P5653Atrial fibrillation in arrhythmogenic right ventricular cardiomyopathy and its association with left atrial volume index

Background

Recent studies in arrhythmogenic right ventricular cardiomyopathy (ARVC) support atrial involvement in the disease progression and consider atrial fibrillation (AF) as one of the primary manifestations of ARVC. We aimed to assess clinical factors, components of 2010 Task Force criteria (TFC2010) and echocardiographic characteristics of atria associated with AF in the Scandinavian cohort of ARVC patients.

Methods

Study sample comprised of 106 definite ARVC patients by TFC2010 from three tertiary care centers participating in the Nordic ARVC Registry (33% females, median age at ARVC diagnosis 41 years [IQR 30–54 years]). No concomitant diseases were observed in 90 patients (85%) while 16 patients had one or more comorbidities: hypertension (n=6), diabetes mellitus (n=5), coronary artery disease (n=5) or congestive heart failure (n=9). AF was included in the registry protocol as a pre-specified clinical event and verified by processing of the electronic ECG databases which contains all ECG recordings from the involved hospitals catchment areas (earliest ECG from 1988). Left (LA) and right atrial (RA) dimensions were obtained by revisiting cardiac ultrasound examinations performed at the time of ARVC diagnosis. Association between AF and clinical characteristics was assessed using multivariable logistic regression analysis adjusted for age and gender.

Results

AF was diagnosed in 29 patients (27%) at a median age of 53 (IQR 38–63) years, 7 females (24%). Median time from ARVC diagnosis to AF onset was 8 (IQR 2–12) years. AF was univariately associated with right ventricular structural abnormalities meeting the definition of major imaging criterion by 2010TFC, ventricular tachycardia (VT) with superior axis (major criterion) and LA volume index. Significantly associated variables were included in a multivariate model, in which LA volume index (OR=1.07, 95% CI 1.01–1.14, p=0.021) and superior axis VT (OR=7.45, 95% CI 1.82–30.55, p=0.005) remained independently associated with AF. In receiver operating characteristic (ROC) curve analysis, LA volume index was significantly associated with AF (AUC=0.703, p=0.005) and with superior axis VT (AUC=0.703, p=0.021). AF was not associated with either RA volume index (univariate OR=1.03, 95% CI 0.99–1.06, p=0.203) or left ventricular ejection fraction (OR=0.97, 95% CI 0.92–1.03, p=0.299).

Conclusion

In patients with ARVC,AF is primarily associated with LA structural abnormalities without indication of RA involvement and is strongly associated with ventricular arrhythmias thus indicating parallel development of atrial and ventricular arrhythmic substrate.

P2247Pregnancies and childbirth in women with arrhythmogenic right ventricular cardiomyopathy are associated with low risk of ventricular arrhythmias

Background

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is associated with a risk of ventricular arrhythmias (VA) and sudden cardiac death (SCD). Even though female patients with ARVC are considered to be at lower risk of VA, the impact of pregnancy and child birth on the arrhythmic risk and development of arrhythmic substrate in the context of ARVC remains insufficiently studied.

Objective

To assess the risk of VA in relation to childbirth in women with ARVC and the impact of multiple pregnancies on progression of arrhythmic manifestations of the disease.

Methods

The study included 186 females with definite ARVC (n=107, 70 probands) or unaffected mutation-carriers (n=79) with median age at the end of follow up of 48 (IQR 34–60) years. Seventeen women had 1, 59 had 2 and 29 had ≥3 child births by the age of 40 years. VA was defined as ventricular tachycardia, appropriate ICD therapy, aborted cardiac arrest or SCD. Proportions of patients who experienced VA by the age of 40 years were compared between nulliparous women (n=81) and those with reported child births (n=105). VA-free survival after accomplished pregnancies was assessed for women ≥40 years of age (n=119). Cumulative probability of VA for each pregnancy (n=230) was assessed from conception through 2 years after child birth and compared between those that occurred before ARVC diagnosis (Pre-Ds, n=164), after it (Post-Ds, n=11) and in unaffected mutation carriers (No-Ds, n=55).

Results

The nulliparous women had lower age at ARVC diagnosis (37 vs 44, p=0.023) and more often had VA before the age of 40 (31% vs 13%, p=0.003) while the number of child births was not related to the prevalence of VA (18% among women with 1 childbirth, 12% in those with 2 and 14% in those with 3 or more, ns). Three women suffered SCD before the age of 40. VA-free survival after 40 years did not differ between nulliparous and those who gave birth (Figure A). Only four pregnancy-related events were documented (Figure B): 1 in the Post-Ds group and three in the Pre-Ds group. No pregnancy-related events were reported in the unaffected mutation carriers.

