P1077Late gadolinium enhancement with cardiac magnetic resonance imaging demonstrates left ventricular involvement is under-recognized in arrhythmogenic right ventricular cardiomyopathy

Funding Acknowledgements

The study is partially funded by Medtronic and the Minneapolis Heart Institute Foundation.

Background/Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is characterized by replacement of the myocardium with fibrous and fatty tissue that may lead to an increased risk of ventricular arrhythmias and heart failure.  Although left ventricular (LV) and biventricular forms have been identified post-mortem resulting in the increased use of the term arrhythmogenic cardiomyopathy, there is only inclusion of right ventricular wall motion abnormalities in the taskforce diagnostic criteria.

Purpose

The aim of our study was to examine the utility of cardiac magnetic resonance (CMR) imaging in characterizing LV or biventricular involvement with late gadolinium enhancement (LGE) in a large cohort of patients with suspected ARVC.

Methods

Retrospective, single-institution, chart review of 76 patients diagnosed with ARVC between January 2009 and July 2019. Data collection and analysis included baseline demographics and parameters specific to diagnosis (definite, borderline, or possible) and risk stratification of ARVC based on 2019 modified taskforce criteria, as well as detailed CMR evaluation.

Results

Of the 76 patients with ARVC, 66 (87%) had at least one CMR with gadolinium administered. In that subset of patients, 27 (41%) had LGE. Of those with LGE, LV involvement was identified in 23 (85%) patients. The pattern of LGE was not localized to one myocardial region but demonstrated variable LV enhancement patterns including anterior, inferior, lateral, septal, basal, mid, apical, and from the sub-epicardium into the mid-myocardium.

Conclusions

  Left ventricular involvement reflected by LGE was identified in a high percentage of patients with suspected ARVC, and there was significant variation in the pattern of distribution in terms of region and depth of myocardial involvement.  While post-mortem examination of patients with ARVC demonstrates a high prevalence of left ventricular involvement, this study shows that CMR can consistently detect late gadolinium enhancement, and ARVC should be considered in the differential diagnosis for biventricular cardiomyopathy.  The identification of variable locations of LGE within the LV suggests there is more than one phenotype, and this imaging modality may help to clarify the implications of left ventricular involvement in disease progression.

Schmerzhafte artifizielle Ekchymosen an Hals und Gesicht

Es wird über den Fall einer 13-jährigen Patientin mit neu aufgetretenen, auf Druck schmerzhaften Hautveränderungen beidseits am Hals und im Gesicht berichtet. Auf Nachfrage traten die Effloreszenzen episodisch im Rahmen von Stresssituationen auf. Im Verlauf kam es zu einer Spontanheilung mit Narbenbildung und mehreren Rezidiven. Nach erfolgter Probebiopsie wurde ein Gardner-Diamond-Syndrom ausgeschlossen und der Verdacht auf selbstinduzierte Hautläsionen geäußert.

Influence of birth cohort on age of onset cluster analysis in bipolar I disorder

Purpose:

Two common approaches to identify subgroups of patients with bipolar disorder are clustering methodology (mixture analysis) based on the age of onset, and a birth cohort analysis. This study investigates if a birth cohort effect will influence the results of clustering on the age of onset, using a large, international database.

Methods:

The database includes 4037 patients with a diagnosis of bipolar I disorder, previously collected at 36 collection sites in 23 countries. Generalized estimating equations (GEE) were used to adjust the data for country median age, and in some models, birth cohort. Model-based clustering (mixture analysis) was then performed on the age of onset data using the residuals. Clinical variables in subgroups were compared.

Results:

There was a strong birth cohort effect. Without adjusting for the birth cohort, three subgroups were found by clustering. After adjusting for the birth cohort or when considering only those born after 1959, two subgroups were found. With results of either two or three subgroups, the youngest subgroup was more likely to have a family history of mood disorders and a first episode with depressed polarity. However, without adjusting for birth cohort (three subgroups), family history and polarity of the first episode could not be distinguished between the middle and oldest subgroups.

Conclusion:

These results using international data confirm prior findings using single country data, that there are subgroups of bipolar I disorder based on the age of onset, and that there is a birth cohort effect. Including the birth cohort adjustment altered the number and characteristics of subgroups detected when clustering by age of onset. Further investigation is needed to determine if combining both approaches will identify subgroups that are more useful for research.

