Determinants and prognostic implications of left atrial reverse remodelling after coarctation of aorta repair in adults

AIMS

Left atrial (LA) dysfunction and atrial fibrillation are also relatively common in adults with coarctation of aorta (COA), and the severity of LA dysfunction is associated with a higher risk of atrial fibrillation in this population. The purpose of this study was to determine whether LA function improved after COA repair (LA reverse remodelling), and the relationship between LA reverse remodelling and atrial fibrillation.

METHODS AND RESULTS

Retrospective cohort study of adults undergoing COA repair (2003-20). LA reservoir strain was assessed pre intervention and 12-24 months post intervention, using speckle tracking echocardiography. Incident atrial fibrillation was assessed from COA repair to last follow-up. Of 261 adults who underwent COA repair [age 37 ± 13 years; males 148 (57%)], 124 (47%) and 137 (53%) presented with native vs. recurrent COA, respectively. Of 261 patients, 231 (82%) and 48 (18%) underwent surgical and transcatheter COA repair, respectively. The LA reservoir strain increased from 32 ± 8% (pre intervention) to 39 ± 7% (post intervention), yielding a relative increase of 21 ± 5%. Older age [β ± standard error (SE) -0.16 ± 0.09 per 5 years, P = 0.02], higher systolic blood pressure (β ± SE -0.12 ± 0.04 per 5 mmHg, P = 0.005), and higher residual COA mean gradient (β ± SE -0.17 ± 0.06 per 5 mmHg, P = 0.002) post intervention were associated with less LA reverse remodelling, after adjustment for sex, hypertension diagnosis, and left ventricular indices. LA reverse remodelling (hazard ratio 0.97, 95% confidence interval 0.96-0.98 per 1% increase from pre-intervention LA function, P = 0.006) was associated with a lower risk of atrial fibrillation after adjustment for age, sex, pre-intervention LA reservoir strain, and history of atrial fibrillation.

CONCLUSION

COA repair resulted in improved LA function and decreased risk for atrial fibrillation, especially in patients without residual hypertension or significant residual COA gradient.

Prognostic role of inferior vena collapsibility index in congenital heart disease: A validation study

BACKGROUND

A recent study showed that inferior vena cava collapsibility index (IVCCI) <60% had better prognostic performance as compared to the American Society of Echocardiogram (ASE) criteria for estimating right atrial pressure (RAP). However, this study was based on a selected cohort of adults with congenital heart disease (CHD) that underwent right heart catheterization and limiting the generalizability of the results. The purpose of this study was, therefore, to validate the prognostic performance of IVCCI in a more representative sample of adults with CHD, which would in turn, improve generalizability of the results.

METHODS

Retrospective cohort study of adults with CHD that underwent echocardiogram at Mayo Clinic (2003-2021). Elevated RAP was defined as RAP >10 mmHg, and was estimated using IVCCI <60% or the ASE criteria (maximum IVC diameter < 2.1 cm and IVCCI <50%). Cardiovascular event was defined as heart failure hospitalization, heart transplant or cardiovascular death.

RESULTS

Of the 4029 patients, 754 (19%) and 601 (15%) had elevated RAP (RAP >10 mmHg) based on IVCCI <60%, and the ASE criteria, respectively. Of the 4029 patients, 374 (9%) had cardiovascular events during 7.6 (4.4-10.5) years of follow-up. IVCCI <60% was independently associated with cardiovascular events (adjusted HR 2.08, 95% CI 1.75-2.42; C-statistic 0.708, 95%CI 0.688-0.728), and provided improved prognostic performance as compared to the ASE criteria (C-statistic difference 0.036, 95%CI 0.017-0.055, P = 0.008).

CONCLUSIONS

IVCCI had superior prognostic performance as compared to the ASE criteria.

Outcomes after implantation of right-sided mechanical valve prostheses in congenital heart disease

BACKGROUND

Bioprosthetic valves are often used for pulmonary valve replacement (PVR) and tricuspid valve replacement (TVR) because of concerns about mechanical valve thrombosis in the right heart. The purpose of this study was to assess prosthetic valve function and outcomes (prosthetic valve dysfunction, reoperations and major bleeding events) after mechanical PVR and TVR and to compare these to bioprostheses implanted in the same positions.

METHOD

Case-control study of adults with congenital heart disease that underwent mechanical TVR or PVR (2003-2021) at Mayo Clinic Rochester, Minnesota. For each mechanical prosthesis, we identified two patients that received bioprosthesis in the same position (1:2 matching).

