Detection of Sleep Apnea Episodes from Multi-lead ECGs Considering Different Physiological Influences

Objectives : This article deals with recognition of sleep apnea, using solely information available from multilead ECGs.

Methods : Characteristic variations in heart rhythm and amplitude of the ECG are compared with respect to their diagnostic accuracy by means of an ROC analysis that is performed on a local similarity index. In 38 8-lead ECGs, each minute is classified with respect to occurrence of apnea events and the result is validated against expert annotations derived from synchronized polysomnographic recordings. Moreover, the results are compared to those obtained from the well known Physionet apnea-ECG database.

Results : Whereas the effect of amplitude modulation yields consistent results on both data sets (ROC-area 89.0% vs. 88.3%), a remarkable loss in performance is observed for the frequently applied heart rhythm (89.8% vs. 77.9%). Examples illustrating the reasons for this difference are given and discussed. With respect to aggregation of multi-lead information, two methods (PCA vs. averaging) are compared. The results indicate that averaging performs better (89.3%) than the adaptively estimated PCA (87.2) even when applied to a reduced set of leads.

Conclusions : It is concluded that sleep apnea recognition from heart rhythm should always be complemented by analysis of the amplitude variations of the ECG.

[Unsuccessful pain treatment over 6 years of a thoracic radiculopathy caused by an unrecognized Tarlov cyst]

This article presents a case of unsuccessful pharmaceutical and invasive pain treatment for 6 years without any adequate diagnostics in a female suffering from unilateral thoracic radiculopathy (Th8, right) leading to severe disability and unemployment. The origin was an undetected Tarlov cyst. After resection of the cyst the pain and other complaints disappeared (follow up: 8 months) without need for further pain medication. This case underlines the necessity of adequate diagnostics ahead of long-term pain treatment. Thoracic Tarlov cysts are very uncommon but should be included in the differential diagnosis because curative treatment may be possible.

Recovery of mechanical detection thresholds after direct digital nerve repair versus conduit implantation

The purpose of this study was to assess sensory and functional nerve recovery after digital nerve injury in patients with an end-to-end suture (S) or with implantation of a collagen conduit (C) to bridge a nerve gap. Fifteen S and 11 C with a follow-up of 6-36 months and 28 healthy control participants were enrolled. Methods of assessments were quantitative sensory testing, the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), range of motion and the painDetect questionnaire. After both procedures, sensory profiles showed largely recovered function of C and Aδ fibres but severe loss of Aβ-fibre function leading to increased mechanical detection thresholds. There was only minimal allodynia. Severe pain was absent. Patients with conduits reported more functional impairment, especially in work performance, which correlated with the assessed loss of Aß-fibre function.

LEVEL OF EVIDENCE

III.

Direct Observation of Dynamical Quantum Phase Transitions in an Interacting Many-Body System

The theory of phase transitions represents a central concept for the characterization of equilibrium matter. In this work we study experimentally an extension of this theory to the nonequilibrium dynamical regime termed dynamical quantum phase transitions (DQPTs). We investigate and measure DQPTs in a string of ions simulating interacting transverse-field Ising models. During the nonequilibrium dynamics induced by a quantum quench we show for strings of up to 10 ions the direct detection of DQPTs by revealing nonanalytic behavior in time. Moreover, we provide a link between DQPTs and the dynamics of other quantities such as the magnetization, and we establish a connection between DQPTs and entanglement production.

Treatment of painful radiculopathies with capsaicin 8% cutaneous patch

BACKGROUND AND OBJECTIVE

The treatment of neuropathic pain due to low-back (lumbosacral) radiculopathies, a common source of neuropathic pain, is challenging and often requires a multimodal therapeutic approach. The capsaicin 8% patch is the first topical analgesic licensed for peripheral neuropathic pain. To evaluate this treatment, a subset of patients with painful radiculopathy (lumbar and cervical, including ventral and dorsal rami) enrolled into the multicenter, non-interventional QUEPP study (Qutenza ² - safety and effectiveness in peripheral neuropathic pain) was analyzed.

METHODS

Of the 1044 study participants, 50 were diagnosed with painful radiculopathy as only peripheral neuropathic pain syndrome and were eligible for evaluation. Patients received a single treatment (visit 1) with follow-up visits 2-5 at weeks 1-2, 4, 8 and 12. Parameters assessed at all visits included pain intensity, neuropathy symptoms and side effects. Quality of life (SF-12) and painDETECT ¹ questionnaires were completed at baseline and final visit. Data was analyzed by patch application site and duration of pain.

