for patients with DF greater than 54 (n = 27) and 54 or below (n = 25) was 22% and 12%, respectively (p = 0.47). Among patients with DF greater than 54, the 30-day mortality for those who did (n = 27) and did not (n = 29) receive steroids was 22% and 24%, respectively (p = 0.87). In our study population, steroids were not futile in patients with a DF score of greater than 54.

Lack of Reperfusion Rather Than Number of Passes Defines Futility in Stroke Thrombectomy: A Matched Case-Control Study

Background and Purpose: There is a robust relationship between the duration of ischemia and functional outcomes after mechanical thrombectomy. Higher number of mechanical thrombectomy passes strongly correlate with lower chances of favorable outcomes. Indeed, previous studies have suggested that after multiple passes the procedure may be futile. However, using uncontrolled thresholds to define thrombectomy futility might be misleading. We aim to compare the outcome of successful reperfusion after 4 to 5 passes and ≥6 passes with those of failed reperfusion. Methods: A prospectively acquired mechanical thrombectomy database from January 2012 to October 2019 was reviewed. Patients were included if they had intracranial internal carotid artery or middle cerebral artery-M1/M2 occlusions and either achieved successful reperfusion after ≥4 passes or failed reperfusion. Reperfused patients (mTICI2b-3) were divided into 2 subgroups; (1) 4 to 5 passes and (2) ≥6 passes. Each subgroup was compared with a matched group of mechanical thrombectomy failure (mTICI0-2a). The primary outcome was the shift in the degree of disability at 90-day as measured by the modified Rankin Scale. Results: A total of 273 patients were included. As compared with matched failed reperfusion patients (n=62), those reperfused after 4 to 5 passes (n=62) had a favorable shift in the overall modified Rankin Scale score distribution (adjusted odds ratio, 3.992 [95% CI, 1.807–8.512], P =0.001] and higher rates of functional independence (31% versus 8.9%, P =0.004, adjusted odds ratio; 9.860 [95% CI, 2.323–41.845], P =0.002) at 90 days. Similarly, when compared with a matched group of failed reperfusion (n=42), patients reperfused after ≥6 passes (n=42) demonstrated a favorable shift in the overall modified Rankin Scale score distribution (adjusted odds ratio, 2.640 [95% CI, 1.073–6.686], P =0.037) and had higher rates of functional independence (36.8% vs 11.1%, P =0.004, adjusted odds ratio, 5.392 [95% CI, 1.185–24.530], P =0.029) at 90 day. Rates of parenchymal hematoma type-2 and 90-day mortality were comparable in the reperfused and nonreperfused groups. Conclusions: Achieving reperfusion despite multiple passes leads to improved outcomes compared with failed procedures. Arbitrary uncontrolled thresholds for a maximum number of passes to predict futile recanalization may lead to inappropriate early termination of procedures.