RESULTS

We identified 48 consecutive patients that underwent mechanical PVR (n=39, age 32 (26-38) years, men 22 (56%)) and/or mechanical TVR (n=17, age 36 (31-42) years, men 9 (53%)), as control group of 78 patients (age 30 (24-36) years, men 44 (56%)) and 34 patients (age 34 (29-39) years, men 18 (53%)) that underwent bioprosthetic PVR and TVR, respectively. The most common diagnoses in patients that received mechanical prosthesis were: tetralogy of Fallot (n=14, 19%), aortic stenosis status post Ross operation (n=11, 23%), truncus arteriosus (n=5, 11%), atrioventricular canal defect (n=4, 8%), Ebstein anomaly (n=3, 6%), double outlet right ventricle (n=2, 4%), valvular pulmonic stenosis (n=2, 4%). Compared with the bioprosthesis group, the mechanical prosthesis group had lower temporal increase in Doppler systolic mean gradient after PVR (∆ -1±2 vs 3±2 mm Hg, p<0.001) and Doppler diastolic mean gradient after TVR (∆ 0±1 vs 2±1 mm Hg, p=0.005). The mechanical prosthesis group also had lower risk of prosthetic valve dysfunction after PVR (1.0% vs 2.8% /year, p=0.02) and after TVR (2.6% vs 4.3% /year, p=0.008), but higher risk of major bleeding events (2.2% vs 0.1% /year, p<0.001).

CONCLUSIONS

Patients that received right-sided mechanical valve prostheses had lower temporal increase in valve gradient, lower risk of prosthetic valve dysfunction, but higher risk of bleeding complications compared with those that underwent right-sided bioprosthetic valve implantation.

Prognostic Value of the Anatomic-Physiologic Classification in Adults With Congenital Heart Disease

BACKGROUND

The prognostic role of the congenital heart disease (CHD) anatomic/physiologic classification has not been systematically studied. The purpose of this study was to determine whether CHD physiologic stage provided improvement in prognostic power (to predict all-cause mortality) beyond conventional clinical risk models.

METHODS

Retrospective study of adults with CHD at the Mayo Clinic (2003-2019). The CHD physiologic stage was assessed at baseline and 36 (24-48) months, and patients were classified into stages A to D at these time points. Clinical stability (remaining in the same stage), clinical improvement (moving to less advanced stage), and clinical deterioration (moving to more advanced stage) were determined at 36 months. We defined conventional clinical risk indices as age/sex, functional class, comorbidities, cardiac procedures, hepatorenal dysfunction, and ventricular/valvular dysfunction.

RESULTS

Of 5321 patients, 1649 (31%), 1968 (37%), 1224 (23%), and 480 (9%) were in stages A, B, C, and D at baseline. Of 5321 patients, 4588 (86%) also had assessments at 36 months, and of these patients, 3347 (73%), 386 (8%), and 855 (19%) had clinical stability, deterioration, and improvement, respectively. Patients with clinical improvement were more likely to have undergone cardiac procedures between both assessments. Both baseline CHD physiologic stage (hazard ratio, 1.13 [95% CI, 1.09-1.17]; P<0.001, per unit increase in stage) and change in CHD physiologic stage (hazard ratio, 1.46 [95% CI, 1.32-1.61]; P=0.007, per unit increase in stage) were associated with mortality after adjustments for conventional risk indices and provided incremental improvement in prognostic power beyond conventional clinical risk models as evidence by an increase in C statistic from 0.702 (0.681-0.724) to 0.769 (0.754-0.787).

CONCLUSIONS

The CHD physiologic stage can potentially be used for risk stratification, as well as to monitor disease progression and response to therapy.

Prognostic Role of Tricuspid Annular Plane Systolic Excursion/Right Ventricular Systolic Pressure Ratio in Coarctation of Aorta

Background

Right ventricular (RV) systolic dysfunction and pulmonary hypertension are associated with mortality in adults with coarctation of aorta (COA). The tricuspid annular plane systolic excursion/RV systolic pressure (TAPSE/RVSP) ratio is a validated noninvasive tool for the assessment of RV-pulmonary arterial (RV-PA) coupling in patients with PA hypertension, but similar data are lacking in adults with COA. The purpose of this study was to assess the relationship between the TAPSE/RVSP ratio and outcomes in this population.