Conclusion

In this Scandinavian cohort of women with ARVC we observed no indication of an increased VA risk either associated with pregnancies or during long-term follow up after the last child birth.

P992Incidence, predictors, and success of ventricular tachycardia catheter ablation in arrhythmogenic right ventricular cardiomyopathy (ARVC): A long-term cohort study from the Nordic ARVC registry

Background

Catheter ablation may reduce ventricular tachycardia (VT) burden in arrhythmogenic right ventricular cardiomyopathy (ARVC) patients. However, little is known about factors predicting need for ablation and various outcomes have been reported.

Purpose

We sought to investigate predictors and use of VT ablation and to evaluate the post-procedural outcome in ARVC patients.

Methods

We studied 435 patients from the Nordic ARVC registry including 220 probands with definite ARVC according to the 2010 task force criteria and 215 mutation-carrying relatives identified through cascade screening. Patients were followed until first-time VT ablation, death, heart transplantation, or January 1st 2018. Additionally, patients undergoing VT ablation were further followed from the time of ablation for recurrent ventricular arrhythmias.

Results

Cumulative use of VT ablation was 4% (95% CI 3%-6%) and 11% (95% CI 8%-15%) after 1 and 10 years. All procedures were performed in probands in whom the cumulative use was 8% (95% CI 5%-12%) and 20% (95% CI 15%-26%). In adjusted analyses restricted to probands, only young age predicted need for ablation. In patients undergoing ablation, risk of recurrent arrhythmias was 59% (95% CI 44%-71%) and 74% (95% CI 59%-84%) 1 and 5 years after the procedure. Despite high recurrence rates, the burden of ventricular arrhythmias was reduced after ablation (p=0.0042). Young age, use of several antiarrhythmic drugs and inducibility to VT immediately after ablation were associated with an unfavorable outcome.

Conclusions

Twenty percent of ARVC probands developed a clinical indication for VT ablation within 10 years after diagnosis whereas mutation-carrying relatives were without such need. Although the burden of ventricular arrhythmias decreased after ablation, risk of recurrence was substantial.

Elevated non-esterified fatty acids impair survival and promote lipid accumulation and pro-inflammatory cytokine production in bovine endometrial epithelial cells

Elevated non-esterified fatty acids (NEFAs) are associated with negative effects on bovine theca, granulosa and oviductal cells but the effects of NEFAs on bovine endometrial epithelial cells (bEECs) are not as well documented. The objective of this study was to define the effects of NEFAs on bEECs. Postprimary bEECs were treated with 150, 300 or 500µM of either palmitic acid (PA), stearic acid (SA) or oleic acid (OA) or a mixture of NEFAs (150µM of each FA) or 0.5% final concentration of vehicle ethanol (control). Viability and proliferation of bEECs exposed to 150µM of each NEFA or a mixture of NEFAs were unaffected. Increased lipid accumulation was found in all treated groups (P<0.01). In cells exposed to 500µM of each NEFA and 300µM PA decreased cell viability (P<0.001), proliferation (P<0.05) and increased apoptosis (P<0.05) were observed. Treatment with 500µM OA, PA and SA had the strongest effects on cell viability, proliferation and apoptosis (P<0.05). Treatment with PA and OA increased interleukin-6 (IL-6) concentrations (P<0.05), whereas only the highest concentration of PA, OA and SA stimulated IL-8 production (P<0.05). These results suggest that high concentrations of NEFAs may impair endometrial function with more or less pronounced effects depending on the type of NEFA and time of exposure.

Frail Older Persons' Experiences of Information and Participation in Hospital Care

The aim of this paper is to describe frail older persons' experiences of hospital care of information and participation when being an inpatient at a hospital. A qualitative method was used. Data were collected at the hospital from 20 interviews with frail older patients, together with observations in the environment at the hospital ward. A content analysis was performed. Patients experienced not receiving information about their care and rehabilitation, or receiving such information in noisy surroundings. They experienced situations of misunderstanding related to their medication, which indicates the need for appropriate discharge calls for frail older patients. They expressed feelings of distress concerning the future, caused by hasty admissions or relatives' problems to handle the situation. The results highlight the need to receive appropriate information and to participate in decision-making. The level of health literacy should be taken notice of when giving information, using peaceful and quiet environments when informing frail older persons. Person-centered care should be recognized to a greater extent in order for healthcare professionals to give information to frail older people in a health literacy-friendly way. This might make it easier for frail older persons to participate in a partnership in care.

