Management of Persistent Syringomyelia in Patients Operated for Chiari Malformation Type 1

BACKGROUND

The treatment of persistent syringomyelia associated with Chiari malformation type 1 (CM1) is unclear. This study aims to evaluate the clinical and radiologic outcomes of syringo-subarachnoid shunt (SSS) as a treatment for persistent syringomyelia following posterior fossa decompression (PFD) for CM1.

METHODS

Forty-nine cases treated for CM1 associated syringomyelia at a single center were analyzed, 17 of them undergoing reoperation due to persistent syrinx formation. The patients' demographic data, neurologic presentations, and radiologic results were analyzed, including cerebellar herniation, posterior fossa volume, the level at which the syrinx started and finished, the size and diameter of the syrinx.

RESULTS

Seventeen patients underwent SSS placement, with 1 minor surgical complication (a cerebrospinal fluid leak) occurring and requiring revision. No morbidity or mortality was observed. Among these 17 reoperated patients, partial or complete resorption of the syrinx was observed in all cases. The results suggest that if the syrinx diameter is >10 mm at its thickest point, extends for more than 10 vertebrae, and starts from the upper cervical region and extends to the upper thoracic region, the syrinx may not regress after the first surgery and potentially predicting the need for a second operation before PFD.

CONCLUSIONS

SSS placement for persistent syrinx following PFD for CM1 is a safe and effective surgical treatment method. These criteria may also help predict the need for a second surgery and the overall disease outcome for both the surgeon and patient.

An investigation on protection properties of Tantalum (V) oxide reinforced glass screens on unexposed breast tissue for mammography examinations

INTRODUCTION

The utilization of radiation shielding material positioned between the both breasts are crucial for the reduction of glandular dose and the safeguarding of the contralateral breast during mammographic procedures. This study proposes an alternative substance for shielding the contralateral breast from radiation exposure during mammography screening.

METHODS

In this study, we present an analysis of the shielding effectiveness of transparent glass that has been doped with Tantalum (V) oxide encoded as BTZT6. The evaluation of this shielding material was conducted using the MCNPX code, specifically for the ipsilateral and contralateral breasts. The design of the left and right breast phantoms involved the creation of three-layer heterogeneous breast phantoms, consisting of varying proportions of glandular tissue (25%, 50%, and 75%). The design of BTZT6 and lead-acrylic shielding screens is implemented using the MCNPX code. The comparative analysis of dose outcomes is conducted to assess the protective efficacy of BTZT6 and lead-acrylic shielding screens.

RESULTS

The utilization of BTZT6 shielding material resulted in a reduction in both breast dose and skin dose exposure when compared to the lead-acrylic shield.

CONCLUSION

Based on the findings acquired, the utilization of BTZT6 shielding material screens during mammography procedures involving X-rays with energy levels ranging from 26 to 30 keV is associated with a decrease in radiation dose.

IMPLICATIONS FOR PRACTICE

It can be inferred that the utilization of BTZT6 demonstrates potential efficacy in mitigating excessive radiation exposure to the breasts and facilitating the quantification of glandular doses in mammography procedures.

Predictive role of magnetic resonance imaging in the distinction of isocitrate dehydrogenase (IDH) mutant grade 4 astrocytomas versus glioblastomas

BACKGROUND

Isocitrate dehydrogenase (IDH) mutation status is a crucial prognostic factor in high-grade glial tumors.

PURPOSE

To investigate whether magnetic resonance imaging (MRI) features can display a diagnostic performance in the determination of IDH mutation in high-grade gliomas.

MATERIAL AND METHODS

A total of 170 patients including 24 IDH mutant grade 4 astrocytomas and 146 glioblastomas (GBM) were retrospectively examined via contrast-enhanced (CE) MRI before surgery. Immunohistochemistry and genomic sequence analyses were performed on specimen materials for the determination of IDH mutational status. Certain morphological and diffusion-weighted imaging (DWI) parameters were utilized to see if they could play a role to be non-invasive potential imaging predictors in the discrimination of IDH mutant versus wild-type (WT) high-grade gliomas.

RESULTS

On histopathological examination, IDH mutation was detected in 24 patients with high-grade glioma and 146 of the patients were found to be WT. Certain morphological criteria of tumor location and involvement, tumor margins, visual detection of diffusion restriction on DWI, and quantitative apparent diffusion coefficient (ADC) parameters consisting of ADC_mean, ADC_min, and ADC_r could be used as imaging predictors in the discrimination of high-grade IDH mutant versus WT tumors.

CONCLUSION

Certain MRI morphologic features and visual detection of diffusion restriction on DWI and quantitative ADC parameters consisting of ADC_mean, ADC_min, and ADC_r can be considered non-invasive, significant independent imaging predictors in the discrimination and can obviate invasive procedures for histopathological diagnosis.

Chiari Type III Malformation Presenting With Two Huge Encephaloceles in a New Born Infant: Case Report

Arnold-Chiari type III malformation constitutes the rarest type of all the Chiari malformations. This extremely rare congenital anomaly shows poor prognosis and results in either early death or development of various severe neurologic deficits in the surviving patients. It is characterized by the herniation of hindbrain contents into an encephalocele sac through a bony defect located in the upper cervical or lower occipital region. Magnetic resonance imaging (MRI) is the preferred imaging modality in the diagnosis of this rare congenital anomaly, especially due to its multiplanar capability. In this case report, we described the imaging findings of Arnold-Chiari type III malformation in a newborn male infant. He presented with two huge encephalocele sacs containing dysplastic brain tissues in the upper cervical and lower occipital regions together with various findings related to the disease. Following a right-sided shunt insertion for hydrocephalus treatment, he has undergone a surgical procedure ensuring removal of the encephalocele sacs with primary closure of the bony defects.

Intermittent systemic exposure to lipopolysaccharide-induced inflammation disrupts hippocampal long-term potentiation and impairs cognition in aging male mice

Age-related cognitive decline, a common component of the brain aging process, is associated with significant impairment in daily functioning and quality of life among geriatric adults. While the complexity of mechanisms underlying cognitive aging are still being elucidated, microbial exposure and the multifactorial inflammatory cascades associated with systemic infections are emerging as potential drivers of neurological senescence. The negative cognitive and neurobiological consequences of a single pathogen-associated inflammatory experience, such as that modeled through treatment with lipopolysaccharide (LPS), are well documented. Yet, the brain aging impacts of repeated, intermittent inflammatory challenges are less well studied. To extend the emerging literature assessing the impact of infection burden on cognitive function among normally aging mice, here, we repeatedly exposed adult mice to intermittent LPS challenges during the aging period. Male 10-month-old C57BL6 mice were systemically administered escalating doses of LPS once every two weeks for 2.5 months. We evaluated cognitive consequences using the non-spatial step-through inhibitory avoidance task, and both spatial working and reference memory versions of the Morris water maze. We also probed several potential mechanisms, including cortical and hippocampal cytokine/chemokine gene expression, as well as hippocampal neuronal function via extracellular field potential recordings. Though there was limited evidence for an ongoing inflammatory state in cortex and hippocampus, we observed impaired learning and memory and a disruption of hippocampal long-term potentiation. These data suggest that a history of intermittent exposure to LPS-induced inflammation is associated with subtle but significantly impaired cognition among normally aging mice. The broader impact of these findings may have important implications for standard of care involving infections in aging individuals or populations at-risk for dementia.

Radioprotective effects of dexmedetomidine on X-ray-induced testicular damage

OBJECTIVE

Approximately 70% of cancer patients require radiotherapy. However, despite its effectiveness in the treatment of cancer, radiotherapy can also affect and damage surrounding healthy tissues in addition to tumorous tissues. Since testicular tissues are highly radiosensitive, radiotherapy can cause impairments in spermatogenesis leading to infertility. The purpose of this study was to examine the potential radio-protective effect of dexmedetomidine (Dex), an α2-adrenoceptor agonist, on oxidative stress and apoptosis in testicular tissues caused by x-irradiation in rats.

MATERIALS AND METHODS

Thirty male Sprague-Dawley rats were allocated into three groups of ten (n=10): control, irradiation (IR), and IR + Dex groups. The IR group was exposed to a single dose of 2 Gy IR. The IR+Dex group was given a single intraperitoneal (i.p.) dose of 100 µg/kg Dex before IR. The control group received a single dose of saline solution i.p. Testicular tissues removed 24 hours after IR were subjected to histochemical, biochemical, and immunohistochemical analysis.