Methods

A retrospective cohort study of adults with repaired COA was performed. RV systolic dysfunction was defined as RV free wall strain ≥-24% at baseline, whereas new-onset RV systolic dysfunction was defined RV free wall strain ≥-24% during follow-up.

Results

Of 661 patients, TAPSE, RVSP, and TAPSE/pulmonary artery systolic pressure ratio were 22 ± 6 mm, 34 ± 12 mm Hg, and 0.71 (0.48-0.89) mm/mm Hg, respectively. Of 661 patients, 152 (23%) had RV systolic dysfunction at baseline, and TAPSE/RVSP <0.43 mm/mm Hg was the optimal threshold to detect RV systolic dysfunction. TAPSE/RVSP <0.43 mm Hg was associated with RV systolic dysfunction (adjusted odds ratio: 3.11 [1.83-6.19], P = 0.004). Of 509 patients with normal RV systolic function, 42 (8%) and 36 (7%) developed new-onset RV systolic dysfunction and new-onset right heart failure, respectively, during follow-up. TAPSE/RVSP <0.43 mm/mm Hg was associated with new-onset RV systolic dysfunction (adjusted hazard ratio: 1.95 [1.46-2.77], P = 0.008) and new-onset right heart failure (adjusted hazard ratio: 0.81 [0.68-0.92], P = 0.005).

Conclusions

The TAPSE/RVSP ratio can potentially be used to identify patients at risk for new-onset RV systolic dysfunction and right heart failure and provide opportunity for proactive interventions to prevent adverse outcomes.

Green Synthesis, Characterization, Antimicrobial and Anticancer Screening of New Metal Complexes Incorporating Schiff Base

A Schiff base ligand of o-vanillin and 4-aminoazobenzene and its transition metal complexes of Ni(II), Co(II), Zn(II), Cu(II), Mn(II), and Zr(IV) were prepared under microwave irradiation as a green approach compared to the conventional method. The structures of new compounds have been characterized and elucidated via elemental and spectroscopic analyses. In addition, magnetic susceptibility, electron spin resonance, and electronic spectra of the synthesized complexes explained their geometrical structures. The thermal stability of Cu(II), Zn(II), and Zr(IV) complexes was studied by thermo-gravimetric analyses (TGA). Coats-Redfern and Horowitz-Metzger equations were used to calculate the thermal and dehydration decomposition activities of proposed structures kinetically. Surface morphologies of the solid compounds were imaged by scanning electron microscopy (SEM). The particle size of prepared complexes was measured by using a particle size analyzer at a diffraction angle of 10.9°. The geometry structures of the synthesized compounds were verified utilizing electronic spectra, ESR spectrum, and magnetic moment value. The newly synthesized compounds were screened for antimicrobial activity. Also, the anticancer activity of the free Schiff base ligand and its metal complexes were studied against two cell lines: human colon (HCT-116) and human liver cancer cells (HepG-2). The obtained results showed that the Cu(II) complex displayed the highest cytotoxic activity (IC₅₀ = 18 and 22 μg/mL for HepG-2 and HCT, respectively) compared to the free Schiff base ligand.

FREQUENCY OF FIBROMYALGIA IN A SAMPLE OF IRAQI PATIENTS IN MOSUL WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE

There is a paucity of data on the occurrence of fibromyalgia (FM) in chronic obstructive pulmonary disease (COPD). The objective of this study was to determine the frequency of fibromyalgia in a group of patients with COPD in Mosul, as well as characterization of the features of COPD patients with concomitant FM. Participants included seventy COPD-patients plus se-venty controls. The "2011 modification of the 2010 American College of Rheumatology's preliminary diagnostic criteria for fibromyalgia" was employed to make the diagnosis of FM. The demographic features and COPD data of the patients were documented. Pulmonary function tests and Chest-X-ray were evaluated for all patients. FM was present in 16 (22.9%) of 70 COPD patients, and only in 4 (5.7%) of the 70 controls, and the difference was significant. FM was found in 58.33% of female COPD patients compared to 15.52% of male COPD patients (p=0.004). There was no statistically significant difference in COPD patients with and without FM in respect to their age or BMI. However, patients with FM tended to have a longer duration of COPD (8.06±2.69 vs. 4.78±2.13, P value < 0.001), and higher scores on the Beck Depression Inventory (BDI) (20.7±9.200 vs. 14.8±7.900, P value=0.0139), and greater COPD severity (P< 0.001). The frequency of FM in patients with COPD was higher than control. FM is more likely to occur in female patients. Patients with comorbid FM and COPD tended to report more depressive symptoms, have longer disease duration, and higher disease severity.

