The Associations of Individual and Subclasses of Nonesterified Fatty Acids With Disability, and Mobility Limitation in Older Adults: The Cardiovascular Health Study

BACKGROUND

We sought to determine the associations between individual nonesterified fatty acids (NEFAs) and disability and mobility limitation.

METHODS

We studied 1 734 participants in the Cardiovascular Health Study (CHS), an ongoing population-based cohort study of community-living older American adults. We measured 35 individual NEFA species in fasting serum samples obtained at the 1996-1997 clinic visit. Using yearly assessments of activities of daily living and self-reported mobility, we identified participants with incident disability or mobility limitation during 15 years of follow-up. Cox proportional hazards regression models were used to determine the associations between per SD increment in the individual NEFAs and incident disability and mobility limitations with adjustment for potential confounding factors.

RESULTS

Higher concentrations of total and a broad range of individual NEFA species were associated with risk of disability and mobility limitation (disability: HR per SD of total NEFA [SD = 174.70] = 1.11, 95% CI = 1.04-1.18, p = .001; mobility limitation: HR per SD of total NEFA = 1.09, 95% CI = 1.02-1.16, p = .01). Among individual saturated NEFAs (SFAs), myristic (14:0) and palmitic (16:0) acids were significantly associated with higher risk of both disability and mobility limitations, but longer-chain FAs were not. Most individual monounsaturated (MUFA), n-6 polyunsaturated fatty acids (PUFAs), and trans FAs were positively significantly associated with higher risks of both disability and mobility limitation. In contrast, most n-3 PUFA species were not associated with disability or mobility limitation.

CONCLUSIONS

Higher risks of disability and mobility limitation were observed for proinflammatory intermediate-chain SFAs, MUFAs, n-6 PUFAs, and trans FAs. Our findings indicated no significant association for anti-inflammatory n-3 PUFAs.

[Telemedical aftercare of patients with skin diseases]

BACKGROUND

Improved technologies, an increased need for medical healthcare as well as the shortage of specialist personnel lead to a growing importance of telemedical applications. Dermatology is especially suitable for telemedical applications because of the visual appearance of skin diseases. This can contribute to optimizing the care and aftercare of patients with skin diseases.

OBJECTIVE

An analysis of patient satisfaction with teledermatological aftercare at the University Hospital Greifswald using the teledermatological application Mobil Skin® (Infokom, Neubrandenburg, Germany) was carried out. Factors that influence patient satisfaction and the suitability of the teledermatological aftercare for different skin diseases were also analyzed.

MATERIAL AND METHODS

The evaluation of standardized questionnaires, analysis of demographic data of the patient collective and analysis of usage data concerning the teledermatological system Mobil Skin® were carried out.

RESULTS

A total of 91 out of 118 telemedically treated patients participated in the survey. The majority of the patients reported a high degree of satisfaction with the teledermatological aftercare. Patient satisfaction was independent of where the patients lived (minor center or middle center/main center). Patient satisfaction correlated with the frequency of use and the number of answers received through the teledermatological system. The aftercare with the teledermatological system Mobil Skin® was suitable for all diagnosis groups surveyed. Both older and younger patients as well as children benefited from this kind of aftercare.

Ultra-high-frequency ECG assessment of QRS fragmentation predicts sudden cardiac death risk in inherited arrhythmia syndromes

Background

Fragmentation of the QRS complex, as a surrogate for scar or functionally disrupted ventricular activation, has been postulated as a risk factor for malignant ventricular arrhythmias across a range of cardiac diagnoses including cardiomyopathies, channelopathies and myocardial infarction. Fragmentation is subtle on the conventionally filtered 12-lead ECG and can easily be missed or over-diagnosed. Isolation of high-frequency (HF) QRS components could overcome this to demonstrate easily identifiable fragmentation but this has previously been limited by technological constraints resulting in a limited range of measured frequencies (150–300Hz). Ultra-high-frequency ECG (UHF-ECG) is a novel technology that utilises amplification and signal-averaging techniques to reliably measure frequencies up to 1000Hz.

Purpose

We explored the use of UHF-ECG in arrhythmia risk stratification.

Methods

We recruited 60 participants to undergo UHF-ECG recordings, including 23 healthy volunteers and 37 patients with inherited arrhythmia syndromes: 25 hypertrophic cardiomyopathy (HCM), 5 Brugada syndrome, 4 arrhythmogenic cardiomyopathy, 3 idiopathic ventricular fibrillation, 2 long QT syndrome and 1 non-ischaemic dilated cardiomyopathy.

The arrhythmia risk status of patients with inherited disease was classified, by two independent researchers, into high or low risk based on their history of cardiac arrest, sustained ventricular arrhythmia, appropriate therapy, syncope and programmed ventricular stimulation result. A third researcher adjudicated disagreement. Two further researchers, blinded to aforementioned risk status, independently assessed the UHF-ECG recordings of all participants.

Results

40 patients were classified as low risk, and 20 as high. Healthy volunteer UHF-ECGs showed uniform ventricular activation with single HF peaks in each lead. High-risk patients' UHF-ECGs showed multiple HF peaks, representing QRS fragmentation. The maximum number of HF peaks in any lead was used to measure severity of fragmentation. Example UHF-ECGs are shown in Figure 1. Fragmentation severity (number of peaks) correlated with arrhythmia risk status (chi-square statistic = 8.95, p-value = 0.03) across all participants (Figure 2) and when comparing high to low risk patients with inherited disease.

UHF-ECG fragmentation could be observed even when the 12-lead ECG did not show any observable fragmentation. Among patients with inherited disease, patients with HCM showed the largest difference in UHF-ECG fragmentation between high and low risk. UHF-ECG fragmentation analysis showed excellent reproducibility with no difference in number of peaks identified between two independent assessors.

Conclusion

We demonstrate proof-of-concept that a novel ultra-high-frequency tool for measuring a broad range of high frequency QRS components can be used for sudden death risk stratification in patients with inherited cardiac conditions.

Funding Acknowledgement

Type of funding sources: None.

A systematic review and meta-analysis of upgrade to biventricular or conduction system pacing approaches

Introduction

Chronic RV pacing has been recognised as being harmful to cardiac function. Patients undergoing a de novo pacemaker implant with even mild LV impairment are recommended to instead receive a physiological pacing strategy (biventricular or conduction system pacing [CSP]). No corresponding guideline recommendation exists for patients who already have a pacemaker.