RESULTS

IR resulted in increased malondialdehyde (MDA) activity and significant changes in testis tissues. However, the application of Dex elevated glutathione levels by preventing MDA formation. In addition, Dex decreased tubular epithelial apoptosis via elevated Cleaved Caspase-3 expressions.

CONCLUSIONS

Dex exhibited a radio-protective effect against lipid peroxidation and apoptosis caused by IR.

Feasibility and image quality of myocardial perfusion imaging by CMR in patients with conditional and non-conditional cardiac devices

Purpose

First, to determine image quality using different cardiovascular magnetic resonance (CMR) perfusion protocols in patients with all available active device types in a real-world setting, including non-conditional devices.

Second, to demonstrate feasibility of high-quality perfusion imaging using spoiled gradient echo (sGE) protocols for non-invasive stress-testing.

Methods

From August 2020 to March 2022, N=222 patients with active cardiac implantable electronic devices (CIED) were scanned on a 1.5-T MR scanner (Philips Ingenia and Ambition). Our CMR scanning protocol was tailored to the clinical indication, and whenever myocardial perfusion imaging was possible, both a conventional steady-state-free-precession (SSFP)-based and a modified sGE-perfusion protocol were applied. Such a tailored perfusion protocol was performed in N=119 patients (70% men) with exclusively left-sided devices (pacemaker (PM), n=45; implantable cardioverter-defibrillator (ICD), n=46; subcutaneous ICD (S-ICD), n=15 and cardiac resynchronization therapy-pacemaker (CRT-P, n=5) or -defibrillator (CRT-D, n=8) with a percentage of 10% non-conditional devices. For assessment of image quality, a semi-quantitative 4-point grading scale was used based on a standard 16-segment model.

Results

A total of N=33 stress-tests with either regadenosone, adenosine or dobutamine and N=86 rest perfusion protocols were performed. Asynchronous pacing was required in 34% of the patients due to a heart rate of <40bpm. Device interrogation before and after CMR scanning showed no significant changes. Image quality was substantially better in sGE-based perfusion protocols compared to conventional SSFP-based perfusion in ICD, CRT-D and S-ICD patients (p<0.001). In patients with PM/ CRT-P image quality was neither significantly impaired in SSFP- nor in sGE-based protocols. Most device artefacts were located primarily in the anterior myocardial segments (1, 7, 13) in transvenous implanted devices and lateral in SICD-patients. A significant relationship between the extent of device artefacts and the parameters LVEDV (p=0.03), LVESV (p=0.005) and non-conditional devices (p=0.029) in SSFP-perfusion protocols were found in patients with PM/CRT-P. In contrast, there was no correlation between clinical and CMR-parameters in patients with ICD/ CRT-D. In S-ICD-patients, there was an inverse relationship between the extent of device artefact and age (p=0.006), BMI (p=0.001) in sGE-perfusion.

Conclusion

Myocardial perfusion imaging by CMR is safe and feasible with high image-quality in patients with all kinds of CIEDs – including MR-conditional as well as non-conditional devices. When performing CMR-based myocardial perfusion imaging in patients with left-sided ICD/CRT-D/S-ICD, a sGE-based perfusion-protocol should be preferred compared to conventional SSFP-based perfusion protocols in order to achieve artefact-free and well interpretable images.

Funding Acknowledgement

Type of funding sources: None.

Therapeutic value of tafamidis in patients with wild-type transthyretin amyloidosis (ATTRwt) with cardiomyopathy based on cardiovascular magnetic resonance (CMR) imaging

Background

Tafamidis was approved in Europe for the treatment of cardiomyopathy (CM) in patients with transthyretin amyloidosis (ATTR) in April 2020. So far, real-world data addressing the therapeutic value of tafamidis for the treatment of ATTR-CM are scarce. The purpose of this study was to carefully analyse the therapeutic benefit of tafamidis in patients with wild-type ATTR (ATTRwt) and CM (ATTRwt-CM) after one year of therapy based on serial multi-parametric cardiovascular magnetic resonance (CMR) imaging.

Purpose

The purpose of this study was to carefully analyse the therapeutic benefit of tafamidis in patients with wild-type transthyretin amyloidosis (ATTRwt) and cardiomyopathy (ATTRwt-CM) after one year of therapy based on serial multi-parametric cardiovascular magnetic resonance (CMR) imaging.

Methods

The present study comprised N=40 patients with ATTRwt-CM who underwent two serial multi-parametric CMR studies within a follow-up period of 12±3 months. Baseline (BL) clinical parameters, serum biomarkers and CMR findings were compared to follow-up (FU) values in patients with treated “with” tafamidis 61mg daily (n=20, group A) and those “without” tafamidis therapy (n=16, group B). CMR studies were performed on a 1.5-T system and comprised (amongst others) cine-imaging for assessment of cardiac anatomy and function including 3D longitudinal strain assessment. In addition, a modified Look-Locker inversion recovery (MOLLI) T1-mapping sequence was performed for measurement of pre- and post-contrast myocardial T1-values with additional calculation of extracellular volume fraction (ECV)-values.

Results

While left ventricular ejection fraction (LV-EF), left ventricular mass index (LVMi), left ventricular wall thickness (LVWT), native T1- and ECV-values remained unchanged in the tafamidis group A, a slight reduction in LV-EF (p=0.003) as well as a subtle increase in LVMi (p=0.034), in LVWT (p=0.001), in native T1- (p=0.038) and ECV-values (p=0.017) were observed in the untreated group B. Serum NT-proBNP levels showed an overall increase in both groups, however, with the untreated group B showing a relatively higher increase compared to the treated group A. Assessment of NYHA class did not result in significant intra-group differences when BL were compared with FU, but a trend to improvement in the treated group A compared to a worsening trend in the untreated group B (Δp=0.005).

Conclusion

Tafamidis does not improve cardiac phenotype in patients with ATTRwt-CM after one year of therapy. However, tafamidis seems to slow down cardiac disease progression in patients with ATTRwt-CM compared to those without tafamidis therapy based on multi-parametric CMR data already after one year of therapy.

Funding Acknowledgement

Type of funding sources: None.

POS1216 POTENTIAL PREDICTORS OF OUTCOME FOR ANAKINRA TREATMENT IN COVID-19 PATIENTS WITH MACROPHAGE ACTIVATION SYNDROME

Background

A hyperinflammatory response compatible with features of macrophage activation syndrome (MAS) contributes to this worse outcome in patients with Coronavirus Disease 2019 (COVID-19). Glucocorticoids have become the standard of care for those requiring oxygen support or mechanical ventilation. More targeted anti-inflammatory treatments with tocilizumab and anakinra have also been shown to be effective.

Objectives

More studies are being awaited to clarify the features of patients who would benefit more, and we investigated the characteristics of the surviving and dead patients who received anakinra.

Methods

The records of hospitalized adult patients between March 2020 and May 2021 in a tertiary referral center were evaluated. Diagnosis of COVID-19-related MAS was based on the expert opinion and preliminary criteria developed by our group that patients with a score of ≥45 were accepted COVID-19-related MAS.1 Patients who received anakinra constituted the study group. Anakinra dose was determined according to the clinical and inflammatory parameters; and doses varied between daily 100-300 mg SC to 400-800 mg IV.

Laboratory data of surviving and died patients were comparatively analyzed by using the ANCOVA method on the relevant days (baseline, anakinra-onset day, first response to anakinra treatment, and discharge or death). The temporal variation (drug onset day-first response day, drug onset day-discharge, or death day) was evaluated using the ANOVA method. A 50% reduction of CRP compared to the anakinra start day was accepted as the first response to the treatment.