RESULTS

Topical treatment led to a significant decrease of pain intensity between weeks 1/2 and week 12 versus baseline at the application sites representing dermatomes of ventral (N = 26) and dorsal rami (N = 13) of spinal nerves. A significant decline (p ≤ .001) of numeric pain rating scale scores was observed between weeks 1/2 following patch application and the end of observation (week 12) in the overall radiculopathy group (N = 50), and the groups with either 3 months to 2 years (N = 14) or >2 years (N = 23) duration of pain. Pain relief of at least 30% was observed in 50.0%, 71.4% and 39.1% of patients in the respective groups. Four patients experienced in total seven adverse drug reactions (application site pain or pruritus).

CONCLUSION

Effective neuropathic pain relief was observed after patch application within the innervation territories of both dorsal and ventral branches of the spinal nerve. Further controlled randomized trials are indicated.

Abstract 3726: INCB52793 JAK1 inhibitor synergizes with ATRA to inhibit expansion of AML

Dysregulated JAK/STAT signaling is known to drive myeloproliferative neoplasms, and targeting JAK1 and JAK2 has led to improvement in morbidity and mortality in these diseases. While dose-dependent anemia and thrombocytopenia limit the use of JAK2 inhibition, selectively targeting JAK1 has been explored as a means to suppress inflammation and STAT-associated neoplastogenesis. Recently, INCB52793 was found to be 100-fold selective for JAK1 over JAK2, and it has recently been explored in the clinic in solid tumors and acute myeloid leukemia (AML). In a large high throughput screen, we detected synergistic effects between INCB52793 and all-trans retinoic acid (ATRA) in several non-promyelocytic AML cell lines. In another in vitro assay, human primary AML blasts exposed to INCB52793 exhibited a marked increase in both CD13 and CD86, two markers indicative of cellular differentiation.

Given these findings, we tested this combination in an in vivo murine model of AML. Human leukemia cells were injected into the tail vein of sublethally irradiated NSGS mice which were then treated days 7-35 post-transplant with ATRA, INCB52793, ATRA/INCB52793, or vehicle. Weekly monitoring for peripheral human CD45+ cells revealed that the INCB52793/ATRA combination effectively decreased the expansion of leukemic cells. At 35-40 days, significant decreases in tumor burden were seen within the bone marrow (BM) and spleens of INCB62793/ATRA treated mice. Bone marrow and splenic cells were also analyzed by mass cytometry, simultaneously measuring 35 signaling, differentiation, and cell death attributes per-cell. The few remaining human cells in the INCB62793/ATRA combo group synergistically displayed 30-fold decreases in CD38, 8-fold increases in CD34, and attained high levels of p-STAT3 and p-STAT5, potentially implying a resistant progenitor population.

Label free proteomics revealed significant fold changes in in vitro INCB52793/ATRA treated cells. Proteins related to cellular differentiation mechanisms, such as SMAD3, BCL11A, RUNX2, HNRNPLL, and SAMHD1, were elevated between 24 to 48 hours post treatment supporting our hypothesis that JAK1 inhibition enhanced ATRA induced differentiation.

Targeting retinoic acid receptor and JAK1 together synergistically resulted in the decreased expansion of multiple AML cell lines, and preferential reduction of AML cells from the blood, spleen and bone marrow of treated mice in vivo. Common CD34-CD38+ tumor cells were eliminated, and rare remaining CD34+ AML cells displayed high p-STAT3 and p-STAT5 levels after INCB52793/ATRA therapy. While ATRA is a critical component in the therapy of acute promyelocytic leukemia (M3), it has not been successfully employed in other AML. These preliminary data represent a potential for INCB52793/ATRA therapy in non-M3 AML.

Citation Format: Haley E. Ramsey, P. Brent Ferrell, Melissa A. Fischer, Agnieszka E. Gorska, Caroline Maier, Jeremy Norris, Melissa Farrow, Danielle Guiterrez, James Pino, Sandra Zinkel, Carlos Lopez, Holly Koblish, Matthew Stubbs, Peggy Scherle, Jonathan M. Irish, Richard Caprioli, Michael R. Savona. INCB52793 JAK1 inhibitor synergizes with ATRA to inhibit expansion of AML [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3726. doi:10.1158/1538-7445.AM2017-3726

[Botulinum toxin A injections in neuropathic pain : A post-hoc subgroup analysis of patients with peripheral nerve injury]

The randomized controlled trial (RCT) presented in this article showed significant relief in neuropathic pain following subcutaneous injections of botulinum toxin A over 24 weeks compared to placebo. This result was confirmed in a novel post-hoc analysis of the subgroup of 46 patients with peripheral nerve injury. Relevant adverse effects did not occur during the RCT.