The extent of pericardial involvement evaluated by cardiac MRI in patients with ST-Segment elevation myocardial infarction: predictors and outcomes

Background

The clinical diagnosis of peri-myocardial infarction pericarditis declined dramatically in the era of primary PCI and novel antiplatelet agents. However, recent data documents the presence of pericardial effusion in substantial proportion of acute MI patients, while recent randomized trial showed that anti-inflammatory drugs seem to improve cardiovascular outcomes, although the mechanism of the benefit remains uncertain.

Methods

We prospectively evaluated 187 consecutive patients, without known prior coronary disease, who underwent primary PCI for STEMI. All patients underwent cardiac MRI (CMR) on day 5±1 post admission. CMR was performed using a 1.5 T (n=101) and 3 T (n=86) scanners. Delayed enhancement (DE) and microvascular obstruction (MVO) were quantified as % of the left ventricular mass (LV). The presence of DE and MVO was recorded according to the AHA segments model. DE was also qualitatively assessed for the degree of transmurality in each segment. CMR pericarditis was defined as evidence of pericardial enhancement on DE images. The presence of pericardial effusion was also documented. Pericarditis extent was expressed as the number of pericardial segments with increased DE. Major adverse cardiac events were defined as the composite of death, recurrent myocardial infarction, stroke, urgent revascularization and hospitalization due to either heart failure or bleeding during the first year following STEMI.

Results

Pericardial effusion was found in 94 patients (50%) and enhancement of the pericardium on DE images in 120 patients (65%). In contrary, a clinical diagnosis of peri-myocardial infarction pericarditis was documented and anti-inflammatory therapy was initiated only in three patients (1%). A significant positive correlation was demonstrated between pericardial involvement and either quantitative or qualitative assessment of DE (p&lt;0.001, r=0.34) and MVO (p&lt;0.001, r=0.282). DE transmurality (per segment) was associated with both location of pericardial involvement and its extent (p&lt;0.001). A multivariate logistic regression analysis revealed that DE extent and MVO were independent predictors of pericardial involvement (OR 1.07; CI 95% 1.06–1.13, p=0.02 and OR 1.29; CI 95% 1.01–1.64, p=0.04 for DE and MVO respectively). Additional parameters that were associated with CMR diagnosis of pericarditis included higher maximal CRP levels and proximal coronary lesions. The 1-year incidence of major adverse events was similar in patients with or without CMR-defined pericarditis.

Conclusions

In contrast to the low rate of clinically diagnosed pericarditis, CMR documented pericardial involvement in more than 65% of STEMI patients. This finding is independently associated with the extent and degree and location of myocardial damage.

Funding Acknowledgement

Type of funding source: None

Frozen section analysis for organ-conserving surgery in penile cancer: Assessing oncological outcomes and trends of local recurrence

Introduction and objectives:

The local recurrence rate of penile cancer following surgical excision is reported in many series to be between 6 and 29%. Intra-operative frozen section (FS) is a useful tool to ensure safe microscopic margins in organ-sparing procedures in penile cancer. In this series, we assessed the rates of positive margins and patterns of local recurrence in a multicentre cohort of patients undergoing penile-preserving surgery assisted by intra-operative FS analysis.

Materials and methods:

We reviewed all those patients for whom intra-operative FS was employed during penile-preserving surgery in three tertiary referral centres between 2003 and 2016. We assessed whether the use of FS altered the surgical technique and what affect it had on positive margins and recurrence rates.

Results:

A total of 169 patients were identified. Of these, intra-operative FS examination of the surgical margin was positive in 21 (12%) cases. Final histological examination confirmed cancer-free margins in all but one patient (99.4%). Overall, 9 patients developed local recurrence (5.3%).

Conclusions:

In this series, intra-operative FS contributed to a very low rate (5.3%) of local recurrence. We noted an extremely low positive margin rate (0.6%) which highlights the benefit of incorporating FS analysis into organ-preserving surgery for penile cancer.

Level of evidence:

Not applicable for this multicentre audit.