Results

Out of 1080 hospitalized patients, 218 (151 male, 67 female, mean age 60.0±14.1) who received anakinra were identified. Among them, 125 (57.3%) patients were followed in the ward, 21 (9.6%) did not need oxygen treatment during the hospitalization; 69 (31.6%) patients were followed at ICU, 40 of them were intubated, 30 (13.7%) died in ICU. Anakinra had been started in a mean of 4.8 days of hospitalization. Twenty had tocilizumab initially and then received anakinra because of ongoing inflammatory parameters. The majority (83.5%) received steroid treatment (79.5% methylprednisolone, 5% of dexamethasone), and 6 received one IV pulse 250 mg of methylprednisolone; 36 (16.5%) were followed before September 2020 and received anakinra without steroids because of the standard of care at that period. Only CRP was different between the alive and dead patients for the baseline parameters (p=0.05). On the first day of drug treatment, CRP and procalcitonin values were significantly higher in dead patients (Table 1). A 50% decrease in CRP level was achieved in 3.1 days in survivors and 4.7 days in dead patients. D-dimer (p=0.018), CRP (p=0.006), LDH (p=0.003), procalcitonin (p=0.005), creatinine kinase (p=0.001), and fibrinogen levels (p=0.05) were significantly different between the surviving and dead patients when the measurements between the first drug administration day and response day were compared. Neutrophil, lymphocyte count, ferritin, D-dimer, CRP, LDH, AST, procalcitonin, creatinine kinase, and fibrinogen levels were significantly different between the patients when the parameters between the first drug administration day and discharge/death day were compared. Dead patients had higher CRP values and they did not show a continuing CRP decrease with the steroids and anakinra (Figure 1).

Conclusion

Retrospective analysis of 218 patients suggests that starting anakinra earlier in hospitalized patients may provide better results, and a decrease in CRP, ferritin, D-dimer values, as well as an increase in lymphocyte count, are associated with favorable outcomes. Increasing values of D-dimer and troponin during treatment are associated with worse outcomes, possibly indicating cardiovascular and thrombotic pathologies not responding to anakinra. Changes in the CRP values are found to help monitor the response to anakinra. Other inflammatory pathways could be targeted in those who are not responding to appropriate doses of anakinra within 5 days.

Disclosure of Interests

None declared

Thoracoscopic Management of Iatrogenic Cardiac Perforations

AIMS

Iatrogenic cardiac perforation is an uncommon but potentially fatal complication of invasive cardiac procedures. When non-surgical management fails, urgent cardiac surgery is required. Standard surgical approach is usually through full sternotomy. However, we propose a less invasive and equally effective technique with video-assisted thoracoscopic surgery (VATS).

METHODS

This single-centre retrospective study in a tertiary hospital identified all patients requiring surgical intervention due to iatrogenic cardiac perforation over a period of 5 years. Patients were grouped by surgical approach, being either sternotomy or VATS. Primary endpoints were operating time, length of ICU stay, hospital stay, 30-day mortality and all round mortality.

RESULTS

25 patients were identified: 11 in the sternotomy-group and 14 in the VATS-group. Preoperative baseline characteristics were equal. Significant difference was found for 30-day mortality (p < 0.05). There was no difference for the other endpoints.

CONCLUSIONS

Video-assisted thoracoscopic surgery is a promising alternative to standard sternotomy for iatrogenic cardiac perforations after invasive cardiac procedures. This article is protected by copyright. All rights reserved.

Surgical adrenalectomy during rescue Extracorporeal Life Support for pheochromocytoma induced cardiogenic shock: a case report

Introduction : Pheochromocytoma, a rare catecholamine-producing tumor, has been described to provoke stress-induced Takotsubo-like cardiomyopathy and even severe refractory cardiogenic shock. In this case report, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was used for hemodynamic stabilization and was continued during the resection of a large neuroendocrine tumor. Description : A 69-year old male, recently diagnosed with a pheochromocytoma, was referred to our center because of severe cardiogenic shock after induction of anesthesia for resection of the mass. Despite adequate alpha-and beta-adrenergic blockade for one month, he developed malignant hypertension with subsequently hemodynamic collapse. After successful cardiopulmonary resusci-tation he developed pulmonary oedema with severe hypoxemia and persistent hemodynamic lability. On arrival in our hospital, echocardiography revealed significant left ventricular impairment. Decision was made to commence him on VA-ECMO for a refractory cardiogenic shock with severe pulmonary oedema. Because of persistent blood pressure swings despite VA-ECMO and beta-adrenergic blockade, we decided to remove the tumor on mechanical circulatory support by an open surgical approach the next day. After clamping of the adrenal circulation, the patient experienced profound hypotension requiring high doses of epinephrine and a methylene blue infusion. Surgical resection was successful but complicated by a postoperative bleeding for which the patient underwent an emergent endovascular embolization of an adrenal artery. Over the next days, there was progressive cardiac recovery and the patient was weaned off VA-ECMO on the fourth postoperative day. The patient was discharged from the intensive care 27 days after admission and left the hospital on day 30. Discussion: VA-ECMO seems to be a feasible last resort therapy in refractory cardiogenic shock induced by pheochromocytoma crisis as suggested by a high survival rate in literature. Despite its support benefit during this type of shock, surgical removal of the tumor is rarely done with mechanical circulatory support and heparinization.

Wide QRS complex tachycardia due to typical atrial flutter with accessory pathway conduction

A 62-year-old male patient was admitted with regular wide QRS complex tachycardia. After ajmaline administration, the heart rate slowed down disclosing atrial flutter with variable QRS morphologies. Electrocardiography after conversion to sinus rhythm showed narrow QRS complexes. Decremental atrial stimulation during electrophysiological study caused progressive pre-excitation. Spontaneously, typical atrial flutter occurred with pre-excited QRS complexes. Both accessory pathway and atrial flutter were ablated in the same session.

Resveratrol prevents acute renal injury in a model of ruptured abdominal aortic aneurysm

OBJECTIVE

To examine the biochemical and histopathological effects of ischemia/reperfusion (I/R) injury in a ruptured abdominal aortic aneurysm (RAAA) model in rats, and to investigate the potential protective role of resveratrol.

METHODS

Thirty-two male Sprague-Dawley rats were randomly assigned into four groups-control, I/R, sham (I/R + solvent/dimethyl sulfoxide), and I/R + resveratrol. The control group underwent midline laparotomy only. In the other groups, infrarenal vascular clamps were attached following 60-min shock to the abdominal aorta. Ischemia was applied for 60 min followed by reperfusion for 120 min. In the I/R + resveratrol group, intraperitoneal 10 mg/kg resveratrol was administered 15 min prior to ischemia and immediately before reperfusion. The I/R + dimethyl sulfoxide group received dimethyl sulfoxide, and the I/R group was given saline solution. All animals were sacrificed by exsanguination from the carotid artery at the end of the experiment. In addition to histopathological examination of the rat kidney tissues, malondialdehyde, glutathione, catalase, and nitric oxide levels were also investigated.

RESULTS

A decrease in glutathione, catalase and nitric oxide levels, together with increases in malondialdehyde levels, numbers of apoptotic renal tubular cells, caspase-3 levels, and tubular necrosis scores, were observed in the IR and I/R + dimethyl sulfoxide groups. In contrast, resveratrol increased glutathione, catalase and nitric oxide levels in renal tissues exposed to I/R, while reducing malondialdehyde levels, apoptotic renal tubular cell numbers, caspase-3 levels, and tubular necrosis scores.

CONCLUSION

Our findings suggest that resveratrol can be effective against I/R-related acute kidney damage developing during RAAA surgery by reducing oxidative stress and apoptosis.

Diagnosis and treatment of cardiac amyloidosis: position statement of the German Cardiac Society (DGK)

Systemic forms of amyloidosis affecting the heart are mostly light-chain (AL) and transthyretin (ATTR) amyloidoses. The latter is caused by deposition of misfolded transthyretin, either in wild-type (ATTRwt) or mutant (ATTRv) conformation. For diagnostics, specific serum biomarkers and modern non-invasive imaging techniques, such as cardiovascular magnetic resonance imaging (CMR) and scintigraphic methods, are available today. These imaging techniques do not only complement conventional echocardiography, but also allow for accurate assessment of the extent of cardiac involvement, in addition to diagnosing cardiac amyloidosis. Endomyocardial biopsy still plays a major role in the histopathological diagnosis and subtyping of cardiac amyloidosis. The main objective of the diagnostic algorithm outlined in this position statement is to detect cardiac amyloidosis as reliably and early as possible, to accurately determine its extent, and to reliably identify the underlying subtype of amyloidosis, thereby enabling subsequent targeted treatment.

COSMIC RADIATION EXPOSURE CALCULATIONS FOR INTERNATIONAL AND DOMESTIC FLIGHTS DEPARTS FROM ISTANBUL AND ANKARA

In this study, cosmic radiation doses were calculated for domestic and international flights departing from Istanbul and furthermore for domestic flights departing from Ankara using a software program called CARI-7A and also a mathematical method approach. Main parameters for calculating cosmic radiation are vertical cut-off rigidity, flight duration, latitude-longitude and altitude of the flight. Our calculation results agree with the measurements for domestic and international flights departing from Istanbul and Ankara.