[Role of anesthesiology in pain medicine and palliative care treatment in German hospitals : Survey of department heads of anesthesiology on treatment structures]

BACKGROUND

The aim of this analysis was to describe the role of anesthesiology departments in pain medicine and palliative care services in German hospitals.

METHOD

In the year 2012, all heads of departments of anesthesiology registered with the German Society of Anesthesiology and Intensive Care Medicine were surveyed about structures of pain medicine and palliative care services in their hospitals using a standardized postal questionnaire.

RESULTS

Out of 408 returned questionnaires (response rate 47%) 403 could be evaluated. Of the hospitals 58% had a designated pain medicine service, in 36 (9%) of the hospitals this was organized as an independent department and in 195 (57%) as part of another department, mostly the department of anesthesiology. The "pain clinic" as an outpatient service was the most common form of structure for pain medicine services (41%). Inpatient pain medicine units were available in 77 (19%) of the hospitals and a partial inpatient unit in the form of a day hospital in 26 (7%) of the hospitals. For the care of inpatients from other departments, there was an intrahospital pain consultation service in 166 of the hospitals, which was the only structure for pain medicine in 32 of the 231 hospitals that reported having a designated pain medicine service. In 160 pain medicine services anesthesiologists were the only medical practitioners and in a further 18 both anesthesiologists and other specialists were available (orthopedist/orthopedic surgeons n = 6, internal medicine n = 4, psychiatrist n = 2, general practitioner = 1 and neurologist n = 1). Only two hospitals had no anesthesiologist in the pain medicine team and for the remaining 51 hospitals no information was provided. In 189 of the 231 hospitals with pain medicine services, there was at least 1 physician with special qualifications in pain management. In 97 (44%) of the hospitals psychologists were part of the team with 53 having at least 1 psychologist with a special qualification in chronic pain management. Of the hospitals, 16% had a specialized department for palliative care, in 32% a specialized palliative care service was part of another department, which was the department of anesthesiology in 30%. Of the hospitals 56% had a palliative care consultation service, 41% had a specialized inpatient palliative care unit, 6% an outpatient clinic, 4% a day hospital and in 16% a specialized outpatient palliative care (SOPC) serving the community was incorporated. Inpatient consultation services and the SOPC were more common when the department of anesthesiology was involved in the palliative care services.

CONCLUSION

In German hospitals, the departments of anesthesiology make a significant contribution to the provision of both pain medicine and palliative care services. Nevertheless, the respective structures of care are often incomplete or even lacking. There were shortcomings in terms of organization and qualification of the team in pain medicine services (e.g. no doctor with special qualifications in pain management or no psychologist). Palliative care services are more often organized as independent departments than as pain medicine services. Engagement of the anesthesiology department in palliative care is linked to a broader scope of the services provided, which might reflect the capacity of many anesthesiologists to work in an interdisciplinary manner and across interfaces.

[Long-term opioid therapy in chronic noncancer pain. A systematic review and meta-analysis of efficacy, tolerability and safety in open-label extension trials with study duration of at least 26 weeks]

BACKGROUND

The efficacy and safety of long-term (≥ 6 months) opioid therapy (LtOT) in chronic noncancer pain (CNCP) is under debate. A systematic review with meta-analysis of the efficacy and harms of opioids in open-label extension studies of randomized controlled trials (RCTs) has not been conducted until now.

METHODS

We screened MEDLINE and clinicaltrials.gov (through to December 2013), as well as reference sections of systematic reviews of long-term RCTs of opioids in CNCP. We included open-label extension trials with a study duration ≥ 26 weeks of RCTs of ≥ 2 weeks duration. Using a random effects model, pooled estimates of event rates for categorical data and standardized mean differences (SMD) for continuous variables were calculated.

RESULTS

We included 11 open-label extension studies with 2445 participants with nociceptive (low back, osteoarthritis) and neuropathic (radicular, polyneuropathy) pain. Median study duration was 26 (range 26-108) weeks. Four studies tested oxycodone, two studies tramadol and buprenorphine; hydromorphone, morphine, oxymorphone and tapentadol were each tested in one study. Of the patients randomized at baseline, 28.5 % (95 % confidence interval, CI, 17.9-39.2 %) finished the open-label period; 53.5 % (95 % CI 38.1-68.2 %) of patients entering the open-label period finished the open-label period. In sum, the total loss was 71.5 % (95 % CI 60.9-83.1 %) of all patients primarily included into the RCT. A total of 4.9 % (95 % CI 2.9-8.2 %) of patients dropped out due lack of efficacy; 16.8 % (95 % CI 11.0-24.8 %) dropped out to due adverse events (AE) in the open-label period and 0.08 % (95 % CI 0.001-0.05 %) of patients died during the open-label period. Only one study systematically assessed aberrant drug behavior of the patients: 5.7 % (95 % CI 3.4-9.6 %) showed aberrant drug behavior in the opinion of the investigators and 2.6 % (95 % CI 1.2-5.8 %) were judged to show aberrant drug behavior by independent expert assessment. There was no significant change (p = 0.50) in pain intensity between the end of the randomized period and the end of open-label phase (SMD 0.19 [- 0.03, 0.41]; six studies with 1360 participants).