P4650Sex differences in clinical presentation and in hospital outcomes among myocarditis and peri-myocarditis patients

Background

Data are scarce regarding sex differences among patients with myocarditis and peri-myocarditis. Our aim was to define the sex differences in clinical characteristics as well as in-hospital outcomes in a cohort of consecutive patients hospitalized due to myocarditis and peri-myocarditis.

Methods and results

We analyzed data of 322 consecutive patients between January 2007 and October 2017 who were hospitalized with the diagnosis of myocarditis or peri-myocarditis at our medical center. Eighty-four percent of the patients were males. Both males as well as females had similar rates of chronic medical conditions. However, males were more likely to present with ST elevation (75% vs. 44%. P<0.001) as well as PR depression in ECG compared to women and have higher admission troponin levels (7.6±11 vs. 2.3±4, P<0.001). Women were older (45±17 vs. 36±14, P<0.001) and tended to present with a rather normal ECG. There were no differences in the incidence of in-hospital mortality or the need for escalation therapy between male and female patients. However, males were more likely to have ventricular arrhythmias (7% vs. 0%, P=0.05). no differences in long term mortality were observed among males and females.

Variable Male (N=272) Female (N=50) P-value Age 36±14 45±17 <0.001 Cardiology Department 243 (90%) 39 (78%) 0.03 Dyspnea 63 (23%) 22 (44%) 0.002 Pericardial chest pain 94 (35%) 20 (40%) 0.52 Admission SBP (mmhg) 122±16 116±16 0.02 Admission HR (b/min) 82±16 89±21 0.04 Normal ECG 37 (14%) 12 (24%) 0.06 ST elevation 204 (75%) 22 (44%) <0.001 LVEF <50% 215 (80%) 45 (90%) 0.08 LGE 176 (88%) 20 (69%) 0.009 Albumin 4±0.3 3.6±0.4 <0.001 Troponin admission 7.6±11 2.3±4 <0.001

Conclusions

Male patients, which constitute the majority of patients. Admitted with myocarditis are younger, with higher troponin levels at admission, are more likely to present with ST elevation, and have a higher rate of ventricular arrythmias when compared to women. However, there are no differences in early as well as long term mortality rates between men and women.

Relaxation and exercise in lymphoma survivors (REIL study): a randomised clinical trial protocol

BACKGROUND

Lymphoma survivors commonly report ongoing complaints including fatigue, pain, depression and decreased quality of life (QoL) following treatment. Although evidence suggests that both relaxation and exercise can significantly improve such symptoms, there is no consensus on which intervention is more effective. This paper presents the REIL (Relaxation and Exercise In Lymphoma) Study protocol. The REIL study aims to compare the effect of two home-based interventions - relaxation and exercise - on QoL in lymphoma survivors.

METHODS

Eligible participants (n = 36) will be randomised to a relaxation or exercise programme to perform at least three times per week. The primary outcome measure is QoL, assessed by the European Organisation for Research and Treatment of Cancer QoL Questionnaire Core 30 (EORTC QLQ-C30). Secondary outcome measures include body composition, cardiovascular status, pulmonary function, grip strength, functional exercise capacity (six minute walk test), well-being assessed by the FACT-Lym questionnaire, and psychological status assessed by the Hospital Anxiety and Depression Scale. Total duration of the study will be twelve weeks and outcome measures will be assessed at baseline, six weeks and at the end of the study.

DISCUSSION

It is anticipated that results from this preliminary study will begin to highlight effective pathways to improve QoL following chemotherapy for this population. This will better inform healthcare professionals to optimise QoL of lymphoma patients, and enable a smooth transition from being a cancer patient to survivor.

TRIAL REGISTRATION

The REIL study has been registered on a publicly accessible database, ClinicalTrials.gov, Registration Number: NCT02272751, October 2014.

Lymphoma survivors' experience of participation in a home-based intervention post-chemotherapy

Purpose

Further research on patient experience and involvement is recommended in order to develop evidence-based and meaningful care pathways for lymphoma survivors. This study aims to explore the experience of a sample of lymphoma survivors participating in a home-based intervention following chemotherapy.

Methods

Eligible participants who completed a 12-week home-based intervention were invited to complete the End of Study Questionnaire designed to explore perceptions, preferences and barriers to participation. Content analysis was used to generate codes, describe frequencies and identify themes.

Results

Participating in a home-based intervention post-treatment was a positive experience overall, and aided recovery in this sample of lymphoma survivors (n = 35). Participants felt the programme provided structure, motivation and liked contact with the researcher. Participants highlighted their need for advice on healthy lifestyle, diet in particular.