Methods

We undertook a random-effects meta-analysis of all RCTs and observational studies covering device upgrade to biventricular pacing or conduction system pacing.

Results

6 RCTs assessing effect of upgrade to BiV pacing randomising 161 patients were eligible for analysis. Eligible observational studies included 46 of BiV upgrade and 7 of CSP upgrade totalling 2795 patients.

Mean LVEF improved by +8.3% from 34.4% in BiV upgrade RCTs (p=0.001) and +8.3% from 25.7% in BiV upgrade observational studies (p<0.001).

In observational studies of upgrade to CSP, LVEF increased by +10.1% from 38.4% (p=0.001) despite less severe LV impairment at baseline (p=0.004 vs mean EF in BiV RCTs and p<0.0001 vs mean EF in BiV observational studies).

LVESV decreased significantly by −25.4 ml, −23.7 ml, and −19.8 ml in BiV RCTs, BiV observational studies and CSP observational studies. Significant changes were also seen in NYHA class (decreased by −0.4, −0.8 and −1.0 respectively).

Minnesota Heart Failure Score (−6.9 points) and peak oxygen uptake (+1.1 ml/kg/min) increased significantly in RCTs of BiV upgrade. This was also seen in observational studies of BiV upgrade (−21.0 points and +2.63 ml/kg/min respectively).

Conclusions

RCTs and observational studies of upgrade to BiV pacing show significant physiological and symptomatic benefit. Observational studies of CSP upgrade show similar benefit with significant improvements in LVEF, LVESV and NYHA class in patients with an even milder degree of baseline LV impairment.

Funding Acknowledgement

Type of funding sources: None.

Associations of Modifiable Behavioral Risk Factor Combinations at 65 to 74 Years Old With Cognitive Health Span for 20 Years

OBJECTIVE

Behavioral risk factors for dementia tend to co-occur and interrelate, especially poor diet, physical inactivity, sleep disturbances, and depression. Having multiple of these modifiable behavioral risk factors (MBRFs) may predict a particularly shortened cognitive health span and therefore may signal high-risk status/high intervention need.

METHODS

These secondary analyses of data from the Cardiovascular Health Study included 3149 participants aged 65 to 74 years (mean [standard deviation {SD}] age = 69.5 [2.5] years; 59.6% female). MBRF exposures were self-reports regarding a) diet, b) activity, c) sleep, and d) depression symptoms. We primarily analyzed MBRF counts. For up to 26 years of follow-up, we assessed the a) number of remaining cognitively healthy life-years (CHLYs) and b) percentage of remaining life-years (LYs) that were CHLYs (%CHLY). We estimated CHLYs as time before a dementia diagnosis, cognitive screener scores indicating impairment, proxy report indicating significant cognitive decline, or dementia medication use.

RESULTS

Participants averaged a remaining 16 LYs (SD = 7 LYs), 12.2 CHLYs (SD = 6.6 CHLYs), and 78.1% of LYs being CHLYs (SD = 25.6 CHLYs). Compared with having no MBRFs, having one was associated with ~1 less LY and CHLY, but not a relatively lower %CHLY. In contrast, having 3+ MBRFs was associated with about 2 to 3 fewer LYs and CHLYs as well as about 6% lower %CHLY (95% confidence interval = -9.0 to -2.5 %CHLYs; p = .001).

CONCLUSIONS

MBRF-related reductions in the cognitive health span are most apparent when people have multiple MBRFs. Future research is needed to determine if/how behavioral risks converge mechanistically and if dementia prevention efficacy improves when targeting MBRF combinations.

Childhood maltreatment is not associated with atopic dermatitis in adults: results from a cross-sectional population-based cohort study

BACKGROUND

Childhood maltreatment (CM) is related to poor physical and mental health outcomes in adults. Knowledge on the impact of CM on skin diseases is limited, and no study has previously addressed the association of CM with atopic dermatitis (AD) in adult age.

OBJECTIVES

To analyze the prevalence of CM in individuals with physician-diagnosed AD, and to examine the relationship between different types of CM with physician-diagnosed AD in a general population sample of German adults.

METHODS

Data from 2973 participants from the cross-sectional population-based Study of Health in Pomerania (SHIP) TREND-0 were analyzed (aged 20 to 83 years; 51.4% female). We administered the Childhood Trauma Questionnaire (CTQ) assessing emotional, physical and sexual abuse, and emotional and physical neglect. AD was diagnosed by dermatologists in a standardized clinical examination. We conducted logistic regression analyses adjusted for age, sex and school education to investigate the association of CM types with AD.

RESULTS

Among all individuals with AD, 20.6% reported to have experienced at least one type of moderate or severe CM. Emotional and physical neglect were the most frequently reported CM types. Overall, the prevalence of CM types among individuals with AD did not differ from those among individuals without AD. We found no association of CM type with AD.

CONCLUSIONS

This is the first study investigating the association of CM with AD in adults. CM was common in the present general population sample, emphasizing that CM is an important public health problem. Our findings suggest that CM is not a risk factor for AD. It might be hypothesized that AD severity is a crucial outcome, and that CM history is a factor with impact on disease severity and course rather than a risk factor for the development of AD. Longitudinal studies are required to address this question.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Improvement of dynamic venous function after thermal ablation with steam vein occlusion - 6-weeks and 1-year follow-up after 167 treatments

BACKGROUND

In this paper, the method of steam vein occlusion for the treatment of the great/small saphenous vein (GSV/SSV) was analyzed in terms of a therapeutic influence on the dynamic parameters of global vein function, its effects on subjective symptoms based on chronic venous insufficiency (CVI) and the side effects of the steam vein sclerosis (SVS). It has been questioned whether the effects of this method lead to a recommendation for routine clinical practice.

METHODS

The venous drainage and the venous refilling time (T0) of the leg treated were determined by photoplethysmography (Elcat, Wolfratshausen, Germany) before, six weeks and one year after the intervention to examine the effects on global venous function. Further changes of clinical symptoms and findings were assessed by the Venous Clinical Severity Score (VCSS), preoperatively and after one year, and the complication rate at 6-week follow-up was monitored.