The initial detection of Toscana virus in phlebotomine sandflies from Turkey

Toscana virus (TOSV) is a prominent arthropod-borne viral agent of human central nervous system infections occurring in the Mediterranean region. The main transmission route to susceptible individuals involves sandflies as vectors. Despite several reports revealing widespread TOSV activity in Turkey, vectors remained unidentified. A sandfly field survey was carried out in five provinces in Central, Southeast and Mediterranean Anatolia in 2017 to identify TOSV and related sandfly-borne phleboviruses and Leishmania parasites, with evidence for circulation in the region. A total of 7136 sandfly specimens, collected via standard methods, were evaluated in 163 pools. TOSV was detected in 11 pools (6.7%), comprising Phlebotomus major sensu lato, Sergentomyia dentata and Phlebotomus papatasi species. TOSV partial L and S segment sequences were characterized, that phylogenetically clustered with local and global genotype A strains. An amino acid substitution outside the conserved motifs of the viral polymerase, also present in previous TOSV sequences in endemic regions, was observed. Leishmania tropica was detected in a single pool of Ph. sergentii (0.6%). This is the first report of TOSV in sandflies from Turkey, and this study further provides evidence for additional sandfly species with the potential to transmit TOSV.

Ruling in or out the presence of cardiac amyloidosis based on cut-off values using T1-mapping – caution is required regarding the control group

Background

Cardiac amyloidosis (CA) is an infiltrative disease that is characterized by accumulation of amyloid deposits in the interstitium of the myocardium. In contrast, hypertrophic cardiomyopathy (HCM) is caused by a disorganized arrangement of myocyte hypertrophy as well as expanded extracellular matrix, composed of interstitial and replacement fibrosis.

Purpose

A diagnostic algorithm based on (native) T1-mapping using cardiovascular magnetic resonance (CMR) was suggested in a recent study for the diagnosis of CA: A native T1 &lt;1,036ms was mentioned to have a 98% negative predictive value (NPV) for ruling out CA whereas a native T1 &gt;1,164ms showed a 98% positive predictive value (PPV) for the presence of CA. In the present study, we critically addressed the calculation of such cut-off values considering possible differences in the composition of the control group.

Methods

N=30 patients with CA, N=20 patients with HCM and N=15 healthy controls without relevant cardiac disease underwent dedicated CMR studies on a 1.5-T MR scanner. The CMR protocol comprised standard sequences for cine-imaging, native and post-contrast MOLLI-based T1-mapping and late-gadolinium-enhancement (LGE). ECV measurements were based on pre- and post-contrast T1-mapping images.

Results

Native T1 and ECV were significantly increased in CA compared to HCM and receiver operating characteristic (ROC) analyses revealed an area-under-the-curve (AUC) = 0.984 for native T1 (p&lt;0.001) and AUC = 0.985 for ECV (p&lt;0.001) regarding the diagnosis of CA). When CA patients were compared to HCM patients (excluding healthy controls), a native T1 &lt;1,036ms or an ECV &lt;33% were associated with a 99% NPV for ruling out CA whereas a native T1 ≥1,082ms or an ECV ≥41% were associated with a 99% PPV for diagnosis of CA. However, when CA patients were compared to healthy controls (excluding HCM patients), a native T1 &lt;1,025ms or an ECV &lt;34% were associated with a 99% NPV for ruling out CA whereas a native T1 ≥1,025ms or an ECV ≥34% were associated with a 99% PPV for diagnosis of CA since there was no overlap in native T1 and ECV values between CA patients and healthy controls.

Conclusion

Cut-off values for native T1 or ECV derived from ROC analyses (in a specific group of study patients) for ruling in or out the presence of CA are – amongst others - determined by the native T1 and ECV values of the respective “control group”. A different composition of the control group (e.g. HCM patients vs. healthy volunteers) will result in different cut-off values. Hence, previously suggested cut-off values obtained in single center studies need to be considered carefully – with a special attention to the control group of the underlying study – and should not be transferred to other centers carelessly.

Funding Acknowledgement

Type of funding source: None

Totally endoscopic aortic valve replacement: technique and first experience

Background

Cardiac surgery is still looking for new minimally invasive techniques with less trauma and better cosmetic results. In the field of aortic valve replacement, several types of less invasive procedures were introduced, allowing a reduction in blood loss, infections, ventilation times, morbidity and mortality. The most common technique for minimally invasive aortic valve replacement is the mini-sternotomy approach. In this report, the initial experience with a non-sternotomy approach for aortic valve replacement by means of a totally endoscopic surgical technique is presented.

Methods

The totally endoscopic aortic valve replacement was carried out in 201 patients (59,7% males, mean age: 71.6±11.7 years) from October 2017 until October 2019. Severe aortic valve stenosis was the surgical indication for all patients, who had a mean EuroSCORE II of 2.35±3.82. The surgery was carried out with the patient in supine position and a standard zero-degree optics was used. A 20 mm working port in the 2nd right intercostal space and two 5 mm trocars gained access to the aorta. After groin cannulation, cardiopulmonary bypass was initiated. Transthoracic aortic cross-clamping followed by antegrade administration of a single shot cold mixed-blood cardioplegia was assessed. The aortotomy was followed by the excision of the stenotic aortic valve and the aortic valve prosthesis was implanted in supra-annular position. After the closure of the aorta, an external pacemaker wire was placed.

Results

Mean cross-clamp and cardiopulmonary bypass times were 62±14 and 94±25 minutes, respectively. No conversion to a sternotomy was needed. The mean length of stay at the intensive care unit was 69.4±149.6 hours while patients spend 9.6±10 days at the hospital. Due to our new fast track protocol, the mean hospital stay in the last two months was 6.1 days (26 patients, 12.9%). The average postoperative blood loss (24h) was 251±298 mL and the patients were ventilated for 6.9±9 hours. In 10 patients (4.9%), re-exploration in an endoscopic way was needed. None of them had a surgical bleeding focus. No paravalvular leakages were detected at discharge. 69 patients (34.7%) developed atrial fibrillation after surgery. In addition, 10 patients (4.9%) underwent a pacemaker implantation postoperatively whereas 4 patients (1.9%) suffered from a CVA. Finally, the 30-day mortality was 2.0%.

Conclusion

These results concerning the feasibility and safety of totally endoscopic aortic valve replacement are promising. The aortic cross clamping times are acceptable, and the morbidity and mortality rates are low. Long term results are needed to confirm these initial findings.

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Jessa Hospital

Hybrid CMR- and FDG-PET-imaging gives new insights into the relationship of myocardial metabolic activity and fibrosis in patients with Becker muscular dystrophy

Background

Cardiac involvement in patients with Becker muscular dystrophy (BMD) is an important predictor of mortality. The cardiac phenotype of BMD patients is characterized by slowly progressive myocardial fibrosis that starts in the left ventricular (LV) free wall segments and extends into the septal wall during the disease course.

Purpose

Since the reason for this characteristic cardiac phenotype is unknown and comprehensive approaches using e.g. hybrid imaging combining cardiovascular magnetic resonance (CMR) with 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) are limited, the present study addressed this issue by a comprehensive non-invasive imaging approach.

Methods

Hybrid CMR- and FDG-PET-imaging was performed in N=14 patients with BMD on a whole-body Biograph mMR system. The CMR protocol comprised cine- and late-gadolinium-enhancement (LGE)-imaging. Metabolism was assessed with FDG-PET after oral glucose loading to effect myocardial carbohydrate uptake. PET was acquired for 65 minutes starting with tracer injection. Uptake values from 60 to 65 minutes p.i. were divided by the area under the blood activity curve and reported as percentages relative to the segment with maximal myocardial FDG uptake.