Metal solubility and transport at a contaminated landfill site - From the source zone into the groundwater

Risks associated with metal contaminated sites are tightly linked to material leachability and contaminant mobility. In this study, metal solubility and transport were characterized within a glass waste landfill through i) lysimeter-collection of pore water and standardized batch leaching tests, ii) soil profiles extending from the landfill surface, through unsaturated soil underneath, and into the groundwater zone, and iii) groundwater samples upstream, at, and downstream of the landfill. The soil analyzes targeted both pseudo-total and geochemically active concentrations of contaminant metals (As, Cd, Pb, Sb) and basic soil geochemistry (pH, org. C, Fe, Mn). Water samples were analyzed for dissolved, colloid-bound and particulate metals, and speciation modelling of the aqueous phase was conducted. The results revealed a highly contaminated system, with mean metal concentrations in the waste zone between 90 and 250 times the regional background levels. Despite severe contamination of the waste zone and high geochemically active fractions (80-100%) of all contaminant metals as well as elevated concentrations in landfill pore water, the concentrations of Cd and Pb decrease abruptly at the transition between landfill and underlying natural soil and no indication of groundwater contamination was found. The efficient cation retention is likely due to the high pH. However, the sorption of As and Sb is weaker at such high pH, which explains their higher mobility from the pore water zone into groundwater. The field soil:solution partitioning (Kd) displayed a high spatial variability within the waste zone (the highest Kd variability was seen for Pb, ranging from 140 to 2,900,000 l kg^-1), despite little variability in basic geochemical variables, which we suggest is due to waste material heterogeneity.

Quality of life measurement in hidradenitis suppurativa: position statement of the European Academy of Dermatology and Venereology task forces on Quality of Life and Patient-Oriented Outcomes and Acne, Rosacea and Hidradenitis Suppurativa

This paper is organized jointly by the European Academy of Dermatology and Venereology (EADV) Task Force (TF) on Quality of Life (QoL) and Patient-Oriented Outcomes and the EADV TF on acne, rosacea and hidradenitis suppurativa (ARHS). The purpose of this paper was to present current knowledge about QoL assessment in HS, including data on HS-specific health-related (HR) QoL instruments and HRQoL changes in clinical trials, and to make practical recommendations concerning the assessment of QoL in people with HS. HS results in significant quimp that is higher than in most other chronic skin diseases. HS impact in published studies was assessed predominantly (84% of studies) by the Dermatology Life Quality Index (DLQI). There is a lack of high-quality clinical trials in HS patients where HRQoL instruments have been used as outcome measures. One double-blind randomized placebo-controlled trial on infliximab with low number of participants reported significantly better HRQoL improvement in the treatment group than in the placebo group. Well-designed clinical studies in HS patients to compare different treatment methods, including surgical methods and assessing long-term effects, are needed. Because of lack of sufficient validation, the Task Forces are not at present able to recommend existing HS-specific HRQoL instruments for use in clinical studies. The EADV TFs recommend the dermatology-specific DLQI questionnaire for use in HS patients. The EADV TFs encourage the further development, validation and use of other HS-specific, dermatology-specific and generic instruments but such use should be based on the principles presented in the previous publications of the EADV TF on QoL and Patient-Oriented Outcomes.

Quality of life measurement in skin cancer patients: literature review and position paper of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes, Melanoma and Non-Melanoma Skin Cancer

The European Academy of Dermatology and Venereology (EADV) Task Forces (TFs) on Quality of Life (QoL) and Patient Oriented Outcomes, Melanoma and Non-Melanoma Skin Cancer (NMSC) present a review of the literature and position statement on health-related (HR) QoL assessment in skin cancer patients. A literature search was carried out to identify publications since 1980 that included information about the impact of SC on QoL. Generic, dermatology-specific, cancer-specific, SC-specific, facial SC-specific, NMSC-specific, basal cell carcinoma-specific and melanoma-specific QoL questionnaires have been used to assess HRQoL in SC patients. HRQoL was assessed in the context of creation and validation of the HRQoL instruments, clinical trials, comparison of QoL in SC and other cancers, other diseases or controls, HRQoL assessment after treatment, comorbidities, behaviour modification, predictors of QoL and survival, supportive care needs, coping strategies and fear of cancer recurrence. The most widely used instruments for HRQoL assessment in SC patients are the European Organisation for Research and Treatment of Cancer Core Questionnaire (EORTC QLQ-C30), the Functional Assessment of Cancer Therapy-Melanoma (FACT-M), Skin Cancer Index (SCI), Short Form 36 Item Health Survey (SF-36) and the Dermatology Life Quality Index (DLQI). The TFs recommend the use of the cancer-specific EORTC QLQ-C30, especially in late stages of disease, and the melanoma-specific FACT-M and SC-specific SCI questionnaires. These instruments have been well validated and used in several studies. Other HRQoL instruments, also with good basic validation, are not currently recommended because the experience of their use is too limited. Dermatology-specific HRQoL instruments can be used to assess the impact of skin-related problems in SC. The TFs encourage further studies to validate HRQoL instruments for use in different stages of SC, in order to allow more detailed practical recommendations on HRQoL assessment in SC.