RESULTS

The SVS was performed on 167 veins (GSV: 124; SSV: 43) in a total of 156 patients. Eight patients (5.1%) did not attend the 6-week follow-up, while 29 patients (18.6%) were lost in the 1-year follow-up. Patients were suffering from symptoms such as leg pain and leg edema, which resulted in a VCSS of 9.4 (cumulated mean score of all patients) preoperatively. The T0 was reduced to mean values of 20.6 s (GSV cohort) and 21 s (SSV cohort). The VCSS improved to 6.0 after one year. This correlated with the hemodynamic parameters. The T0 increased in the GSV cohort after six weeks to 31.8 s, p <  0.001, and showed a nonsignificant improvement to 32.2 s, p = 0.509, in the 1-year check. The T0 also increased in the SSV cohort significantly after 6 weeks to 30.1 s, p <  0.001, and showed a nonsignificant reduction after one year, p = 0.289. A total of 71%of the GSV and 69.8%of the SSV of the patients involved no complications following the treatment. Light complications (grade 1) occurred (reddening, hematoma, hyperpigmentation) in the majority: 24.2%of the GSV and 18.6%of the SSV. We noticed one grade 3 complication with thrombosis in the SSV cohort, which led to a pulmonary embolism. Forty-seven complete questionnaires were analyzed (responder rate: 28.1%); 40.4%of the patients had light complaints after the treatment, such as pain, warmth or local pressure sensations (Fig. 7); 63%of those patients noticed only slight pain at a maximum of 3 out of 10. The majority (91%) would recommend this procedure.

CONCLUSION

The SVS revealed endoluminal catheter-based intervention to abolish venous reflux of the G/SSV as safe. As one therapeutic target is to eliminate venous reflux, effectiveness of a method cannot be based on sonographic data alone; one must further assess patients' symptoms and dynamic venous function. This data shows an improvement of patients' symptoms which correlated well with the improvement of the venous function in digital photoplethysmography. The SVS can be recommended as a catheter-based treatment in the future.

Nosocomial or not? A combined epidemiological and genomic investigation to understand hospital-acquired COVID-19 infection on an elderly care ward

Background

COVID-19 has the potential to cause outbreaks in hospitals. Given the comorbid and elderly cohort of patients hospitalized, hospital-acquired COVID-19 infection is often fatal. Pathogen genome sequencing is becoming increasingly important in infection prevention and control (IPC).

Aim

To inform the understanding of in-hospital SARS-CoV-2 transmission in order to improve IPC practices and to inform the future development of virological testing for IPC.

Methods

Patients detected COVID-19 positive by polymerase chain reaction on Ward A in April and May 2020 were included with contact tracing to identify other potential cases. Genome sequencing was undertaken for a subgroup of cases. Epidemiological, genomic, and cluster analyses were performed to describe the epidemiology and to identify factors contributing to the outbreak.

Findings

Fourteen cases were identified on Ward A. Contact tracing identified 16 further patient cases; in addition, eight healthcare workers (HCWs) were identified as being COVID-19 positive through a round of asymptomatic testing. Genome sequencing of 16 of these cases identified viral genomes differing by two single nucleotide polymorphisms or fewer, with further cluster analysis identifying two groups of infection (a five-person group and a six-person group).

Conclusion

Despite the temporal relationship of cases, genome sequencing identified that not all cases shared transmission events. However, 11 samples were found to be closely related and these likely represented in-hospital transmission. This included three HCWs, thereby confirming transmission between patients and HCWs.

Laser doppler derived peripheral perfusion can distinguish haemodynamically tolerated VT from haemodynamically compromised VT

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): NIHR Imperial Biomedical Research Centre

Introduction

Implantable Cardioverter-Defibrillators (ICDs) cannot distinguish between ventricular tachycardia (VT) with haemodynamic compromise from haemodynamically tolerated VT to ensure that therapies are delivered only when necessary. Currently, unnecessary therapies are reduced by longer duration thresholds and higher rate thresholds. This can result in ICDs withholding or delaying therapies during haemodynamically compromising VT while potentially still providing therapies during rapid or prolonged VT that is haemodynamically well tolerated.

Laser doppler perfusion monitoring (LDPM) allows assessment of peripheral blood flow as a surrogate for haemodynamic status. We have previously demonstrated that laser doppler perfusion signals, analysed using an electro-mechanical coupling algorithm (SafeShock), can reliably identify loss of perfusion during ventricular fibrillation (VF), as well as discriminate VF from simulated lead fractures and T wave over-sensing. The utility of LDPM signals in VT, however, has not been established.

Purpose

In this study we assessed the utility of LDPM using the SafeShock algorithm to discriminate haemodynamically tolerated VT from VT with haemodynamic compromise.

Methods

Recruited participants underwent a rapid ventricular pacing protocol to simulate VT at different rates. Pacing was performed using the right ventricular lead of an implanted pacing device or a temporary pacing wire in the right ventricular apex. 3-lead ECG, blood pressure (either invasively using a radial artery catheter or non-invasively using beat-by-beat finometry) and LDPM signal were continuously recorded during the protocol. LDPM signals during simulated VT were analysed using the SafeShock electro-mechanical algorithm and compared to blood pressure change from baseline intrinsic rhythm to simulated VT.

Results

We obtained 588 recordings of simulated VT in 56 patients at rates of 100 bpm, 120 bpm, 140 bpm, 160 bpm, 180 bpm and 200 bpm. Percentage change in systolic blood pressure from baseline to VT correlated with LDPM-derived perfusion value during VT (Spearman’s Rho = 0.7786, p &lt; 0.0001).

Using a cut-off of 5 units, perfusion value predicted a 20% drop in systolic blood pressure in VT with an accuracy of 89.4% (sensitivity 94.8%, specificity 83.6%, p value &lt;0.0001).

Conclusions

Peripheral perfusion measurements, analysed using an electro-mechanical algorithm, can accurately discriminate haemodynamically tolerated VT from VT with haemodynamic compromise. ICDs with integrated LDPM sensors and algorithms could make therapy decisions based on the circulatory status of patients with arrhythmias not just rate and duration parameters. This could reduce unnecessary therapies while facilitating prompt treatment of compromising arrhythmias. Abstract Figure 1

Non-selective and selective His bundle pacing both preserve left ventricular activation time and pattern

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): British Heart Foundation

Background: His bundle pacing can be achieved in two ways

selective His bundle pacing, where the His bundle is captured alone, and non-selective His bundle pacing, where local myocardium is also captured resulting a pre-excited ECG appearance. We assessed the impact of this ventricular pre-excitation on left and right ventricular dys-synchrony.