CONCLUSION

Only a minority of patients selected for opioid therapy at randomization finished the long-term open-label study. However, sustained effects of pain reduction could be demonstrated in these patients. LtOT can be considered in carefully selected and monitored CNCP patients who experience clinically meaningful pain reduction with at least tolerable AE in short-term opioid therapy. The English full-text version of this article is freely available at SpringerLink (under "Supplementary Material").

[Recommendations of the updated LONTS guidelines. Long-term opioid therapy for chronic noncancer pain]

BACKGROUND

The regular update of the German S3 guidelines on long-term opioid therapy for chronic noncancer pain (CNCP), the"LONTS" (AWMF registration number 145/003), began in November 2013.

METHODS

The guidelines were developed by 26 scientific societies and two patient self-help organisations under the coordination of the Deutsche Schmerzgesellschaft (German Pain Society). A systematic literature search in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Scopus databases (up until October 2013) was performed. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of the recommendations was established by multistep formal procedures, in order to reach a consensus according to German Association of the Medical Scientific Societies ("Arbeitsgemeinschaft der Wissenschaftlich Medizinischen Fachgesellschaften", AWMF) regulations. The guidelines were reviewed by the Drug Commission of the German Medical Association, the Austrian Pain Society and the Swiss Association for the Study of Pain.

RESULTS

Opioids are one drug-based treatment option for short- (4-12 weeks), intermediate- (13-25 weeks) and long-term (≥ 26 weeks) therapy of chronic osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia and low back pain. Contraindications are primary headaches, as well as functional somatic syndromes and mental disorders with the (cardinal) symptom pain. For all other clinical presentations, a short- and long-term therapy with opioid-containing analgesics should be evaluated on an individual basis. Long-term therapy with opioid-containing analgesics is associated with relevant risks (sexual disorders, increased mortality).

CONCLUSION

Responsible application of opioid-containing analgesics requires consideration of possible indications and contraindications, as well as regular assessment of efficacy and adverse effects. Neither an uncritical increase in opioid application, nor the global rejection of opioid-containing analgesics is justified in patients with CNCP.

WIP1 modulates responsiveness to Sonic Hedgehog signaling in neuronal precursor cells and medulloblastoma

High-level amplification of the protein phosphatase PPM1D (WIP1) is present in a subset of medulloblastomas (MBs) that have an expression profile consistent with active Sonic Hedgehog (SHH) signaling. We found that WIP1 overexpression increased expression of Shh target genes and cell proliferation in response to Shh stimulation in NIH3T3 and cerebellar granule neuron precursor cells in a p53-independent manner. Thus, we developed a mouse in which WIP1 is expressed in the developing brain under control of the Neurod2 promoter (ND2:WIP1). The external granule layer (EGL) in early postnatal ND2:WIP1 mice exhibited increased proliferation and expression of Shh downstream targets. MB incidence increased and survival decreased when ND2:WIP1 mice were crossed with an Shh-activated MB mouse model. Conversely, Wip1 knockout significantly suppressed MB formation in two independent mouse models of Shh-activated MB. Furthermore, Wip1 knockdown or treatment with a WIP1 inhibitor suppressed the effects of Shh stimulation and potentiated the growth inhibitory effects of SHH pathway-inhibiting drugs in Shh-activated MB cells in vitro. This suggests an important cross-talk between SHH and WIP1 pathways that accelerates tumorigenesis and supports WIP1 inhibition as a potential treatment strategy for MB.