Lenalidomide as immune adjuvant to a dendritic cell vaccine in chronic lymphocytic leukemia patients

OBJECTIVES

We previously showed that immunization with ex vivo- generated autologous dendritic cells loaded with apoptotic tumor cells (Apo-DC) potentiated tumor-specific immunity in chronic lymphocytic leukemia (CLL) patients. Here, we evaluated safety and immunogenicity of Apo-DC in combination with lenalidomide, granulocyte-macrophage colony-stimulating factor (GM-CSF), and low-dose cyclophosphamide (CTX).

METHODS

Ten previously untreated patients with slowly progressing CLL received 5 Apo-DC vaccinations and lenalidomide orally for 24 weeks either alone (cohort I, n = 5) or together with subcutaneous GM-CSF and intravenous CTX (cohort II, n = 5). Tumor-specific T-cell responses were measured by proliferation and IFN-γ ELISPOT assays. Immune monitoring was performed by flow cytometry.

RESULTS

Dose-limiting toxicity was observed in 3/10 patients, 2 in cohort I and one in cohort II. One patient developed autoimmune hemolytic anemia and another grade 4 thrombocytopenia. Vaccine-induced immune responses were seen in 5/5 and 4/5 patients in cohort I and II, respectively. The expression of immune checkpoints on T cells did not change significantly.

CONCLUSIONS

Lenalidomide alone or in combination with GM-CSF and low-dose CTX as immune adjuvant to the Apo-DC vaccine elicited tumor-specific T-cell responses in CLL patients. However, unexpected toxicity was observed and caution is suggested in further exploring this drug as immune adjuvant in CLL.

Factor Xa and VIIa inhibition by tissue factor pathway inhibitor is prevented by a monoclonal antibody to its Kunitz-1 domain

Essentials Activated FVII (FVIIa) and FX (FXa) are inhibited by tissue factor pathway inhibitor (TFPI). A monoclonal antibody, mAb2F22, was raised against the N-terminal fragment of TFPI (1-79). mAb2F22 bound exclusively to the K1 domain of TFPI (KD ∼1 nm) and not to the K2 domain. mAb2F22 interfered with inhibition of both FVIIa and FXa activities and restored clot formation.

SUMMARY

Background Initiation of coagulation is induced by binding of activated factor VII (FVIIa) to tissue factor (TF) and activation of factor X (FX) in a process regulated by tissue factor pathway inhibitor (TFPI). TFPI contains three Kunitz-type protease inhibitor domains (K1-K3), of which K1 and K2 block the active sites of FVIIa and FXa, respectively. Objective To produce a monoclonal antibody (mAb) directed towards K1, to characterize the binding epitope, and to study its effect on TFPI inhibition. Methods A monoclonal antibody, mAb2F22, was raised against the N-terminal TFPI(1-79) fragment. Binding data were obtained by surface plasmon resonance analysis. The Fab-fragment of mAb2F22, Fab2F22, was expressed and the structure of its complex with TFPI(1-79) determined by X-ray crystallography. Effects of mAb2F22 on TFPI inhibition were measured in buffer- and plasma-based systems. Results mAb2F22 bound exclusively to K1 of TFPI (KD ~1 nm) and not to K2. The crystal structure of Fab2F22/TFPI (1-79) mapped an epitope on K1 including seven residues upstream of the domain. TFPI inhibition of TF/FVIIa amidolytic activity was neutralized by mAb2F22, although the binding epitope on K1 did not include the P1 residue. Binding of mAb2F22 to K1 blocked TFPI inhibition of the FXa amidolytic activity and normalized hemostasis in hemophilia human A-like plasma and whole blood. Conclusion mAb2F22 blocked TFPI inhibition of both FVIIa and FXa activities and mapped a FXa exosite for binding to K1. It reversed TFPI feedback inhibition of TF/FVIIa-induced coagulation and restored clot formation in FVIII-neutralized human plasma and blood.