Methods

We recruited patients who displayed both selective and non-selective His bundle pacing. We performed non-invasive epicardial electrical mapping to determine left and right ventricular activation times and patterns.

Results

In the primary analysis (n = 20, all patients), non-selective His bundle pacing did not prolong LVAT compared to select His bundle pacing by a pre-specified non-inferiority margin of 10ms (LVAT prolongation: -5.5ms, 95% confidence interval (CI): -0.6 to -10.4, non-inferiority p &lt; 0.0001). Non-selective His bundle pacing did not prolong right ventricular activation time (4.3ms, 95%CI: -4.0 to 12.8, p = 0.296) but did prolong QRS duration (22.1ms, 95%CI: 11.8 to 32.4, p = 0.0003).

In patients with narrow intrinsic QRS (n = 6), non-selective His bundle pacing preserved left ventricular activation time (-2.9ms, 95%CI: -9.7 to 4.0, p = 0.331) but prolonged QRS duration (31.4ms, 95%CI: 22.0 to 40.7, p = 0.0003) and mean right ventricular activation time (16.8ms, 95%CI: -5.3 to 38.9, p = 0.108) compared to selective His bundle pacing.

Activation pattern of the left ventricular surface was unchanged between selective and non-selective His bundle pacing. Non-selective His bundle pacing produced early basal right ventricular activation, which was not observed with selective His bundle pacing.

Conclusions

Compared to selective His bundle pacing, local myocardial capture during non-selective His bundle pacing produces right ventricular pre-excitation resulting in prolongation of QRS duration. However, non-selective His bundle pacing preserves the left ventricular activation time and pattern of selective His bundle pacing. When choosing between selective and non-selective His bundle pacing, left ventricular dyssynchrony is not an important factor. Abstract Figure: Selective vs Non-Selective HBP

Non-Esterified Fatty Acids and Risks of Frailty, Disability, and Mobility Limitation in Older Adults: The Cardiovascular Health Study

BACKGROUND/OBJECTIVES

Non-esterified fatty acids (NEFAs) play central roles in the relationship between adiposity and glucose metabolism, and they have been implicated in the pathogenesis of cardiovascular disease, but few studies have assessed their effects on complex geriatric syndromes like frailty that cross multiple organ systems. We sought to determine the relationships between NEFAs and incident frailty, disability, and mobility limitation in a population-based cohort of older persons.

METHODS

We analyzed 4,710 Cardiovascular Health Study (CHS) participants who underwent measurement of circulating total fasting NEFAs in 1992-1993 and were assessed for frailty in 1996-1997 and for disability and mobility limitation annually. We used ordinal logistic regression to model incident frailty, linear regression to model components of frailty, and Cox regression to model disability and mobility limitation in relation to baseline NEFAs. To ensure proportional hazards, we truncated follow-up at 9 years for disability and 6.5 years for mobility limitation.

RESULTS

A total of 42 participants became frail and 510 became pre-frail over a 4-year period, and we documented 1,720 cases of disability and 1,225 cases of mobility limitation during follow-up. NEFAs were positively associated in a dose-dependent manner with higher risks of incident frailty, disability, and mobility limitation. The adjusted odds ratios for frailty were 1.37 (95% confidence interval [CI] = 1.01-1.86; P = .04) across extreme tertiles and 1.17 (95% CI = 1.03-1.33; P = .01) per standard deviation increment. The corresponding hazard ratios for incident disability were 1.14 (95% CI = 1.01-1.30; P = .04) and 1.11 (95% CI = 1.06-1.17; P < .0001); those for incident mobility limitation were 1.23 (95% CI = 1.06-1.43; P = .006) and 1.15 (95% CI = 1.08-1.22; P < .0001). Results were largely consistent among both men and women. Among individual components of frailty, NEFAs were significantly associated with self-reported exhaustion (β = .07; standard error = .03; P = .02).

CONCLUSION

Circulating NEFAs are significantly associated with frailty, disability, and mobility limitation among older adults. These results highlight the broad spectrum of adverse health issues associated with NEFA in older adults.

A method to assess heart rate variability in neonate rats: validation in normotensive and hypertensive animals

Several studies have focused on the heart rate variability (HRV) of murine species, while studies discussing HRV in murine neonates and infants remain scarce, since recording hemodynamic signals through invasive methods in small animals has been found to be quite challenging. Thus, this study aimed at describing and validating a novel method to assess HRV in newborn rats. An electrocardiogram (ECG) system was used to determine RR intervals in awake newborns and evaluate HRV in normotensive (Wistar) and hypertensive (SHR) neonate rats. After birth, ECG was recorded in the awake newborns, and they were allowed to rest on a heated surface, restricted only by the weight of the adhesive ECG electrodes. The electrodes were cut and adapted to provide more comfort to the animal, and gently placed on the newborn's skin. RR intervals were recorded over a 30-min period using an ECG system together with LabChart software (4 KHz). Three sequences of 5 min each from the ECG recording period were analyzed in time and frequency domains, using CardioSeries software. ECG data resulted in a clearly interpretable signal that was used to generate an RR interval sequence through time for the analysis of HRV. SHR neonates presented increased cardiac sympathovagal balance compared to Wistar neonates (low frequency/high frequency: 3.85±0.71 vs 0.90±0.09). In conclusion, the ECG setup here described may be used to record RR intervals to assess HRV in neonate rats, thus detecting early impairment of HRV in hypertensive newborns.

P1449Anti-thrombotic management for electrophysiological procedures: results of the European Heart Rhythm Association (EHRA) young investigators survey

Funding Acknowledgements

none

Background

Electrophysiological studies (EPS), with or without ablation, require percutaneous introduction of catheters into the heart to record local electrical activity. Instrumentation of catheters within the blood causes activation of the clotting cascade, increasing the risk of thrombus formation. To date, the electrophysiological community lacks international guidelines on the use of anti-thrombotic therapies before, during and after EPS.

Purpose

To survey the current practice regarding the use of anti-thrombotic therapies across member countries of the European Heart Rhythm Association (EHRA).