Conclusions

Lymphoma survivors in this study reported participation in a home-based intervention following treatment beneficial and aided recovery.

Implications for cancer survivors

A large proportion of lymphoma survivors would benefit from a rehabilitation intervention post-chemotherapy. Intervention programmes should include follow-ups to monitor progress and provide support and motivation. Health professionals should recommend healthy lifestyle guidelines to survivors on completion of treatment or refer patients to appropriate services for rehabilitation and advice.

Is there a correlation in frontal plane knee kinematics between running and performing a single leg squat in runners with patellofemoral pain syndrome and asymptomatic runners?

BACKGROUND

Knee kinematics when running, specifically knee valgus, have been linked to patellofemoral pain syndrome. Assessing running biomechanics requires skill, equipment and time. Clinically, the single leg squat is used to make inferences about knee kinematics during running. No evidence supports this practice.

METHODS

Sixteen asymptomatic runners and sixteen runners with patellofemoral pain syndrome were recruited. Asymptomatic runners were sub-divided by dominant and non-dominant leg and runners with patellofemoral pain syndrome by painful and non-painful leg. This gave four groups. Participants were videoed performing single leg squats and running on a treadmill. Frontal plane knee kinematics were calculated using the frontal plane projection angle. Correlation in frontal plane projection angle between running and single leg squat were calculated using Pearson's correlation coefficient. Differences in frontal plane projection angle between groups for running and single leg squat were calculated using multiple independent t-tests with Bonferroni correction.

FINDINGS

Correlation in frontal plane projection angle between running and the single leg squat was not statistically significant for the painful leg group (p = 0.19) but was for the remaining groups (p < 0.05). There was no statistically significant difference in frontal plane projection angle between the four groups when running. Single leg squat frontal plane projection angle was significantly larger for the painful leg group (10.3°) than the dominant leg (-0.2° (p = 0.003)) and non-dominant leg (-0.4° (p = 0.004)) in the asymptomatic runners group.

INTERPRETATION

The single leg squat cannot be used to make inferences about frontal plane knee kinematics in running gait in patellofemoral pain syndrome sufferers.

Relaxation and Exercise in Lymphoma Survivors (REIL Study): A Randomised Clinical Trial Protocol

Background: Cancer survivors commonly report ongoing physical and psychological needs and adverse effects due to disease and treatment exposures including fatigue, pain, depression and decreased quality of life (QoL). Both relaxation and exercise interventions have demonstrated a positive effect on these symptoms. However these benefits have been relative to a control group, and there has been a call for further intervention studies in survivors to move beyond wait-list control groups and to compare with active control or other empirically supported interventions, such as comparison of relaxation to exercise intervention, to determine which is more beneficial. Aim: This paper presents the REIL (Relaxation and Exercise In Lymphoma) study protocol using recommended SPIRIT 2013 guidelines. The primary aim of the REIL Study is to compare the effect of two interventions - exercise and relaxation on QoL in a sample of lymphoma patients in remission postchemotherapy. Secondary aims are to investigate the effects of the two interventions on body composition, cardiovascular status, pulmonary function, muscle strength, functional exercise capacity, well-being and psychological status; and explore perceptions about participation in the posttreatment intervention program. Methods: Eligible participants (n=36) will be randomized to an exercise or relaxation home-based program to perform at least three times per week. The primary outcome measure is QoL, assessed by the European Organization for Research and Treatment of Cancer QoL Questionnaire Core 30 (EORTC QLQ-C30). Secondary outcome measures include body composition, cardiovascular status, pulmonary function, strength, functional exercise capacity, well-being and psychological status. Total duration of the study will be 12 weeks and outcome measures will be assessed at baseline, 6 weeks and at the end of the study. Results: Results from this study will inform development of effective care pathways for the increasing population of cancer survivors in general, and lymphoma in particular. It is anticipated that preliminary results from this study will be available by October 2018. Conclusion: Although it is well documented that cancer survivors commonly suffer from consequences of treatment which have a negative impact on their QoL, there are currently no recommended care pathways following completion of primary medical treatment. Evidence suggests that both relaxation and exercise can significantly improve ongoing symptoms in cancer survivors, but there is no consensus on which intervention is more effective. Results from the REIL study will aid in the development of evidence-based survivorship care pathways for cancer and lymphoma survivors, potentially prevent long-term complications, and help in a smooth transition from being a cancer patient to a fully-functioning member of society. This may lead to reduced use of healthcare resources by this population.