Results

In the total study group, mean left ventricular (LV) ejection fraction (EF) was 55±5% and there were 6/14 patients with a reduced LV-EF &lt;55%. A characteristic pattern of LGE in LV lateral wall was observed in 13/14 patients whereas an additional septal LGE pattern was documented in 6/14 patients only. Segmental FDG uptake was 88±6% in the LV lateral wall vs. 77±10% in the septal wall (p&lt;0.001). There was a rather inverse relationship between segmental FDG activity compared to segmental LGE extent (r=−0.33, p=0.089). There were N=6 patients (= ΔFDG-high) with a segmental difference in FDG uptake of &gt;15% in the LV lateral wall compared to the septal wall (lateral FDG = 91±3% vs. septal FDG = 69±8%; p&lt;0.001) while the remaining N=8 patients (= ΔFDG-low) showed a segmental difference in FDG uptake of ≤15% (lateral FDG = 85±7% vs. septal FDG = 83±5%; p=0.37). Patients in the ΔFDG-high group showed a similar LV lateral wall vs. septal wall LGE extent of 12±6% vs. 7±15%, respectively, while those patients in the ΔFDG-low group demonstrated a large difference in LV lateral wall vs. septal wall LGE extent of 33±24% vs. 4±6%, respectively.

Conclusions

Segmental FDG uptake – reflecting myocardial metabolic activity – is in principal higher in the LV free wall of BMD patients – possibly due to a higher segmental work load. However, segmental metabolic activity seems to be dependent on and limited by the respective segmental extent of myocardial fibrosis as depicted by LGE-imaging.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Deutsche Gesellschaft für Kardiologie (DGK)

Hybrid coronary revascularization with endoscopic closed-chest arterial coronary bypass technique (endo-CABG)

Introduction

Treatment of three-vessel coronary disease in minimally invasive manner could be complex in some cases. Percutaneous coronary intervention (PCI) with drug-eluting stents (DES) gives good patency rates which outlive vein grafts. The hybrid approach, combination of PCI with minimally invasive endoscopic coronary artery bypass graft (endo-CABG), might be a valuable option for treatment of multivessel coronary disease. Hereby we describe our series of patients undergoing arterial revascularization of the anterior and/or lateral wall combined with PCI of the right coronary artery or a marginal branch.

Methods

From March 2013 until December 2019, 208 patients (82.2% males, mean age: 66.69±10.44 years) underwent hybrid coronary revascularization for multivessel disease. Patients with multivessel disease suitable for hybrid approach were accepted at the heart team. All patients received total arterial revascularisation by endo-CABG. The PCI was prior or after the endo-CABG. There was no discontinuation of dual platelet therapy. Uni or bilateral internal mammary artery (IMA) harvesting was performed through three 5mm endoscopic ports in the 2nd, 3rd and 4th intercostal space. Cardiopulmonary bypass was established using a minimally invasive extracorporeal circulation (MiECC) with groin cannulation. Transthoracic aortic cross-clamping was followed by antegrade administration of a single shot cold mixed blood cardioplegia. A utility port of three centimeter was used for direct vision anastomosis.

Results

The procedure was successful in all patients, requiring no conversion to full sternotomy. Mean cross-clamping and cardiopulmonary bypass times were 44.38±28.33 and 91.75±37.97 minutes, respectively, with a mean of 2.1±0.91 bypasses for each patient. All patients received total arterial revascularization. The mean ICU and hospital length of stay were 62.5±39.74 hours and 8.80±4.64 days, respectively. Average postoperative blood loss over 24 hours was 555.20±859.19 mL. There were 8 re-interventions on the target vessels (3.8%) and 2 patients suffered from a stroke (1%). The 30-day mortality rate was 0.5%.

Conclusion

Minimally invasive hybrid arterial coronary revascularization is a safe and valuable alternative to coronary artery bypass grafting in many patients with multivessel coronary artery disease. The endo-CABG is a safe and feasible technique without compromising operative morbidity and providing good postoperative results.

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Jessa Hospital

A rare case of cervical metastatis of glioblastoma after cranial tumor resection: case report and review of literature

Glioblastoma multiforme (GBM) is the most common and the most malignant primary intracranial tumor in adults. GBM extraneural metastases occur in only approximately 0.2-0.4% of patients. We present a case of a cervical metastasis of glioblastoma after cranial tumor resection. In concord with case presentation, we reviewed the metastatic location and metastasis time of the gliablastomas seen in the literature.

Effects of Complement Regulators and Chemokine Receptors in Type 2 Diabetes

CD55 and CD59 are complement regulatory proteins suggested to be related with progression of diabetes and its complications. The stromal cell-derived factor 1 (SDF-1) and C-X-C chemokine receptor type 4 (CXCR-4) are chemokine proteins. We aimed to investigate the relation of CD55 and CD59 expression levels and polymorphisms of SDF-1 and CXCR-4 with type 2 diabetes mellitus (T2DM) and its complications. Seventy-five T2DM patients and 73 controls were enrolled. Expression levels of CD55 and CD59 were measured by FACS Calibur; qRT-PCR was used to determine SDF-1 and CXCR-4 gene polymorphisms. CD55 and CD59 expressions in patients with nephropathy, retinopathy and cardiovascular disease were significantly lower than controls. Frequency of CXCR-4 T allele carrying was high in patients and created 1.6 fold risk for the disease (p = .07). CXCR-4 a allele carriers had decreased nephropathy; although there was no statistical significance in carrying CXCR-4 T allele, presence of nephropathy was approximately 2 times higher (p = .254). The nephropathy risk increased 10-fold in CXCR-4 TT genotype carriers (p = .02). All SDF-1 CC genotype carriers had retinopathy, so, it was considered that the CC genotype was effective in retinopathy development (p = .031). For the presence of cardiovascular disease, significant difference was observed for SDF-1 genotypes. Increased cardiovascular risk of 5- and 1.9-fold in SDF-1 T (p = .007) and CXCR-4 T (p = .216) allele carriers, respectively, was observed. We suggest that CD55 and CD59 protein levels and SDF-1 and CXCR-4 have predictive importance in process, complications and tendency of T2DM.

Early cranioplasty associated with a lower rate of post-traumatic hydrocephalus after decompressive craniectomy for traumatic brain injury

BACKGROUND

Post-traumatic hydrocephalus (PTH) is one of the primary complications during the course of traumatic brain injury (TBI). The aim of this study was to define factors associated with the development of PTH in patients who underwent unilateral decompressive craniectomy (DC) for TBI.

METHODS

A total of 126 patients, who met the inclusion criteria of the study, were divided into two groups: patients with PTH (n = 25) and patients without PTH (n = 101). Their demographic, clinical, radiological, operative, and postoperative factors, which may be associated with the development of PTH, were compared.

RESULTS

Multivariate logistic regression analysis revealed that cranioplasty performed later than 2 months following DC was significantly associated with the requirement for ventriculoperitoneal shunting due to PTH (p < 0.001). Also, a significant unfavorable outcome rate was observed in patients with PTH at 1-year follow-up according to the Glasgow Outcome Scale-Extended (p = 0.047).

CONCLUSIONS

Our results show that early cranioplasty within 2 months after DC was associated with a lower rate of PTH development after TBI.

Molecular characterisation and phylogenetic analysis of Marek's disease virus in Turkish layer chickens

1. There is no current data about the genotypes of Marek's disease virus (MDV) in Turkish poultry flocks; hence, this study was performed to analyse CVI988/Rispens, turkey herpesvirus (HVT) vaccine viruses and MDV field viruses as well as to perform phylogenetic analysis of MDV in Turkish layer chickens. 2. In 2017 and 2018, a total of 602 spleen samples from 49 layer flocks were collected from the Marmara, West Black Sea and Aegean regions. DNA was extracted from the spleen samples and the samples were analysed by real-time PCR probe assay to detect CVI988/Rispens and HVT vaccine viruses and MDV field strains. Samples found positive for MDV by real-time PCR were subjected to PCR using the Meq gene primers for phylogenetic analysis. 3. Amongst 49 flocks, virulent MDV was detected in nine flocks. CVI988/Rispens and HVT vaccine strains were detected in 47 flocks and HVT in all 49 flocks. Splenomegaly, hepatomegaly and tumours in the oviduct were observed in chickens of affected flocks. Virulent MDV was detected in 120 out of 602 spleen samples. Sequencing and phylogenetic analyses showed that MDVs detected in this study were closely related to MDV strains from Italy, Poland, Saudi Arabia, Iraq, India and China but showed diversity with MDV strains from Egypt and Hungary. Multiple sequence analysis of the Meq protein revealed several point mutations in deduced amino acid sequences. Interestingly, CVI988/Rispens vaccine virus from China (AF493555) showed mutations at position 66 (G66R) and 71 (S66A) along with two other vaccine strains from China (GU354326.1) and Russia (EU032468.1), in comparison with the other vaccine strain CVI988/Rispens (DQ534538). The molecular analyses of the Meq gene suggested that Turkish field strains of MDV are in the class of virulent or very virulent pathotypes. 4. The results have shown that MDV still affects poultry health, and the phylogenetic and amino acid variation data obtained will help in vaccination and control strategies.