Methods

The survey was conducted in February 2019. Electrophysiologists from EHRA member countries were contacted to complete the survey by e-mail, utilizing the EHRA Young EP network. They were asked to answer a questionnaire containing information on anti-thrombotic and anticoagulation management before, during and after left-sided EPS and ablation: atrial tachycardia (AT), accessory pathway (AP) and ventricular tachycardia (VT).

Results

We obtained 41 answers responses from 40 centers in 15 European EHRA member countries. Regarding of antiaggregation, the most used antiplatelet is aspirin (100% before, during and after ablation). The most used anticoagulant was novel oral anticoagulants (NOAC) before ablation (47.1%), during hospitalization (85.2%) and at discharge (70.3%). The administration of anti-thrombotic therapy depended on the procedure time only in 10 cases (24.4%).

For AP, before ablation, only 4 centers (9.7%) administered anti-platelets and 2 (4.9%) anticoagulants. During ablation, heparin was used by 85.4% of respondents maintaining ACT target 300-350 s in 36.6% of cases. At discharge, antiaggregation therapy was prescribed by 22 colleagues (53.7%) and anticoagulation only by one (2.4%).

In patients with AT, before ablation, antiaggregation prophylaxis was prescribed by only 4 centers (19.5%) and anticoagulation by 11 (26.8%). During procedure, almost all centers (40, 97.6%) used heparin with ACT target 300-350 s in 58.5% of cases. At discharge, antiplatelet therapy was recommended by 12 colleagues (29.3%) and anticoagulation by 24 (58.5%).

Regarding VT, before procedure, 8 centers (19.5%) prescribed antiaggregation and 5 (12.2%) anticoagulation prophylaxis. During ablation, all centers used heparin, maintaining ACT target 300-350 s in 58% of cases. The use of antiaggregation or anticoagulation depended on the left ventricle (LV) access in 15 centers (37.5%) and on LV ejection fraction in 11 (26.8%). At discharge, anti-thrombotic therapy was recommended by 16 colleagues (39%) and anticoagulation by 13 (31.7%).

Conclusion

Our survey showed that there is considerable variation in the management of anti-thrombotic therapy surrounding left-sided EPS and ablation. Further studies are necessary to evaluate the right approach to these procedures.

Eine seltene kutane Manifestation eines systemischen B-Zell-Lymphoms unter dem klinischen Bild einer seltenen Infektionserkrankung

Dargestellt wird der seltene Fall eines diffus großzelligen B-Zell-Lymphoms unter dem klinischen Verdacht einer kutanen Anthrax-Infektion. Bei Aufnahme präsentierte der 82-jährige Patient an der Stirn rechtsseitig oberhalb der Augenbraue eine ca. 3,5 cm messende ulzerierte Plaque mit zentral festhaftender schwarzer Nekrose und erhabenem livid-erythematösen Randwall. Wir sahen im Verlauf des stationären Aufenthaltes eine fulminante AZ-Verschlechterung des Patienten mit rezidivierenden Fieberschüben bis 40,0 °C und plötzlich disseminierter Aussaat neuer kutaner Herde ähnlich der Morphe der primären Läsion. In der CT zeigten sich multiple pulmonale und hepatische Rundherde sowie einzelne in den Nieren sowie in der rechten Nebenniere. In der Biopsie eines Leberrundherdes und in einer Hautbiopsie wurde die Diagnose eines diffus großzelligen B-Zell-Lymphoms vom ABC-Subtyp gesichert. Bei rezidivierenden Fieberschüben über 39 °C unter eskalierter Antibiose sowie persistierender nicht invasiver Beatmung wurde der Patient im Verlauf auf eine Intensivstation verlegt und verstarb nach 6-wöchiger Krankheitsdauer. Die Autoren schlussfolgern, dass bei sich extrem fulminant darstellenden Krankheitsverläufen, die klinisch einer dermatologischen Infektionserkrankung entsprechen können, jedoch unkontrollierbar unter antimikrobieller Therapie verlaufen, immer an die kutane Manifestation eines systemischen Lymphoms gedacht werden sollte. Hier können auch die primär der Infektionserkrankung zugeordnete B-Symptomatik und die elevierten Akute-Phase-Proteine auftreten. Lymphom-Manifestationen erscheinen an der Haut häufig unspezifisch mit ekzematöser, lichenoider oder pruriginös-nodulärer Morphe. Der Verlauf machte die Einordnung der Dignität der Erkrankung in unserem Fall dann möglich.

Sorting Beef Subprimals by Ribeye Size at the Packer Level to Maximize Utility and Product Uniformity in Foodservice and Retail Sectors

ObjectivesTo determine the impact of sorting beef carcasses at the packer level by ribeye area, instead of sorting subprimals by weight, to provide more consistent products for the end user via foodservice and retail channelsMaterials and MethodsInstrument grading technology was used to select 100 USDA Choice, yield grade 2 or 3 sides, and 100 USDA Select, yield grade 2 or 3 sides. Carcass sides were sorted into one of five ribeye area (REA) categories, as outlined in Tabsle 6.USDA Choice carcass sides were fabricated to remove beef rib, ribeye, lip-on (IMPS 112A) and beef loin, strip loin, boneless (IMPS 180) from each USDA Choice. Beef loin, tenderloin, full, side muscle on, partially defatted (IMPS 189B) subprimals were procured from each USDA Select side. Subprimals were weighed, trimmed to specification, and passed through a 3-D visual analysis portioning machine and to obtain scan data for a variety of portioning outcomes generated by simulation software.ResultsBased on input from our foodservice collaborators, 1.25 inches (3.18 cm) was identified, for ribeye and strip loin steaks, as the targeted optimal thickness to meet consumer expectations. After evaluation of multiple portioning outcomes, it was determined that a 14.00-ounce (396.89 g) portion, for each REA category, most consistently delivered the preferred steak thickness identified previously. REA categories 1 and 2 most frequently produced desirable thickness and portion weight outcomes in ribeye and strip loin steaks. Statistical analysis of number of portions per subprimal stratified by portion weight and portion thickness revealed differences (P < 0.05) across all REA area categories in both ribeyes and strip loins. As portion weight and thickness increased, steak portion number tended to decrease. In tenderloins, an optimal steak thickness of 1.75 to 2.00 in (4.45 to 5.08 cm) was identified as optimal. Most frequently, 8, 9, and 10-ounce (226.80, 255.15, and 283.50 g) portions met the targets for optimal portion weight and thickness parameters. For tenderloins, number of portions by portion weight showed significant differences (P < 0.05) in all ribeye area categories with the exception of 7-ounces (198.45 g) and showed no differences when stratified by portion thickness. In this investigation, USDA Choice carcasses (r = 0.76) and USDA Select carcasses (r = 0.56) expressed moderate correlation between REA area and hot carcass weight.ConclusionResults of the present study suggest strip loin, ribeye, and tenderloin subprimals from carcasses possessing a ribeye area ranging from 74.8 cm2 to 87.1 cm2 offered the greatest level of utility when portioned for use in foodservice and retail sectors. Further research is warranted to continue examining the merit of sorting carcasses by ribeye area at the packer level, but results of this study suggest that there is potential for improved consistency and utility of subprimals in the foodservice and retail sectors.Table 6.Ribeye area (REA) categories and associated acceptable REA ranges.