On-site CAD templates reduce surgery time for complex craniostenosis repair in infants: a new method

INTRODUCTION

The surgical correction of craniostenosis in children is a time-consuming and taxing procedure. To facilitate this procedure, especially in infants with complex craniostenosis, we refined the computer-aided design and manufacturing technique (CAD/CAM) based on computed tomography (CT)-generated DICOM data. We used cutting guides and molding templates, which allowed the surgeon to reshape and fixate the supraorbital bar extracorporeally on a side table and to control the intracorporal fit without removing the template.

METHOD AND PATIENTS

To compare our traditional concept with the possibility of preoperative virtual planning (PVP) technique, the surgical treatment and courses of 16 infants with complex craniostenosis following fronto-orbital advancement (FOA) (age range 8-15 months) were analyzed in two groups (group 1: traditional, control group n = 8, group 2: CAD/CAM planned, n = 8).

RESULTS

While in both groups, the head accurately reshaped postoperatively during the follow-up; the CAD group 2 showed a significantly shorter operating time with a mean of 4 h 25 min compared with group 1 with a mean of 5 h 37 min (p = 0.038). Additionally, the CAD group 2 had a significantly lower volume of blood loss (380 ml vs. 575 ml mean, p = 0.047), lower blood transfusion volume (285 ml vs. 400 ml mean, p = 0.108), lower fresh frozen plasma (FFP) volume (140 ml vs. 275 ml mean, p = 0.019), shorter stay in the pediatric intensive care unit (PICU) (3 vs. 5 days mean (p = 0.002), and shorter total length of hospital stay (6 days vs. 8 days mean, p = 0.002).

CONCLUSION

CAD/CAM cutting guides and templates offer optimizing operative efficiency, precision, and accuracy in craniostenosis surgery in infants. As shown in this single-center observational study, the use of on-site templates significantly accelerates the reconstruction of the bandeau. The virtual 3D planning technique increases surgical precision without discernible detrimental effects.

[Assessing pain in patients with dementia]

The diagnostics of pain in older people with cognitive impairments should always consist of a subjective self-report of pain and a structured observation of pain behavior. It is important to note that the subjective self-report of pain becomes less valid with increasing cognitive decline (starting with a moderate degree of dementia). The external observation of pain behavior should include at least the three behavioral domains facial expressions, body movements and vocalization and should be performed during resting situations and during activities of daily living. Moreover, the patient should be observed for at least 3 min. Online forms of training have recently been developed and are freely available for training in external observation.

The exotic species Senecio inaequidens pays the price for arriving late in temperate European grassland communities

The exotic South African ragwort (Senecio inaequidens DC.) rapidly spread across Central Europe after its introduction, but we still do not know to what extent its timing of arrival in a plant community (i.e. before or after natives) and the composition of the native community being invaded affect (1) its capacity to invade a European grassland, (2) the performance of the native species, and (3) the direction and strength of priority effects. In a greenhouse experiment, we manipulated the timing of arrival of the exotic species (Senecio) and the composition of the native community to test the influence of these factors on the productivity and N content of exotic and native species. We also investigated if the plant species origin (native or exotic) and the native community composition affected the benefit of arriving early and the cost of arriving late in the community. The establishment success of Senecio strongly depended on its timing of arrival in a grassland community. Senecio benefited more from arriving early than did the natives. The presence of legumes in the community did not favour invasion by Senecio. When natives arrived later than Senecio, however, priority effects were weaker when legumes were part of the native community. Our results showed that inhibitory priority effects created by natives can lower the risk of invasion by Senecio. An early arrival of this species at a site with low native species abundance is a scenario that could favour invasion.

Observational pain assessment in older persons with dementia in four countries: Observer agreement of items and factor structure of the Pain Assessment in Impaired Cognition

BACKGROUND

Recognition of pain in people with dementia is challenging. Observational scales have been developed, but there is a need to harmonize and improve the assessment process. In EU initiative COST-Action TD1005, 36 promising items were selected from existing scales to be tested further. We aimed to study the observer agreement of each item, and to analyse the factor structure of the complete set.

METHODS

One hundred and ninety older persons with dementia were recruited in four different countries (Italy, Serbia, Spain and The Netherlands) from different types of healthcare facilities. Patients represented a convenience sample, with no pre-selection on presence of (suspected) pain. The Pain Assessment in Impaired Cognition (PAIC, research version) item pool includes facial expressions of pain (15 items), body movements (10 items) and vocalizations (11 items). Participants were observed by health professionals in two situations, at rest and during movement. Intrarater and interrater reliability was analysed by percentage agreement. The factor structure was examined with principal component analysis with orthogonal rotation.