[Diagnostics and Treatment of Cardiac Sarcoidosis - Consensus Paper of the German Respiratory Society (DGP) and the German Cardiac Society (DGK)]

Sarcoidosis is a multisystemic granulomatous disorder which affects the respiratory system in the majority of the cases. Symptomatic cardiac manifestations are found in less than 10 % of the affected cohorts and show a large heterogeneity based on the ethnic background. Cardiac sarcoidosis is not only found in patients with rhythmogenic heart disease, such as atrial and ventricular fibrillation but also in all phenotypes of cardiomyopathy. The overall morbidity and mortality caused by cardiac sarcoidosis in Germany remains unclear and large prospective international observational studies.underline the importance of this disease entity. This consensus paper on diagnostic and therapeutic algorithms for cardiac sarcoidosis is based on a current literature search and forms an expert opinion statement under the auspices of the German Respiratory Society and the German Cardiac Society. The rationale of this statement is to provide algorithms to facilitate clinical decision-making based on the individual case situation.

Carcass and meat quality of Karacabey Merino and Kivircik lambs under an intensive finishing system

Carcass and meat quality traits of male and female lambs are important considerations in planning gender-based production and developing a marketing strategy for the product. Thus, the aim of this study was to determine the effects of sex on carcass and meat quality of Kivircik and Karacabey Merino lambs. Twenty male and 17 female lambs were used. Lambs were weaned at 45 days old and then fed ad libitum with concentrates and roughage until slaughter at 120 days. The study was carried out in two experiments at three-month intervals. Kivircik lambs had greater dressing percentage (47.96% vs 46.49%, P <0.05) and omental-mesenteric fat proportion (1.71% vs 1.10%, P <0.01), while Karacabey Merino lambs had a greater proportion of skin (11.14% vs 9.42%, P =0.001). Breed had no influence on water-holding capacity, shear force, L* and hue values (P >0.05). The meat of Karacabey Merino lambs had greater a*, b* and chroma values after blooming for 24 hours than meat from Kivircik lambs. Male lambs had greater proportions of head (5.39% vs 4.62%, P <0.001), feet (2.65% vs 2.46%, P <0.01) and visceral organs (4.53% vs 4.15%, P <0.05), while females had a greater proportion of visceral fat (1.76% vs 1.05%, P =0.001). Meat from female lambs was darker than meat from male lambs. In conclusion, under intensive conditions, the indigenous Kivircik breed had similar carcass and meat quality characteristics to the Karacabey Merino, a wool and meat breed. Keywords: breed effect; carcass quality; sex; lamb; meat quality

P6287Analysis of novel cardiac markers sST2 and IL-33 in chronic heart failure with reduced ejection fraction

Background

Soluble (s) ST-2 has been recently evaluated as a monitoring parameter in heart failure (HF). Besides being a marker for cardiac strain and hemodynamic stress, studies also found an influence of ST2 on the immune system, above all mediated through its Janus-Face ligand IL-33, an alarmin released under stress conditions or by cellular death. In contrast to sST2, the role of IL-33 in HF is yet unknown.

Objective

In this project, we aimed for an analysis of the ST2/IL33 pathway in patients with heart failure with reduced ejection fraction (HFrEF).

Methods

In total, 200 patients were included in the study: 59 with ischemic (ICM), 65 with dilated (DCM) cardiomyopathy (mean LVEF 38%), as well as 76 control patients without coronary artery disease or signs of heart failure. Serum samples were analyzed by use of ELISA after informed consent.

Results

sST2 showed a significant elevation in all HF patients (p<0.0001) compared to the control group. No significant differences in levels of sST2 were observed between ICM and DCM patients. In contrast to sST2, no differences between HF patients and control group were observed for IL-33. Furthermore, sST2 showed a significant correlation with CRP (p<0.001, r=0.28), NT-pro-BNP (p<0.0001, r=0.40) and an inverse correlation with ejection fraction (p<0.0001, r=−0.40). Additionally, sST2 showed a significant elevation in patients in NYHA stages I-II (p=0.030) and NYHA stages III-IV (p<0.01). Again, no significant correlations were observed between IL-33 and parameters mentioned above.

Analysis of sST2 in heart failure

Conclusions

We observed a significant increase and correlation with disease severity of sST2 in chronic HFrEF patients of both ischemic and non-ischemic origin, but contrary to our expectations, no significant changes in serum levels of IL-33. Thus, a mechanism independent of ST2/IL33 axis could be responsible of sST2 secretion in HF. Further studies including acute decompensated patients could provide a better understanding of the IL-33 role in HF.

P5274Characterization of cardiac involvement in patients with MELAS syndrome in comparison to HCM patients by conventional LGE imaging and novel T1-mapping

Background

MELAS syndrome (mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes) is a rare clinical subtype of mitochondrial myopathy. Cardiovascular magnetic resonance (CMR) images of MELAS-patients at an advanced state of the disease often show characteristic patterns: septal pronounced left ventricular (LV) hypertrophy and distinct focal myocardial scars in late-gadolinium-enhancement (LGE) images. This specific pattern is different from those seen in patients with hypertrophic cardiomyopathy (HCM) due to sarcomere protein mutations. Besides LGE imaging another method for the assessment of myocardial integrity, T1-mapping, has been established recently. This is the first study comparing native and enhanced T1-mapping (T1-na/en) as well as extracellular volume (ECV) values in HCM and MELAS.

Methods

12 patients with confirmed MELAS syndrome at different states of the disease, 13 HCM patients and 15 controls were included. All CMR studies were performed on a 1.5T MR scanner (Ingenia, Philips) using bSSFP cine sequences for the assessment of LV-function and MOLLI sequences for T1-na/en mapping. 15min after IV injection of 0.1mmol/kg BW Gadobutrol for LGE imaging, T1-en maps were acquired. For comparison of groups T1-na/en and ECV values in a basal short axis slice were used.

Results

Median and interquartile ranges of LV function, T1 and ECV are shown in the table. There was no difference in LV ejection fraction (LVEF) between the groups, but end-diastolic LV-mass was increased in HCM- and MELAS-patients vs. controls (p<0.001, p=0.028). In MELAS-patients, myocardial fibrosis was detected in focal spots clearly defined in both septum and free lateral wall. In HCM patients there was a rather diffuse LGE pattern in the hypertrophic septum and the RV insertion points. Here T1-na/en and ECV significantly differed from those measured in healthy controls (p<0.001, p<0.001, p=0.002). In the MELAS group T1-na values were significantly higher compared to controls (p=0.004) and significantly lower compared to HCM patients (p=0.003).

LV-function and mapping parameters of compared groups LV-EF, % LV-EDV, ml/m2 LV-mass, g/m2 T1-na, ms T1-en, ms ECV, % MELAS 57 (44–63) 86 (81–122) 80 (50–131) 969 (940–1033) 409 (381–465) 27 (24–35) HCM 60 (57–65) 50 (73–94) 94 (72–102) 1041 (1021–1074) 362 (346–430) 31 (28–36) Controls 61 (58–65) 72 (67–89) 53 (42–60) 937 (894–951) 464 (446–513) 26 (24–27)

Conclusion

Compared to healthy controls and HCM-patients, cardiac involvement in MELAS-patients is not only reliably visualized by conventional LGE imaging but also detected without the use of contrast agent by native T1-mapping. MELAS vs. HCM-patients show a different pattern of LGE and higher native T1 values, respectively.

P608Exercise testing and multi-parametric CMR assessment in patients with Ebstein anomaly

Background

Ebstein anomaly (EA) is a rare congenital heart disease characterized by an apically displaced tricuspid valve. It is associated with tricuspid valve regurgitation and right heart dilatation leading to significant morbidity. While echocardiography remains the mainstay of routine outpatient cardiac imaging, assessment of right ventricular (RV) anatomy and function is still challenging. Cardiovascular magnetic resonance imaging (CMR) has been shown to be of advantage in these patients being free from acoustic window limitations and offering superior volume quantification. In the present study, parameters obtained from cardiopulmonary exercise testing (CPET) were compared to conventional and novel CMR parameters in patients with EA.

