Heart failure with mildly reduced and preserved ejection fraction: A review of disease burden and remaining unmet medical needs within a new treatment landscape

This review provides a comprehensive overview of heart failure with mildly reduced and preserved ejection fraction (HFmrEF/HFpEF), including its definition, diagnosis, and epidemiology; clinical, humanistic, and economic burdens; current pharmacologic landscape in key pharmaceutical markets; and unmet needs to identify key knowledge gaps. We conducted a targeted literature review in electronic databases and prioritized articles with valuable insights into HFmrEF/HFpEF. Overall, 27 randomized controlled trials (RCTs), 66 real-world evidence studies, 18 clinical practice guidelines, and 25 additional publications were included. Although recent heart failure (HF) guidelines set left ventricular ejection fraction thresholds to differentiate categories, characterization and diagnosis criteria vary because of the incomplete disease understanding. Recent epidemiological data are limited and diverse. Approximately 50% of symptomatic HF patients have HFpEF, more common than HFmrEF. Prevalence varies with country because of differing definitions and study characteristics, making prevalence interpretation challenging. HFmrEF/HFpEF has considerable mortality risk, and the mortality rate varies with study and patient characteristics and treatments. HFmrEF/HFpEF is associated with considerable morbidity, poor patient outcomes, and common comorbidities. Patients require frequent hospitalizations; therefore, early intervention is crucial to prevent disease burden. Recent RCTs show promising results like risk reduction of composite cardiovascular death or HF hospitalization. Costs data are scarce, but the economic burden is increasing. Despite new drugs, unmet medical needs requiring new treatments remain. Thus, HFmrEF/HFpEF is a growing global healthcare concern. With improving yet incomplete understanding of this disease and its promising treatments, further research is required for better patient outcomes.

[Systematic investigation of surgical site infections (SSI) in plastic reconstructive and aesthetic surgery (ERCS): Feedback]

Surgical site infection (SSI) in plastic, reconstructive and aesthetic surgery (ERCP) is quite uncommon compared to other surgical specialities but remains one of the main complications. The aim of our study was to provide feedback on the systematic investigation of SSI in ERCP. This is a monocentric retrospective study, including all paediatric and adult patients who have undergone ERCP surgery between 01/01/2014 and 31/12/2021. During this period, the department systematically investigated all SSI cases. Eight thousand eight hundred and seventy-eight surgical procedures were performed. The SSI rate was 0.34%. Thirty SSIs (19W,11M), with a mean age of 56 years (none paediatric), were investigated. Twenty-seven patients suffered from comorbidities. The surgical indications included 17 cases of skin cancer, 7 cases of weight loss, 4 cases of breast reconstruction, 1 lipoma, 1 pectus excavatum. Eleven surgeries consisted in lymphnode procedures (8 sentinel lymphnodes, 3 curage). The average operating time was 116minutes. Nineteen patients received antibiotic prophylaxis. The average time to onset of SSI after surgery was 10 days. The most prevalent bacteria were commensals of the skin flora and the digestive tract. Apart from surgical management, 100% of patients were treated with antibiotics. High age, multiple comorbidities, long, combined procedures, placement of equipment, lymph node surgery, post-operative punctures on implanted equipment, are all risks factors for SSI. The implementation of a systematic monitoring of SSI within our department has provided us with the opportunity to analyse our data in real time and allow us to adjust our practices if necessary. This process can be used in other plastic reconstructive and aesthetic surgery departments. The collection and analysis of SSIs is both easily done and the procedure is well standardized. The assistance of the operational hygiene team is a key asset for the success of this project. The development of this type of procedure on a national level could be an asset to improve the management of SSI by taking advantage of the experience of a larger number of centres.

Impact du vaccin ARNm BNT162b2 anti-SARS-CoV-2 sur la production d’interféron alpha et l’auto-immunité cellulaire au cours du lupus érythémateux systémique : le projet COVALUS

Introduction

Alors que la vaccination anti-SARS-CoV-2 est devenue un enjeu important de la prise en charge des patients atteints de maladies auto-immunes systémiques telles que le lupus érythémateux systémique (LES), nous manquons de données sur l’impact de la vaccination par ARN messager sur l’auto-immunité. Notre objectif était de décrire l’impact de la vaccination par ARNm sur la production d’interféron alpha et l’auto-immunité cellulaire au cours du lupus.

Patients et méthodes

Nous avons réalisé une étude prospective, observationnelle, monocentrique au cours de laquelle nous avons inclus des patients atteints de LES, éligibles à la vaccination anti-SARS-CoV-2 par le vaccin BNT162b2 selon les recommandations françaises alors en vigueur. Nous avons secondairement exclu les patients non-naïfs vis-à-vis de l’infection par le SARS-CoV-2 à T0 et les patients sous mycophénolate, azathioprine ou rituximab. Les patients étaient évalués juste avant la première dose, puis à 1 mois (M1), à 3 mois (M3) et à 6 mois (M6) de leur première dose. En plus du suivi clinicobiologique habituel de la maladie, nous avons évalué la production d’IFN-alpha par les cellules dendritiques plasmacytoïdes (pDCs) en cytométrie de flux. Nous avons également quantifié l’auto-immunité T en mesurant la proportion de cellules T activées (CD154+ CD69+) après stimulation des cellules sanguines mononucléées périphériques (PBMCs) par des antigènes nucléaires (U1-RNP, histones, SS-A, SS-B).