MISCLASSIFICATION IN DEMENTIA DATA IN THE CARDIOVASCULAR HEALTH STUDY: A PROBABILISTIC BIAS ANALYSIS

Data routinely collected in observational studies from phone calls, medical records, and death certificates can be used to categorize dementia, though there may be misclassification. We applied probabilistic bias analyses to assess the magnitude, direction, and uncertainty of the error due to misclassification of dementia data in the Cardiovascular Health Study (CHS). We categorized dementia among all participants (73,284 person-years) using medications, ICD-9 codes, use of proxy, and death certificates, and compared to the gold standard adjudicated dementia in the CHS Memory Studies (28,250 person-years). Using the gold standard, positive (PPV) and negative predictive values (NPV) of dementia categorization were estimated within strata defined by age and sex. In probabilistic bias analyses, we reclassified participants from the full study using estimated PPVs and NPVs in 5,000 replicates. We estimated the hazard ratio (HR) of dementia associated with age, race, sex, hypertension, diabetes, and APOE4 genotype in this bias analysis and compared these results to those using original data. ICD-9 codes had low specificity and were excluded in further analyses. The NPV was differential by sex (66% for females and 79% for males) and race (51% for blacks, 60% for whites). In bias analysis, the HR for black race was attenuated from 2.81 (95%CI:1.36-5.80) to 1.23 (95%CI:1.14-1.33). The estimate for hypertension was statistically significant only in bias analysis. Estimates and inferences for the other covariates were modestly different. Differential misclassification may lead to important biases of risk factors, but can be recognized and addressed using probabilistic bias analyses.

USING OBSERVATIONAL DATA TO INFORM CANDIDATE PHENOTYPES FOR GEROSCIENCE TRIALS

Geroscience trials will manipulate aging mechanisms which may have pleiotropic effects and alter multiple biologic processes and clinical outcomes. Determining an intervention’s efficacy and safety will require measuring several aspects of aging and intermediate endpoints with less regard to specific diseases. Picking the right measurements will significantly impact a trial’s cost-effectiveness and chance of success. Observational studies are ideal resources to test candidate phenotypes before investing in trials. We present a decade’s worth of results from the Cardiovascular Health Study as examples of using observational data to inform measurement in geroscience trials. Specifically, we illustrate the underlying theory, construction, operational characteristics, and inter-relationships of candidate phenotypes spanning circulating biomarkers, tissue and organ structure, and functional status, all of which can be used in geroscience trials depending on the intervention’s target and predicted outcome.

Propofol use in children with allergies to egg, peanut, soybean or other legumes

Propofol is the most commonly administered intravenous agent for anaesthesia in children. However, there are concerns that the emulsified preparation may not be safe in children with an allergy to egg, peanut, soybean or other legumes. We conducted a retrospective study of children with immunologically confirmed egg, peanut, soybean or legume allergy and who underwent general anaesthesia at Princess Margaret Hospital for Children between 2005 and 2015. We extracted details regarding allergy diagnosis, each anaesthetic administered and any adverse events or signs of an allergic reaction in the peri-operative period. A convenience sample of patients without any known food allergies was identified from our prospective anaesthesia research database and acted as a control group. We identified 304 food-allergic children and 649 procedures where propofol was administered. Of these, 201 (66%) had an egg allergy, 226 (74%) had a peanut allergy, 28 (9%) had a soybean allergy and 12 (4%) had a legume allergy. These were compared with 892 allergy-free patients who were exposed to propofol. In 10 (3%) allergy patients and 124 (14%) allergy-free patients, criteria for a possible allergic reaction were met. In nine of the food-allergic children and in all the controls valid non-allergic explanations for the clinical symptoms were found. One likely mild allergic reaction was experienced by a child with a previous history of intralipid allergy. We conclude that genuine serious allergic reaction to propofol is rare and is not reliably predicted by a history of food allergy.

Die kontralaterale doppelte Transpositionslappenplastik

Das Prinzip der einfachen Transpositionslappenplastik (TLP) (Synonym: Schwenklappenplastik) besteht darin, dass in der unmittelbaren Umgebung eines Hautdefektes ein gestielter Lappen mit axialer oder randomisierter Gefäßversorgung generiert und durch eine geringfügige Drehbewegung an seiner Basis über eine dazwischenliegende Zone von normaler Haut in den Defekt eingeschwenkt wird. Häufig erwähnte Varianten der einfachen Transpositionslappenplastik sind die Rhomboidplastiken nach Limberg und Dufourmentel sowie die unilateralen „bi-lobed“ und „tri-lobed“ Schwenklappen 1, 2, 3, 4, 5, 6. Die kontralaterale doppelte TLP findet hingegen in der Literatur nur sehr selten Erwähnung 4.

Vasculitis allergica – ein nicht-IgE-vermitteltes Hypersensitivitätssyndrom

Die Diagnose „Vasculitis allergica“ suggeriert eine klassisch allergische IgE-vermittelte Genese. Dies ist jedoch nicht der Fall, vielmehr handelt es sich um einen hochkomplex ablaufenden Mechanismus, der häufig das eigentlich auslösende Antigen vor der Detektion bewahrt.