A semi-automated technique for labeling and counting of apoptosing retinal cells

BACKGROUND

Retinal ganglion cell (RGC) loss is one of the earliest and most important cellular changes in glaucoma. The DARC (Detection of Apoptosing Retinal Cells) technology enables in vivo real-time non-invasive imaging of single apoptosing retinal cells in animal models of glaucoma and Alzheimer's disease. To date, apoptosing RGCs imaged using DARC have been counted manually. This is time-consuming, labour-intensive, vulnerable to bias, and has considerable inter- and intra-operator variability.

RESULTS

A semi-automated algorithm was developed which enabled automated identification of apoptosing RGCs labeled with fluorescent Annexin-5 on DARC images. Automated analysis included a pre-processing stage involving local-luminance and local-contrast "gain control", a "blob analysis" step to differentiate between cells, vessels and noise, and a method to exclude non-cell structures using specific combined 'size' and 'aspect' ratio criteria. Apoptosing retinal cells were counted by 3 masked operators, generating 'Gold-standard' mean manual cell counts, and were also counted using the newly developed automated algorithm. Comparison between automated cell counts and the mean manual cell counts on 66 DARC images showed significant correlation between the two methods (Pearson's correlation coefficient 0.978 (p < 0.001), R Squared = 0.956. The Intraclass correlation coefficient was 0.986 (95% CI 0.977-0.991, p < 0.001), and Cronbach's alpha measure of consistency = 0.986, confirming excellent correlation and consistency. No significant difference (p = 0.922, 95% CI: -5.53 to 6.10) was detected between the cell counts of the two methods.

CONCLUSIONS

The novel automated algorithm enabled accurate quantification of apoptosing RGCs that is highly comparable to manual counting, and appears to minimise operator-bias, whilst being both fast and reproducible. This may prove to be a valuable method of quantifying apoptosing retinal cells, with particular relevance to translation in the clinic, where a Phase I clinical trial of DARC in glaucoma patients is due to start shortly.

Esophageal motility pattern and gastro-esophageal reflux in chronic obstructive pulmonary disease

BACKGROUND/AIMS

The association of esophageal motility and gastroesophageal reflux symptoms with respiratory symptoms is not well established in patients with chronic obstructive pulmonary disease (COPD). The aim of this work is to study the abnormalities of esophageal function in COPD patients and study its relation to smoking index, body mass index and indices of hyperinflation.

METHODOLOGY

This study included 40 male COPD patients and 10 healthy controls. The patients and controls were subjected to spirometry, body plethysmography, esophageal manometry and 24hr pH-metry.

RESULTS

Upper gastrointestinal symptoms were found in 55% of patients, hypotensive upper esophageal sphincter pressure in 65% of patients and hypotensive lower esophageal sphincter pressure in 52.5% of patients. Pathological acid reflux was found in 35% of patients. The severity of GERD increased with increased age, smoking index and body mass index, p<0.005. There was negative correlation between LESP and UESP compared with indices of hyperinflation, p<0.001.

CONCLUSIONS

There was high prevalence of esophageal motility disorders in COPD patients, LESP and UESP were significantly negatively correlated to indices of hyperinflation. There was a high prevalence of GERD in COPD patents especially elderly, severe stage of COPD, high smoking index and high body mass index (BMI).

Informal health providers and the transmission of hepatitis C virus: pilot study in two Egyptian villages

The roles and practices of informal health care providers were studied in 2 Egyptian villages, focusing on practices which might be associated with the bloodborne transmission of hepatitis C virus (HCV). In the study areas, many people resorted to male providers for injections, dentistry, wound treatment and male circumcision. Traditional birth attendants oversaw > 50% of all births. "Injectionists", barbers and staff at pharmacies performed services that may be associated with HCV transmission. These providers knew little about HCV, but were willing to learn. As villagers trust these providers and visit them even if primary health care facilities are accessible, efforts should be made to upgrade their practices in order to reduce the transmission of HCV.

An outbreak of Streptococcus canis mastitis in a dairy herd in Israel

CASE HISTORY

An increase in the bulk somatic cell count (BSCC) of up to 1,000 x 103 cells/ml occurred in a dairy herd in Israel at the end of 2001 and beginning of 2002.