RESULTS

Health professionals performed observations in 40-57 patients in each country. Intrarater and interrater agreement was generally high (≥70%). However, for some facial expression items, agreement was sometimes below 70%. Factor analyses showed a six-component solution, which were named as follows: Vocal pain expression, Face anatomical descriptors, Protective body movements, Vocal defence, Tension and Lack of affect.

CONCLUSIONS

Observation of PAIC items can be done reliably in healthcare settings. Observer agreement is quite promising already without extensive training.

SIGNIFICANCE

In this international project, promising items from existing observational pain scales were identified and evaluated regarding their reliability as an alternative to pain self-report in people with dementia. Analysis on factor structure helped to understand the character of the items. Health professionals from four countries using four different European languages were able to rate items reliably. The results contributed to an informed reduction of items for a clinical observer scale (Pain Assessment in Impaired Cognition scale with 15 items: PAIC15).

The Pain Assessment in Impaired Cognition scale (PAIC15): A multidisciplinary and international approach to develop and test a meta-tool for pain assessment in impaired cognition, especially dementia

BACKGROUND

Over the last decades, a considerable number of observational scales have been developed to assess pain in persons with dementia. The time seems ripe now to build on the knowledge and expertize implemented in these scales to form an improved, "best-of" meta-tool. The EU-COST initiative "Pain in impaired cognition, especially dementia" aimed to do this by selecting items out of existing observational scales and critically re-assessing their suitability to detect pain in dementia. This paper reports on the final phase of this collaborative task.

METHODS

Items from existing observational pain scales were tested for "frequency of occurrence (item difficulty)," "reliability" and "validity." This psychometric testing was carried out in eight countries, in different healthcare settings, and included clinical as well as experimental pain conditions.

RESULTS

Across all studies, 587 persons with dementia, 27 individuals with intellectual disability, 12 Huntington's disease patients and 59 cognitively healthy controls were observed during rest and movement situations or while receiving experimental pressure pain, respectively. The psychometric outcomes for each item across the different studies were evaluated within an international and multidisciplinary team of experts and led a final selection of 15 items (5x facial expressions, 5x body movements, 5x vocalizations).

CONCLUSIONS

The final list of 15 observational items have demonstrated psychometric quality and clinical usefulness both in their former scales and in the present international evaluation; accordingly, they qualified twice to form a new internationally agreed-on meta-tool for Pain Assessment in Impaired Cognition, the PAIC-15 scale.

SIGNIFICANCE

Using a meta-tool approach by building on previous observational pain assessment scales and putting the items of these scales through rigorous empirical testing (using experimental as well as clinical pain studies in several European countries), we were able to identify the best items for pain assessment in individuals with impaired cognition. These selected items form the novel PAIC15 scale (pain assessment in impaired cognition, 15 items).

Executive Functions and Pain

Abstract. A growing body of literature suggests that chronic-pain patients suffer from problems in various neuropsychological domains, including executive functioning. In order to better understand which components of executive functioning (inhibition, shifting and/or updating) might be especially affected by pain and which mechanisms might underlie this association, we conducted a systematic review, including both chronic-pain studies as well as experimental-pain studies. The chronic-pain studies (N = 57) show that pain is associated with poorer executive functioning. The findings of experimental-pain studies (N = 28) suggest that this might be a bidirectional relationship: Pain can disrupt executive functioning, but poorer executive functioning might also be a risk factor for higher vulnerability to pain.

Absence of herb-drug interactions of mistletoe with the tamoxifen metabolite (E/Z)-endoxifen and cytochrome P450 3A4/5 and 2D6 in vitro

Background

Women diagnosed with breast cancer frequently seek complementary and alternative (CAM) treatment options that can help to cope with their disease and the side effects of conventional cancer therapy. Especially in Europe, breast cancer patients use herbal products containing mistletoe (Viscum album L.). The oldest and one of the most prescribed conventional drugs for the treatment of estrogen receptor positive breast cancer is tamoxifen. Aside from positive clinical experience with the combination of tamoxifen and mistletoe, little is known about possible herb-drug interactions (HDIs) between the two products. In the present in vitro study, we investigated the effect of standardized commercial mistletoe preparations on the activity of endoxifen, the major active metabolite of tamoxifen.