Die aktuelle Nomenklatur für dieses dermatologische Erkrankungsbild lautet kutane IgM oder IgG Immunkomplex-Vaskulitis, es handelt sich um eine leukozytoklastische Vaskulitis der postkapillären Venolen 3. Diese neue Einordnung legt die mit dem ursprünglichen Namen einhergehende Assoziation mit einer typisch IgE-vermittelten allergischen Erkrankung ab.

Vaskulitiden werden immunologisch betrachtet den Immunkomplex-Erkrankungen, der sogenannten Typ III Reaktion nach Coombs und Gell, zugeordnet 14, 15, 16. Sie werden als entsprechend dem dahinter liegenden immunologischen Prozess als „non-IgE-mediated allergic hypersensitivity Syndrom“ eingestuft 14, 15, 16. Viele Vaskulitiden machen sich klinisch zuerst an der Haut u. a. durch akut auftretende, rasch progrediente Ulzerationen bemerkbar, häufig assoziiert mit starker Schmerzhaftigkeit. Sie sind damit in der Ursachenabklärung eines Ulcus cruris bedeutsam, rangieren hier aber unter den seltenen Diagnosen.

Der lange bestehende Begriff einer „leukozytoklastischen Vaskulitis“ für diese Erkrankung steht entsprechend nicht länger für ein einzelnes Erkrankungsbild, sondern vielmehr für ein histologisches Muster einer Gruppe von Vaskulitiden, den sogenannten Immunkomplexvaskulitiden. 3 Hierbei handelt es sich von Gefäßkaliber überwiegend um „small vessel“ Vaskulitiden, diese können als „single organ vasculitis“ (SOV) mit alleiniger Manifestation an der Haut oder auch als kutanes Teilsymptom einer anderen „multi organ vasculitis“ (MOV) zum Beispiel im Rahmen eines systemischen Lupus erythematodes auftreten 1. Die kutane IgM oder IgG Immunkomplex-Vaskulitis zeigt den für Vaskulitiden klassisch plötzlich auftretenden, rasch progredienten Verlauf und ist klinisch durch eine typische Primäreffloreszenz, die palpable Purpura, mit hoher Inflammation charakterisiert. 2 Im Therapiekonzept steht an erster Stelle das auslösende Agens zu identifizieren und zu eliminieren 2, 42, 44. In der Regel zeigt dieser Typ von Vaskulitis eine überwiegend residuenfreie Abheilung mit niedrigem Rezidivrisiko unter der Voraussetzung, dass das auslösende Agens identifiziert und beseitigt ist 2, 41, 42, 44.

Long-term outcome of open surgery in CVI patients concerning postoperative complications, perioperative hemodynamics and clinical efficacy, Part II1

BACKGROUND

Chronic venous disease (CVD) is extremely common worldwide with prevalence increasing with age. It is associated with a reduced quality of life, particularly in relation to pain, physical function and mobility. Symptomatic chronic venous insufficiency (CVI) with venous ulcer at its' endpoint, indicates interventional surgery to cure venous reflux therewith promoting wound healing and preventing recurrence. In this retrospective, single-centre, consecutive case-control study in a single patient population of a university clinic in northern Germany a holistic evaluation of varicose vein surgeries has been undertaken. Part I covered postoperative complications in relation to co-morbidities, co-medication and clinical presentation. Part II of this article presents now the hemodynamic results in relation to the perioperative evolution of CVI specific symptoms.

METHODS

Records of n = 429 (467 extremities) patients from 2009-2013 treated with open surgery were analysed with regards to perioperative hemodynamics. Evolution of CVI symptomology was accessed postoperatively with the help of a questionnaire and patient records in the case of complication development. Venous hemodynamics was analysed in the whole patient population and with regards to complication subgroups: no events (NE), neglectable adverse events (NAE) and non-neglectable adverse events (NNAE).

RESULTS

Postoperatively, patients' CVI-symptoms like pain (p < 0.001), swelling (p < 0.001) and itching (p = 0.003) significantly improved. The venous refill time and venous pump capacity improved significantly after open vein surgery (p < 0.05). Regardless of the development of postoperative complications there was a significant improvement of venous function at 6 weeks- and one-year postoperative in follow-up (p < 0.05). Symptom regression was strongly correlated with hemodynamic improvement.

CONCLUSION

A significant improvement of patients' symptoms was achieved by means of open-surgery, regardless of postoperative complication development. This was in accordance with the improvement of venous hemodynamics. A strong correlation between symptom regression and improvement in venous hemodynamics could be proven.

Die kontralaterale doppelte Transpositionslappenplastik

Das Prinzip der einfachen Transpositionslappenplastik (TLP) (Synonym: Schwenklappenplastik) besteht darin, dass in der unmittelbaren Umgebung eines Hautdefektes ein gestielter Lappen mit axialer oder randomisierter Gefäßversorgung generiert und durch eine geringfügige Drehbewegung an seiner Basis über eine dazwischenliegende Zone von normaler Haut in den Defekt eingeschwenkt wird. Häufig erwähnte Varianten der einfachen Transpositionslappenplastik sind die Rhomboidplastiken nach Limberg und Dufourmentel sowie die unilateralen „bi-lobed“ und „tri-lobed“ Schwenklappen 1 2 3 4 5 6. Die kontralaterale doppelte TLP findet hingegen in der Literatur nur sehr selten Erwähnung 4.

Outcomes from the first multidrug-resistant tuberculosis programme in Kenya

SETTING

In March 2006, the first multidrug-resistant tuberculosis (MDR-TB) treatment programme was implemented in Kenya.

OBJECTIVE

To describe patients' treatment outcomes and adverse events.

DESIGN

A retrospective case note review of patients started on MDR-TB treatment at two Médecins Sans Frontières-supported sites and the national referral hospital of Kenya was undertaken. Sites operated an ambulatory model of care. Patients were treated for a minimum of 24 months with at least 4-5 drugs for the intensive phase of treatment, including an injectable agent.