Methods

In this prospective single centre study, N=17 patients with EA (mean age = 33.8±12.7yrs; N=10 females) underwent clinical assessment, CPET and multi-parametric CMR. Maximal work load (maxWL) and peak oxygen uptake (maxO2) were derived from CPET. CMR studies were performed on a 1.5-T Philips scanner and respective CMR parameters comprised a) anatomical, b) functional and c) myocardial deformation values of both ventricles.

Results

The majority of patients presented in NYHA class I or II (mean NYHA = 1.6±0.7) and with normal or mildly elevated NT-proBNP values (mean NT-proBNP = 189±158pg/ml). CPET-based maxWL was 147.14±55 watts and maxO2 19.32±5 ml/kg/min. CMR-based mean LVEF was 57.1±6.4% and RVEF was 46.5±11.1%, respectively. Deformation imaging revealed (amongst others) a LV global longitudinal strain (LV-gLS) of −13.7±3.0 and a RV global longitudinal strain (RV-gLS) of −14.7±5.0. Non-ischemic presence of late-gadolinium-enhancement was documented in 36% of our patients. Comprehensive correlation analysis revealed a substantial correlation a) between LV-gLS and NYHA class (r=0.64, p=0.01), but not between RV-gLS and NYHA class (r=0.19, p=0.46), b) between serum NT-proBNP levels and maxO2 (r=−0.53, p=0.03) as well as maxWL (r=−0.63, p=0.02), and c) between LV-EF and LV-gLS (r=−0.64, p=0.01).

Conclusion

Our preliminary data suggest that serum markers such as NT-proBNP and novel CMR parameters such as LV-gLS – but not RV-gLS - correlate with CPET-derived exercise parameters in patients with EA. The predictive value of these parameters regarding cardiac disease progression in EA has to be evaluated in future follow-up studies.

Effects of infliximab against carbon tetrachloride-induced intestinal injury via lipid peroxidation and apoptosis

Carbon tetrachloride (CCL₄) is often employed in the production of chlorofluorocarbons, petroleum refining, oil and rubber processing, and laboratory applications. Oral, subcutaneous, and inhalation exposure to CCL₄ in animal studies have been shown to be capable of leading to various types of cancer (benign and malignant, liver, breast, and adrenal gland tumors). The present study also evaluated the protective role of infliximab (INF) against the deleterious effects of CCL₄ on the intestinal system. Twenty-four male Sprague-Dawley rats were randomly assigned into three groups, control (n = 8), CCL₄ (n = 8), and CCL₄ + INF (n = 8). The control group received 1 mL isotonic saline solution only via intraperitoneal (i.p.) injection. The CCL₄ group received a single i.p. dose of 2 mL/kg CCL₄. The CCL₄ + INF group received a single i.p. dose of 7 mg/kg INF followed 24 h later by a single dose of 2 mL/kg CCL₄. All rats were euthanized 2 days following drug administration. CCL₄ group samples also exhibited diffuse loss of enterocytes, vascular congestion, neutrophil infiltration, an extension of the subepithelial space and significant epithelial lifting along the length of the villi with a few denuded villous tips. In addition, CCL₄ treatment increased intestinal malondialdehyde (MDA) level and caspase-3 positivity. On the other hand, INF decreased MDA levels, caspase-3 positivity, and loss of villous. Our findings suggest that CCL₄ appears to exert a highly deleterious effect on the intestinal mucosa. On the other hand, INF is effective in preventing this CCL₄-induced intestinal injury by reducing oxidative stress and apoptosis.

Artificial intelligence and amniotic fluid multiomics: prediction of perinatal outcome in asymptomatic women with short cervix

OBJECTIVE

To evaluate the application of artificial intelligence (AI), i.e. deep learning and other machine-learning techniques, to amniotic fluid (AF) metabolomics and proteomics, alone and in combination with sonographic, clinical and demographic factors, in the prediction of perinatal outcome in asymptomatic pregnant women with short cervical length (CL).

METHODS

AF samples, which had been obtained in the second trimester from asymptomatic women with short CL (< 15 mm) identified on transvaginal ultrasound, were analyzed. CL, funneling and the presence of AF 'sludge' were assessed in all cases close to the time of amniocentesis. A combination of liquid chromatography coupled with mass spectrometry and proton nuclear magnetic resonance spectroscopy-based metabolomics, as well as targeted proteomics analysis, including chemokines, cytokines and growth factors, was performed on the AF samples. To determine the robustness of the markers, we used six different machine-learning techniques, including deep learning, to predict preterm delivery < 34 weeks, latency period prior to delivery < 28 days after amniocentesis and requirement for admission to a neonatal intensive care unit (NICU). Omics biomarkers were evaluated alone and in combination with standard sonographic, clinical and demographic factors to predict outcome. Predictive accuracy was assessed using the area under the receiver-operating characteristics curve (AUC) with 95% CI, sensitivity and specificity.

RESULTS

Of the 32 patients included in the study, complete omics, demographic and clinical data and outcome information were available for 26. Of these, 11 (42.3%) patients delivered ≥ 34 weeks, while 15 (57.7%) delivered < 34 weeks. There was no statistically significant difference in CL between these two groups (mean ± SD, 11.2 ± 4.4 mm vs 8.9 ± 5.3 mm, P = 0.31). Using combined omics, demographic and clinical data, deep learning displayed good to excellent performance, with an AUC (95% CI) of 0.890 (0.810-0.970) for delivery < 34 weeks' gestation, 0.890 (0.790-0.990) for delivery < 28 days post-amniocentesis and 0.792 (0.689-0.894) for NICU admission. These values were higher overall than for the other five machine-learning methods, although each individual machine-learning technique yielded statistically significant prediction of the different perinatal outcomes.

CONCLUSIONS

This is the first study to report use of AI with AF proteomics and metabolomics and ultrasound assessment in pregnancy. Machine learning, particularly deep learning, achieved good to excellent prediction of perinatal outcome in asymptomatic pregnant women with short CL in the second trimester. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

The casual association of cervical spinal cord ischemia and axonal degeneration in second motor neuron following subarachnoid hemorrhage: Experimental study

AIM

Muscle abnormalities after spinal cord ischemia caused by subarachnoid hemorrhage (SAH) have not been explored for degenerative variations in the soma of second motor neurons of the spinal cord gray matter. This study aimed to investigate histopathological alterations in the gray matter and the role of peripheral nerves in SAH.

MATERIAL AND METHODS

Twenty-two rabbits were allocated in the control (Group I, n = 5), SHAM (Group II, n = 5), and research (Group III, n = 12) groups. Muscle weakness of the upper extremities innervated by radial nerves was evaluated at the initial day, and outcomes were recorded as control data. Re-measurements were done after injecting 0.5 ml of SF for SHAM and autolog artery blood inside craniocervical subarachnoid space for the study group. After 3 weeks, radial nerve roots, their ganglia, and segments of the spinal cord around C5-6 root entry zones were extracted bilaterally. Degenerated second motor neuron somas and the degenerated radial nerve motor axons at the intervertebral foramen were assessed.

RESULTS

The average degenerated soma intensity/mm³ at the C5-6 levels in the spinal cord was 2 ± 1/mm³, 13 ± 4/mm³, and 56 ± 10/mm³ for Groups I, II, and Group III. The average degenerated axon intensity of radial nerves was 3 ± 1/mm², 34 ± 9/mm², and 234 ± 78/mm² for Groups I, II, and III.

CONCLUSION

Gray matter ischemia in the spinal cord may lead to axonal deterioration on equal levels at the peripheral nerves with advanced SAH. Detected or undetected spinal SAH should be considered an important factor on the etiology of second motor neuron diseases.

Factors associated with mortality in acute subdural hematoma: Is decompressive craniectomy effective?

BACKGROUND

Despite rapid diagnosis and aggressive neurosurgical intervention, acute subdural hematoma (ASDH) is a severe type of head injury that can result in high morbidity and mortality. Although surgical procedures, such as craniotomy and decompressive craniectomy (DC), can be effective, the preferred approach for treating an ASDH remains controversial. The aim of this report was to evaluate factors associated with mortality in patients with ASDH and determinants of outcome in those with ASDH who underwent DC.