Methods

The estrogen receptor positive human breast carcinoma cell line MCF-7 was treated with (E/Z)-endoxifen hydrochloride in the presence and absence of a defined estradiol concentration. Each concentration of the drug was combined with fermented Viscum album L. extracts (VAE) at clinically relevant doses, and proliferation, apoptosis and cell cycle were analyzed. In parallel, possible inhibition of CYP3A4/5 and CYP2D6 was investigated using 50-donor mixed gender pooled human liver microsomes (HLMs).

Results

VAE did not inhibit endoxifen induced cytostasis and cytotoxicity. At higher concentrations, VAE showed an additive inhibitory effect. VAE preparations did not cause inhibition of CYP3A4/5 and CYP2D6 catalyzed tamoxifen metabolism.

Conclusions

The in vitro results suggest that mistletoe preparations can be used in combination with tamoxifen without the risk of HDIs.

Electronic supplementary material

The online version of this article (10.1186/s12906-019-2439-2) contains supplementary material, which is available to authorized users.

Does EEG activity during painful stimulation mirror more closely the noxious stimulus intensity or the subjective pain sensation?

BACKGROUND

Many researchers have tried to investigate pain by studying brain responses. One method used to investigate pain-related brain responses is continuous electroencephalography (EEG). The objective of the current study is to add on to our understanding of EEG responses during pain, by differentiation between EEG patterns indicative of (i) the noxious stimulus intensity and (ii) the subjective pain sensation.

METHODS

EEG was recorded during the administration of tonic experimental pain, consisting of six minutes of contact heat applied to the leg via a thermode. Two stimuli above pain threshold, one at pain threshold and two non-painful stimuli were administered. Thirty-six healthy participants provided a subjective pain rating during thermal stimulation. Relative EEG power was calculated for the frequency bands alpha1, alpha2, beta1, beta2, delta, and theta.

RESULTS

Whereas EEG activity could not be predicted by stimulus intensity (except in one frequency band), subjective pain sensation could significantly predict differences in EEG activity in several frequency bands. An increase in the subjective pain sensation was associated with a decrease in alpha2, beta1, beta2 as well as in theta activity across the midline electrodes.

CONCLUSION

The subjective experience of pain seems to capture unique variance in EEG activity above and beyond what is captured by noxious stimulus intensity.

Which Facial Descriptors Do Care Home Nurses Use to Infer Whether a Person with Dementia Is in Pain?

Objectives

Pain assessment in people with advanced dementia relies strongly on observable pain behaviors, such as facial expressions, body movement, and vocalizations. However, the process of inferring pain in others based on such observations is not well understood. We aimed to investigate which features of facial expressions caregivers rely on when inferring the presence and intensity of pain in people with dementia.

Methods

A questionnaire, including items on 13 facial descriptors, which were extracted from established observational scales for pain in dementia, was sent to 366 nursing homes in Germany. We asked the nurses to observe patients with dementia and then rate their observations using the facial descriptors, as well as to provide an overall pain estimate of the residents' pain. We used regression analyses to identify which facial descriptors nurses use most commonly to infer whether a person with dementia is in pain and to grade the pain's intensity.

Results

Seventy-nine nursing homes participated (22% response rate), and a total of 284 completed observer ratings were returned. The observed individuals suffered from moderate to severe dementia and were observed in everyday care situations. The average pain estimated by the caregivers was slight to moderate. Mainly anatomically based descriptors ("frowning," "narrowed eyes") and indicators of emotional arousal ("looking tense," looking frightened") significantly predicted the overall pain ratings by nurses, explaining approximately 45% of the variance.

Conclusions

Although all presented facial descriptors were used by the nurses, some descriptors were used clearly more frequently than others to infer whether a resident with dementia was in pain. Development of observational pain tools and training in their use should consider the preexisting assumptions that nurses use to infer pain as well as their potential bias.

Using observational facial descriptors to infer pain in persons with and without dementia

Background

For patients with advanced dementia, pain diagnosis and assessment requires observations of pain-indicative behavior by others. One type of behavior that has been shown to be a promising candidate is the facial response to pain. To further test how pain-indicative facial responses are, we investigated the predictive power of observational facial descriptors to (i) predict the self-report of pain and (ii) to differentiate between non-painful and painful conditions. In addition, the expertise of the observers (nurses vs. healthy controls) and the cognitive status of the observed (dementia vs. cognitively healthy) were considered.

Methods

Overall 62 participants (32 nurses and 30 control subjects) watched 40 video-clips, showing facial expressions of older individuals with and without dementia during non-painful and painful pressure stimulation. After each clip, participants were asked to rate the videos using commonly used facial descriptors of pain and also to provide global pain estimate ratings of how much pain the observed individual might have experienced.