Abstract 2451: Cancer stem cell survival postradiation in medulloblastomas requires YAP, YB1, and IGF2

Sonic hedgehog (Shh)-mediated medulloblastoma growth requires IGF2 (Insulin-like Growth Factor 2) and we recently showed that Yes Associated Protein (YAP1) induces IGF2 expression by Y-box protein 1(YB1) in Shh-stimulated cerebellar granule neural precursors (CGNPs), proposed cells-of-origin for the Shh molecular subclass of medulloblastoma, and mouse Shh-medulloblastoma cells. We found elevated levels of YAP1, YB1 and IGF2 in tumor cells occupying the peri-vascular niche, a microenvironmental niche proposed to house so-called tumor re-populating cells that survive radiation and contribute to medulloblastoma recurrence, which is fatal. We have developed an ex vivo approach using organotypic brain tumor slice cultures to better understand how YAP1, YB1, and IGF2 regulate peri-vascular niche cell survival post-radiation. We observed that the perivascular niche cell population expressing stem cell markers increases markedly following exposure to radiation. Additionally, on targeting any component of the YAP1-YB1-IGF2 axis we observed increased level of cell death within the niche and compromised cancer stem cell niche expansion post-radiation. These findings strongly indicate that therapeutic approaches intended to impair the function of this pathway could be used to reduce the use of cranio-spinal radiation of medulloblastoma patients, which causes life-long side effects that drastically impair quality of life.

Citation Format: Abhinav Dey, Caroline Maier, Anshu Malhotra, Anna Kenney. Cancer stem cell survival postradiation in medulloblastomas requires YAP, YB1, and IGF2. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2451.

[Survey of pain after ambulatory surgery: An internet-based instrument]

BACKGROUND AND AIM

Pain after surgery continues to be undermanaged. Studies and initiatives aiming to improve the management of postoperative pain are growing; however, most studies focus on inpatients and pain on the first day after surgery. The management of postoperative pain after ambulatory surgery and for several days thereafter is not yet a major focus. One reason is the low return rate of the questionnaires in the ambulatory sector. This article reports the development and feasibility of a web-based electronic data collection system to examine pain and pain-related outcome on predefined postoperative days after ambulatory surgery.

MATERIAL AND METHODS

In this prospective pilot study 127 patients scheduled for ambulatory surgery were asked to participate in a survey to evaluate aspects related to pain after ambulatory surgery. The data survey was divided in (1) a preoperative, intraoperative and postoperative part and (2) a postoperative internet-based electronic questionnaire which was sent via e-mail link to the patient on days 1, 3 and 7 after surgery. A software was developed using a PHP-based platform to send e-mails and retrieve the data after web-based entries via a local browser. Feasibility, internet-based hitches and compliance were assessed by an additional telephone call after day 7.

RESULTS

A total of 100 patients (50 female) between 18 and 71 years (mean 39.1 ± 12.7 years) were included in the pilot study. Return rates of the electronic questionnaires were 86% (days 3 and 7) and 91% (day 1 after surgery). All 3 electronic questionnaires were answered by 82% of patients. Aspects influencing the return rate of questionnaires were work status but not age, gender, education level and preoperative pain. Telephone interviews were performed with 81 patients and revealed high operability of the internet-based survey without any major problems.

CONCLUSION

The user-friendly feasibility and operability of this internet-based electronic data survey system explain the high compliance and return rate of electronic questionnaires by patients at home after ambulatory surgery. This survey tool therefore provides unique opportunities to evaluate and improve postoperative pain management after ambulatory surgery.

Spectroscopy of Interacting Quasiparticles in Trapped Ions

The static and dynamic properties of many-body quantum systems are often well described by collective excitations, known as quasiparticles. Engineered quantum systems offer the opportunity to study such emergent phenomena in a precisely controlled and otherwise inaccessible way. We present a spectroscopic technique to study artificial quantum matter and use it for characterizing quasiparticles in a many-body system of trapped atomic ions. Our approach is to excite combinations of the system's fundamental quasiparticle eigenmodes, given by delocalized spin waves. By observing the dynamical response to superpositions of such eigenmodes, we extract the system dispersion relation, magnetic order, and even detect signatures of quasiparticle interactions. Our technique is not limited to trapped ions, and it is suitable for verifying quantum simulators by tuning them into regimes where the collective excitations have a simple form.

[Optimising pain therapy for neurological inpatients]

BACKGROUND

The Department of Neurology at the Medical University Graz has implemented a multiprofessional pain management concept and evaluated the outcome by means of a patient survey.

METHODS

Standard operating procedures for standardised pain measurement, documentation and therapy were developed. All engaged professional participants were trained before implementation.

RESULTS

88.7 % of the surveyed 63 patients reported pain during the hospitalisation. During the night and in the morning, the occurrence of severe pain was most likely. The position or activity most likely triggering severe pain was mobilisation (19 %). Patients with degenerative diseases of the spine without radiculopathy reported the highest levels of pain.

CONCLUSIONS

Pain is an important problem for neurological inpatients. Nocturnal pain, pain induced by mobilisation, and pain therapy for patients with degenerative diseases of the spine without radiculopathy require particular attention.