CLINICAL FINDINGS

Bacteriological examination of milk from 69 cows revealed a high prevalence of Streptococcus group G bacteria, identified as S. canis, affecting 38% of cows and 20% of all quarters. Isolates were sensitive to cephalothin and moderately sensitive to penicillin G. Infected cows were separated from the herd, treated with intramammary antibiotics, milked last, and strict hygiene practices were introduced to the milking routine. The pathogen was cleared from the herd and BSCC decreased to 250-350 x 103 cells/ml after 6 months.

DIAGNOSIS

Streptococcus canis mastitis.

CLINICAL RELEVANCE

Streptococcus canis infection may cause subclinical mastitis and high bulk SCC in dairy herds and be resolved by treatment with intramammary antibiotics and the introduction of strict hygiene practices.

Staphylococcus aureus leucocidin, a virulence factor in bovine mastitis

The involvement of Staphylococcus aureus exosecretions in bovine udder infection (Younis et al. 2003) suggests that four different monomer protein bands appearing between 36 and 31 kDa, are associated with the severity of the cow's infection response. Three out of these four bands have been identified by means of protein sequencing. Band B, with a MW of 35 kDa was identified as Panton-Valentaine leucocidin LukF'-PV chain- Staph. aureus; band C, with a MW of 32 kDa was identified as leucocidin chain LukM precursor- Staph. aureus; and band D was found to be similar, but not identical, to phosphatidylinositol-specific phospholipase-C-X. Bands B and C were purified by gel filtration using FPLC. The ability of these proteins to induce udder inflammation in vivo, and proliferation response in vitro and cytokine secretion were tested for both the crude exosecretions and purified bands. Three cows were inoculated intracisternally, with three quarters receiving either 0·007–0·008 mg (as total proteins) of Staph. aureus FR2449/1 bacterial exosecretion, pooled fraction 39–41 (bands B and C), or culture broth medium. The fourth quarter was left free as a control. Quarters that received fraction 39–41 of Staph. aureus FR2449/1, exhibited induced inflammation, which was indicated by increased somatic cell count and enhanced NAGase activity that was significantly higher than that of the original Staph. aureus FR2449/1 bacterial exosecretion. Proliferation tests of bovine blood lymphocytes in vitro showed that the pooled fraction 39–41 stimulated bovine proliferation of mononuclear cells much more than the original Staph. aureus FR2449/1 bacterial exosecretion. Secretion of TNF-α, IL-1β, IL-6 and IL-8 was in accordance with the contents of LukF'-PV and LukM precursor in the exosecretions. The results suggest that LukM/LukF' induce inflammation into the udder by a mechanism similar to that of LPS or by a unique mechanism(s) which requires further investigation.

Staphylococcus aureus strains isolated from bovine mastitis: virulence, antibody production and protection from challenge in a mouse model

Septic arthritis in mice was used as a model to evaluate the virulence of Staphylococcus aureus and coagulase-negative staphylococci (CNS) isolated from cases of bovine mastitis. In addition, the model was used to evaluate the cross protection elicited by heterologous antibodies. Mice were intramuscularly inoculated with serial bacterial doses of different strains of S. aureus or CNS, for virulence determination; they were monitored for arthritis, gangrene or death up to 20 days. Antibody response, cross reactivity and resistance to challenge were tested by subcutaneous inoculation with a low dose of one of the S. aureus or CNS strains followed by challenge with two S. aureus strains. S. aureus alpha-hemolysin isolate was the most virulent, followed by alpha+beta-hemolysin and beta-hemolysin isolates. The least virulent isolates were the non-hemolytic S. aureus strains but even they were more virulent than the CNS strains tested. Antibodies against three different S. aureus antigens were detected by the ELISA in all mice that were inoculated with the S. aureus strains but not in any of those with the CNS strains. Immunoblot test against various S. aureus strains as antigens showed high cross-reactivity among the S. aureus strains but only a slight similarity, restricted to the bands above 36 kDa, with the CNS sera. Low-dose inoculation of alpha or alpha+beta strains before challenge with homologous and heterologous strains protected the mice, whereas the two beta strains provided only partial protection. The inoculations of non-hemolytic S. aureus or the CNS strains did not elicit any protection. Our findings demonstrate that pre-exposure of mice to a low dose of certain S. aureus strains could provide protection and that the antibodies produced could have an important protective role.