METHODS

The demographic details and clinical and radiological characteristics of a total of 93 patients with ASDH who underwent DC during a 60-month period from 2012 to 2017 were evaluated to determine the effect on mortality and any association with the Glasgow Coma Scale (GCS) score recorded on arrival.

RESULTS

Sixty-five male and 28 female subjects with a mean age of 59.82+-19.49 years (range: 16-88 years) were included in the study. Sixteen patients (17.2%) died following the surgery. Older age (p=0.007) and lower GCS scores (p=0.022) were statistically significantly associated with the mortality rate. The mean hematoma thickness was 15.46+-5.73 mm, and the mean midline shift was 9.90+-4.84 mm. The mortality rate was positively correlated with an excessive midline shift (p=0.011; r=0.262) and age (p=0.022; r=0.237) in patients with ADSH. A midline shift of ≥10 mm and a hematoma thickness of ≥15 mm was significantly associated with mortality (p=0.014; p=0.039). The etiology of the trauma; comorbidities of subarachnoid, epidural, or intracranial hemorrhage; compression fractures; or contusions were not significantly correlated.

CONCLUSION

The results indicated that there was a higher mortality rate among older patients and those with a GCS score of <6 on arrival. A midline shift of ≥10 mm and a hematoma thickness of ≥15 mm were significantly related to mortality. Our study supports the conclusion that DC may help prevent further midline shift and be associated with a lower mortality rate compared with a craniotomy.

Phylogeny and evolution of infectious bursal disease virus circulating in Turkish broiler flocks

The emergence of new infectious bursal disease virus (IBDV) variants can threaten poultry health and production all over the world causing significant economic losses. Therefore, this study was performed to determine IBDV molecular epidemilogy, VP2 gene variation, and corresponding pathological lesions in IBDV infected chickens in Turkey. For this, 1855 bursa of Fabricius samples were collected from 371 vaccinated broiler flocks. Atrophia and haemorrhages were seen in the bursa Fabricius of very virulent IBDV (vvIBDV) infected chickens. Partial VP2 gene was sequenced and phylogenetic, recombination, and evolutionary analyses were performed. 1548 (83.5%) out of 1855 of bursa of Fabricius samples were IBDV positive and 1525 of those could be sequenced. The recombination analysis did not detect occurrence of any recombination event among the Turkish strains. Among 1525 sequenced samples, 1380 of them were found to be classical strains. Among 1380 classical strains, 1317 were similar to IBDV 2512, 11 to Faragher 52/70, 40 to 228 E, and 12 to Lukert strain. Out of 1525 reverse transcriptase ploymerase chain reaction positive samples, 144 of them were found to be similar to vvIBDV-VP2 gene reported to GenBank previously. The phylogenetic tree performed on a broad sequence dataset demonstrated grouping of vvIBDV Turkish strains in three different clusters, including sequences collected also from Iraq and Kuwait (Cluster 1), Indian (Cluster 2), and a distinct Turkish-only cluster (Cluster 3). The evolutionary rate estimation on branches/clades including Turkish strain mirrored the expected one for RNA viruses and no significant differences were found among different considered branches. In conclusion, results of this study indicate that vvIBDV strains similar to those circulating in various countries in the Middle East are present and undergoing evolution in chickens from Turkish broiler flocks. This point needs to be taken into account in planning adequate control strategies.

Endobronchial ultrasound-guided transbronchial needle aspiration is useful in the diagnosis of lymphoma: don't give up!

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is considered cautiously in the diagnosis of lymphoma. In this study, we present our data with literature review, to ask the readers to re-evaluate this opinion.

MATERIALS AND METHODS

Several demographic, clinical and procedural variables of patients who had been diagnosed with lymphoma with EBUS-TBNA at our institution between January 2011 and December 2016 were noted and analyzed.

RESULTS

We analyzed 27 patients with a proven diagnosis of lymphoma, out of whom twenty patients were with classical Hodgkin's lymphoma and seven with non-Hodgkin's lymphoma. The sensitivity, specificity, positive and negative predictive values and accuracy of EBUS-TBNA for the diagnosis of lymphoma was found to be 70.3 %, 100 %, 100 %, 99.4 % and 99.4 %, respectively. The diagnostic sensitivity of EBUS-TBNA in ten patients with the history of lymphoma was 100 %; while in patients with no history of lymphoma it was 52.9 %. The patients with non-Hodgkin's lymphoma were presented at older ages (p = 0.001), with larger lesions (p = 0.046) and higher SUVmax values (p < 0.001). No complications occurred.

CONCLUSION

EBUS-TBNA may be used as an initial diagnostic modality in patients suspicious for lymphoma instead of repeated mediastinoscopy (Tab. 2, Fig. 1, Ref. 34).

First Molecular Characterization of Avian Metapneumovirus (aMPV) in Turkish Broiler Flocks

Viral respiratory diseases, including avian metapneumovirus (aMPV), have a significant economic impact on poultry industries. The frequency and genotype diversity of aMPV in Turkish broiler flocks is not known at present. The aim of this study was to report the first molecular identification and phylogeny of aMPV, which is circulating in Turkish broiler flocks. Trachea tissue samples and tracheal swabs were collected from 110 broiler flocks distributed in different geographical regions in Turkey between March 2017 and March 2018. Detection of aMPV was confirmed with the use of universal reverse transcriptase (RT) PCR, and eight (7.2%) broiler farms were positive for aMPV. Sequence analysis of the G gene revealed the exclusive presence of subtype B viruses. Three field isolates clustered closely with a 2002 Israel isolate, indicating a potential transmission route between these two countries and through the Middle East. The remaining five field isolates were closely related to a vaccine strain, even though broiler flocks in Turkey are not routinely vaccinated against aMPV. Therefore, we speculate these five isolates could have originated from nearby vaccinated turkey farms. Additionally, the presence of some nucleotide substitutions compared to the reference vaccine sequence suggests prolonged circulation and evolution of the original vaccine virus or a vaccine subpopulation was selected under field conditions. This evidence emphasizes the need for further detailed and more systemic approaches to evaluate aMPV spread and evolution in order to design effective control strategies.

Additively manufactured biodegradable porous iron

Additively manufactured (AM) topologically ordered porous metallic biomaterials with the proper biodegradation profile offer a unique combination of properties ideal for bone regeneration. These include a fully interconnected porous structure, bone-mimicking mechanical properties, and the possibility of fully regenerating bony defects. Most of such biomaterials are, however, based on magnesium and, thus, degrade too fast. Here, we present the first report on topologically ordered porous iron made by Direct Metal Printing (DMP). The topological design was based on a repetitive diamond unit cell. We conducted a comprehensive study on the in vitro biodegradation behavior (up to 28 days), electrochemical performance, time-dependent mechanical properties, and biocompatibility of the scaffolds. The mechanical properties of AM porous iron (E = 1600-1800 MPa) were still within the range of the values reported for trabecular bone after 28 days of biodegradation. Electrochemical tests showed up to ≈12 times higher rates of biodegradation for AM porous iron as compared to that of cold-rolled (CR) iron, while only 3.1% of weight loss was measured after 4 weeks of immersion tests. The biodegradation mechanisms were found to be topology-dependent and different between the periphery and central parts of the scaffolds. While direct contact between MG-63 cells and scaffolds revealed substantial and almost instant cytotoxicity in static cell culture, as compared to Ti-6Al-4V, the cytocompatibility according to ISO 10993 was reasonable in in vitro assays for up to 72 h. This study shows how DMP could be used to increase the surface area and decrease the grain sizes of topologically ordered porous metallic biomaterials made from metals that are usually considered to degrade too slowly (e.g., iron), opening up many new opportunities for the development of biodegradable metallic biomaterials.

STATEMENT OF SIGNIFICANCE

Biodegradation in general and proper biodegradation profile in particular are perhaps the most important requirements that additively manufactured (AM) topologically ordered porous metallic biomaterials should offer in order to become the ideal biomaterial for bone regeneration. Currently, most biodegradable metallic biomaterials are based on magnesium, which degrade fast with gas generation. Here, we present the first report on topologically ordered porous iron made by Direct Metal Printing (DMP). We also conducted a comprehensive study on the biodegradation behavior, electrochemical performance, biocompatibility, and the time evolution of the mechanical properties of the implants. We show that these implants possess bone-mimicking mechanical properties, accelerated degradation rate, and reasonable cytocompatibility, opening up many new opportunities for the development of iron-based biodegradable materials.