RESULTS

Of 169 patients, 25.6% were human immunodeficiency virus (HIV) positive and 89.3% were culture-positive at baseline. Adverse events occurred in 67.4% of patients: 45.9% had nausea/vomiting, 43.9% electrolyte disturbance, 41.8% dyspepsia and 31.6% hypothyroidism. The median time to culture conversion was 2 months. Treatment outcomes were as follows: 76.6% success, 14.5% deaths, 8.3% lost to follow-up and 0.7% treatment failure. HIV-positive individuals (adjusted odds ratio [aOR] 3.51, 95% confidence interval [CI] 1.12-11.03) and women (aOR 2.73, 95%CI 1.01-7.39) had a higher risk of unfavourable outcomes, while the risk was lower in those with culture conversion at 6 months (aOR 0.11, 95%CI 0.04-0.32).

CONCLUSION

In Kenya, where an ambulatory model of care is used for MDR-TB treatment, treatment success was high, despite high rates of HIV. Almost half of the patients experienced electrolyte disturbance and one third had hypothyroidism; this supports the view that systematic regular biochemical monitoring is needed in Kenya.

No Association of Plasma Prothrombin Concentration or the G20210A Mutation with Incident Cardiovascular Disease

Prothrombin is a key factor in blood clotting, a process intimately involved in thrombotic disease. We assessed prothrombin levels and G20210A genotype in a case-control study within the Cardiovascular Health Study. Cases included angina, myocardial infarction, stroke, and the presence of MRI-detectable infarcts (n ≈ 250 each). Populationbased controls free of clinical cardiovascular disease (CVD) (n ≈ 500) and a subset free of clinical and subclinical CVD (n ≈ 250) were used for comparison. The 20210 A allele, frequency 2.9%, was associated with higher mean prothrombin levels: 166.3 vs. 139.5 µg/ml (P <0.001). Significant correlates of prothrombin included gender, plasma lipids, other vitamin K-dependent proteins, and inflammatory markers, but not race, smoking, hypertension, diabetes, measures of subclinical CVD, or markers of procoagulant activity. Compared to controls, neither genotype nor prothrombin level was associated with any CVD case group. We conclude that, in the elderly, neither prothrombin level nor 20210 genotype were associated with either CVD risk factors or events. This is consistent with the lack of association of prothrombin levels with measures of underlying CVD or procoagulant markers.

Therapy of ulcus cruris of venous and mixed venous arterial origin with autologous, adult, native progenitor cells from subcutaneous adipose tissue: a prospective clinical pilot study

BACKGROUND

The stromal vascular fraction (SVF) of adipose tissue consists of cellular subpopulations with distinct regenerative potential.

OBJECTIVE

To investigate the regenerative capacities of autologous SVF cells in the treatment of chronic leg ulcers of venous (VLU) and arterial-venous (AVLU) origin.

METHODS

Multimorbid ulcer patients received a singular topical treatment with 9-15 × 10⁶ SVF cells, separated from abdominal lipoaspirates by digestion with collagenase and neutral protease and applied immediately after isolation. The primary endpoints were the change in wound size 12 weeks after treatment and evaluation of adverse events. Secondary endpoints included the time to complete wound epithelialization and change in pain levels. Postoperative wound treatment modalities and treatment of comorbidities were not intensified compared with pre-operative management. Follow-up period was at least 6 months.

RESULTS

Sixteen elderly ulcer patients (seven with VLU, nine with AVLU) were treated as described. All VLU patients (median ulcer size: 48.25 cm² ) and four of nine AVLU patients showed complete epithelialization of the ulcers within 71-174 days. In three patients with large ulcerations on both legs, ulcerations on the non-treated, contralateral leg also epithelialized. Patients reported a considerable rapid decrease in pain intensity by 2.5 points on average on a visual scale from 1 to 5 within the first 2 weeks after treatment. The patients were followed up for 9-44 months (median: 30 months). No severe side-effects were observed.

CONCLUSIONS

The use of SVF cells presents an effective, minimally invasive option for the treatment of VLU and AVLU even in multimorbid patients. In patients with larger predominantly ischaemic AVLU and comorbidities, one-time application of the used amounts of SVF cells was not sufficient in the majority of cases.

Understanding the controls on deposited fine sediment in the streams of agricultural catchments

Excessive sediment pressure on aquatic habitats is of global concern. A unique dataset, comprising instantaneous measurements of deposited fine sediment in 230 agricultural streams across England and Wales, was analysed in relation to 20 potential explanatory catchment and channel variables. The most effective explanatory variable for the amount of deposited sediment was found to be stream power, calculated for bankfull flow and used to index the capacity of the stream to transport sediment. Both stream power and velocity category were highly significant (p ≪ 0.001), explaining some 57% variation in total fine sediment mass. Modelled sediment pressure, predominantly from agriculture, was marginally significant (p<0.05) and explained a further 1% variation. The relationship was slightly stronger for erosional zones, providing 62% explanation overall. In the case of the deposited surface drape, stream power was again found to be the most effective explanatory variable (p<0.001) but velocity category, baseflow index and modelled sediment pressure were all significant (p<0.01); each provided an additional 2% explanation to an overall 50%. It is suggested that, in general, the study sites were transport-limited and the majority of stream beds were saturated by fine sediment. For sites below saturation, the upper envelope of measured fine sediment mass increased with modelled sediment pressure. The practical implications of these findings are that (i) targets for fine sediment loads need to take into account the ability of streams to transport/retain fine sediment, and (ii) where agricultural mitigation measures are implemented to reduce delivery of sediment, river management to mobilise/remove fines may also be needed in order to effect an improvement in ecological status in cases where streams are already saturated with fines and unlikely to self-cleanse.

Longitudinal Relationship Between Loneliness and Social Isolation in Older Adults: Results From the Cardiovascular Health Study

OBJECTIVE

To understand the longitudinal relationship between loneliness and isolation.

METHOD

Participants included 5,870 adults 65 years and older (M = 72.89 ± 5.59 years) from the first 5 years of the Cardiovascular Health Study. Loneliness was assessed using a dichotomized loneliness question. Social isolation was assessed using six items from the Lubben Social Network Scale. Yearly life events were included to assess abrupt social network changes. Mixed effects logistic regression was employed to analyze the relationship between isolation and loneliness.

RESULTS

Higher levels of social isolation were associated with higher odds of loneliness, as was an increase (from median) in level of social isolation. Life events such as a friend dying were also associated with increased odds of loneliness.

DISCUSSION

These results suggest that average level of isolation and increases in the level of isolation are closely tied to loneliness, which has implications for future assessment or monitoring of loneliness in older adult populations.