Greenland records of aerosol source and atmospheric lifetime changes from the Eemian to the Holocene

The Northern Hemisphere experienced dramatic changes during the last glacial, featuring vast ice sheets and abrupt climate events, while high northern latitudes during the last interglacial (Eemian) were warmer than today. Here we use high-resolution aerosol records from the Greenland NEEM ice core to reconstruct the environmental alterations in aerosol source regions accompanying these changes. Separating source and transport effects, we find strongly reduced terrestrial biogenic emissions during glacial times reflecting net loss of vegetated area in North America. Rapid climate changes during the glacial have little effect on terrestrial biogenic aerosol emissions. A strong increase in terrestrial dust emissions during the coldest intervals indicates higher aridity and dust storm activity in East Asian deserts. Glacial sea salt aerosol emissions in the North Atlantic region increase only moderately (50%), likely due to sea ice expansion. Lower aerosol concentrations in Eemian ice compared to the Holocene are mainly due to shortened atmospheric residence time, while emissions changed little.

Past climate changes in Greenland ice were accompanied by large aerosol concentration changes. Here, the authors show that by correcting for transport effects, reliable source changes for biogenic aerosol from North America, sea salt aerosol from the North Atlantic, and dust from East Asian deserts can be derived.

Quality of life measurement in acne. Position Paper of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes and Acne, Rosacea and Hidradenitis Suppurativa

Acne causes profound negative psychological and social effects on the quality of life (QoL) of patients. The European Dermatology Forum S3-Guideline for the Treatment of Acne recommended adopting a QoL measure as an integral part of acne management. Because of constantly growing interest in health-related QoL assessment in acne and because of the high impact of acne on patients' lives, the European Academy of Dermatology and Venereology Task Force on QoL and Patient Oriented Outcomes and the Task Force on Acne, Rosacea and Hidradenitis Suppurativa have documented the QoL instruments that have been used in acne patients, with information on validation, purposes of their usage, description of common limitations and mistakes in their usage and overall recommendations.

Flawed communications: Health professionals' experience of collaboration in the care of frail elderly patients

AIMS

Frail elderly patients who have multiple illnesses do not fare well in modern health care systems, mainly due to a lack of care planning and flawed communication between health professionals in different care organisations. This is especially noticeable when patients are discharged from hospital. The aim of this study was to explore health care professionals' experience of obstacles and opportunities for collaboration.

METHODS

Health professionals were invited to participate in three focus groups, each consisting of a hospital physician, a primary care physician, a hospital nurse, a primary care nurse, a municipal home care nurse or an assistant officer, a physical or occupational therapist and a patient or a family member representative. These individual people were then asked to discuss the obstacles and opportunities for communication between themselves and with the patients and their relatives when presented with the case report of a fictitious patient. Content analysis was used to identify categories.

RESULTS

Several obstacles were identified for effective communication and care planning: insufficient communication with patients and relatives; delayed collaboration between care-givers; the lack of an adequate responsible person for care planning; and resources not being distributed according to the actual needs of patients. The absence of an overarching responsibility for the patient, beyond organisational borders, was a recurring theme. These obstacles could also be seen as opportunities.

CONCLUSIONS

Obstacles for collaboration were found on three levels: societal, organisational and individual. As health care professionals are well aware of the problems and also see solutions, management for health care should support employees' own initiatives for changes that are of benefit in the care of frail elderly patients with multiple illnesses.

Dose related effects of LPS on endometrial epithelial cell populations from dioestrus cows

Lipopolysaccharides (LPS) from Gram negative bacteria are involved in the pathogeny of uterine diseases in cows. This study aimed to investigate LPS effects on the growth of bovine endometrial epithelial cells (bEEC) and relationships between LPS response and tissue characteristics. Uteri from 35 females were characterized for parity and stage of oestrous cycle. Densities of glandular tissue (dGT), CD11b+ cells and Ki67+ cells were measured in the endometrial tissue. Cells from 13 dioestrus cows were exposed to 0, 2, 4, 8, 12, 16 or 24μg/mL LPS. Effects of parity and stage of the oestrous cycle on tissue characteristics and effects of LPS dosage, cow and tissue characteristics on changes in cell numbers were analyzed by ANOVA. The dGT was higher in metoestrus and dioestrus samples than in pro-oestrus ones whereas densities of CD11b+ and Ki67+ cells were higher at pro-oestrus (p<0.05-p<0.01). LPS influenced bEEC populations in a dose related manner. An increase in number of live cells was observed for dosages ranging from 2 to 12μg/mL LPS (p<0.0001 vs controls). No effect was found on numbers and frequencies of dead cells. With higher dosages, the numbers of live cells did not increase but the numbers of dead did increase. No relationships were observed between cow or tissue characteristics and growth patterns or frequencies of viable bEEC in controls nor in the response to LPS. To conclude this model is suitable for further studies on dysregulations induced by LPS in endometrial tissue.