Results

Out of the 12 facial descriptors used, only 7 were able to differentiate between non-painful and painful conditions. Moreover, participants were better in predicting the pain self-report of the observed individuals when using facial descriptors than when using global pain estimates. Especially, the anatomically-orienting descriptors (e.g. opened mouth, narrowing eyes) showed greatest predictive power. Results were not affected by pain-expertise of the observers (nurses vs. control subjects) or diagnostic status of the observed (patients with dementia vs. cognitively unimpaired subjects).

Conclusions

The fine-grained and specific observation of facial responses to acute pain appeared to provide valid indication of pain that is not compromised when patients with dementia are observed. The regular professional training does not put nurses at advantage to detect pain via facial responses.

Facial Pain Expression in Dementia: A Review of the Experimental and Clinical Evidence

The analysis of the facial expression of pain promises to be one of the most sensitive tools for the detection of pain in patients with moderate to severe forms of dementia, who can no longer self-report pain. Fine-grain analysis using the Facial Action Coding System (FACS) is possible in research but not feasible for clinical use at the moment because it is too time and effort consuming. Studies using the FACS showed either enhanced facial responses or no alterations of facial activity during pain in patients with cognitive impairment. Pain assessment in the clinical context relies strongly on the use of observational scales when self-report has become invalid. All of the established scales include items describing facial responses to pain. Despite this agreement, the content of these face items is very different, ranging from anatomically-based descriptions to inference of internal states. Recent studies let the anatomical orientation appear more promising. Automated video systems for the detection of pain in patients with dementia may lead to ground-breaking improvements of pain care in the future.

Solar insolation in springtime influences age of onset of bipolar I disorder

OBJECTIVE

To confirm prior findings that the larger the maximum monthly increase in solar insolation in springtime, the younger the age of onset of bipolar disorder.

METHOD

Data were collected from 5536 patients at 50 sites in 32 countries on six continents. Onset occurred at 456 locations in 57 countries. Variables included solar insolation, birth-cohort, family history, polarity of first episode and country physician density.

RESULTS

There was a significant, inverse association between the maximum monthly increase in solar insolation at the onset location, and the age of onset. This effect was reduced in those without a family history of mood disorders and with a first episode of mania rather than depression. The maximum monthly increase occurred in springtime. The youngest birth-cohort had the youngest age of onset. All prior relationships were confirmed using both the entire sample, and only the youngest birth-cohort (all estimated coefficients P < 0.001).

CONCLUSION

A large increase in springtime solar insolation may impact the onset of bipolar disorder, especially with a family history of mood disorders. Recent societal changes that affect light exposure (LED lighting, mobile devices backlit with LEDs) may influence adaptability to a springtime circadian challenge.

Psychometric Properties of the German Version of the Pain Vigilance and Awareness Questionnaire (PVAQ) in Pain-Free Samples and Samples with Acute and Chronic Pain

Purpose

The way individuals attend to pain is known to have a considerable impact on the experience and chronification of pain. One method to assess the habitual “attention to pain” is the Pain Vigilance and Awareness Questionnaire (PVAQ). With the present study, we aimed to test the psychometric properties of the German version of the PVAQ across pain-free samples and across patients with acute and chronic pain.

Method

Two samples of pain-free individuals (student sample (N = 255)/non-student sample (N = 362)) and two clinical pain samples (acute pain patients (N = 105)/chronic pain patients (N = 36)) were included in this cross-sectional evaluation of the German PVAQ. Factor structure was assessed using exploratory and confirmatory factor analyses. Reliability was assessed using internal consistency (Cronbach’s alpha). Construct validity was tested by assessing correlations between PVAQ and theoretically related constructs.

Results

Exploratory factor analysis (non-student sample) and confirmatory factor analysis (student sample, acute pain patient sample) suggested that a two-factor solution best fitted our data (“attention to pain,” “attention to changes in pain”). Internal consistency ranged from acceptable to good in all four samples. As hypothesized, the PVAQ correlated significantly with theoretically related constructs in all four samples, suggesting good construct validity in pain-free individuals and in pain patients.

Conclusion

The German PVAQ shows good psychometric properties across samples of pain-free individuals and patients suffering from pain that are comparable to PVAQ versions of other languages. Thus, the German PVAQ seems to be a measure of pain vigilance equally valid as found in other countries.