Résultats

Trente-six patients lupiques et 11 contrôles sains ont été inclus. Les patients lupiques étaient majoritairement des femmes (31/36, 81 %) d’un âge médian de 44 [36–50] ans. Nous avons observé une augmentation significative de la proportion de pDCs produisant spontanément de l’IFN-alpha à M1 (1,27 % [0,6–2,6]) et M3 (1,25 % [0,87–1,83]) comparativement à T0 (0,64 [0,27–1,09] %, respectivement p < 0,001 et p < 0,01) chez les lupiques. Nous avons observé une augmentation similaire dans le groupe contrôle, mais uniquement à M1 (1,46 [0,95–2,12] %) comparativement à T0 (0,25 [0,12–0,47] %, p < 0,02). Par ailleurs, les pDCs des patients lupiques exprimaient à leur surface plus de marqueurs d’activation CD86 et HLA-DR à M3 que à T0. Concernant la proportion de cellules T auto-réactives des patients lupiques, nous avons observé, qu’après une hausse non significative entre T0 et M1, les cellules auto-réactives diminuaient significativement dans le temps (coefficient β d l’effet fixe associé au temps dans le modèle linéaire à effet mixte = −0,00067, p = 0,015). Nous n’avons pas observé une telle tendance chez les contrôles. Au cours du suivi, nous avons observé 2 poussées cliniques de la maladie. À l’exception de ces patients, nous n’avons pas constaté de modification significative du SLEDAI, du taux d’anti-dsDNA, de C3 ou de C4 dans la cohorte.

Conclusion

Chez les patients lupiques, la vaccination anti-SARS-CoV-2 par ARNm entraîne (1) une augmentation modeste infra-clinique de la production spontanée d’IFN-alpha par les pDCs et (2) une diminution des cellules T auto-réactives spécifiques des antigènes nucléaires.

Impact of blood transfusion on survival after nephrectomy for localized or locally advanced renal cancer

OBJECTIVE

Several studies have reported blood transfusion were associated with a decrease of survival after oncological surgery. For kidney cancer, the effect of blood transfusion is still debated. The objective of this study was to determine the effect of blood transfusion after oncological nephrectomy on overall, specific and recurrence-free survival in a retrospective cohort of localized or locally advanced kidney cancer.

MATERIAL AND METHODS

We performed a monocentric retrospective analysis of all patients managed by surgery for localized or locally advanced renal cancer between January 2000 and December 2016. We compared overall and specific survival and recurrence-free survival between two groups: patients transfused and not transfused. Demographic, surgical and tumor characteristics were compared. Survival analyses were performed using univariate Cox regression and multivariate Cox proportional regression test.

RESULTS

We included 382 patients in this study: 320 (83.8%) were not transfused and 62 (16.2%) were transfused. Transfused patients were significantly older (P=0.001) and had a lower pre-operative hemoglobin level (P=0.008). Operative and oncological characteristics were also different between both groups. In univariate analysis, we showed that blood transfusion was associated with lower overall survival (P<0.001), specific survival (P<0.001), and recurrence-free survival (P<0.001). In multivariate analysis, we found that blood transfusion was not associated with overall survival, or specific survival, but it was associated with lower recurrence-free survival (HR: 1.967, CI95% [1.024-3.780], P=0.042).

CONCLUSIONS

Perioperative blood transfusion is an independent risk factor that increases tumor recurrence among patients treated with nephrectomy for renal cancer.

Prognostic value of coronary artery calcium score in hospitalized COVID - 19 patients

Funding Acknowledgements

Type of funding sources: None.

Background

The association of known cardiovascular risk factors with poor prognosis of coronavirus disease 2019 (COVID-19) has been recently emphasized (1). Coronary artery calcium (CAC) score is considered a risk modifier in primary prevention of cardiovascular disease and has shown to improve cardiovascular risk prediction in addition to classical risk factors (2). 

Purpose

We hypothesized that the absence of CAC might have an additional predictive value for an improved cardiovascular outcome of hospitalized COVID-19 patients.

Methods

We prospectively included 310 consecutive hospitalized patients with COVID-19. Thirty patients with a history of coronary artery disease were excluded. Low dose non - contrast chest computed tomography (CT) was performed in all patients at admission. Visual assessment of CAC in every coronary artery was obtained by using an ordinal scoring of 0, 1, 2 or 3 corresponding to absent, mild, moderate or severe CAC score. A total score was calculated by summing the score of each vessel, which was further categorized as 0 (undetectable), 1-3 (mild), 4-5 (moderate) and ≥ 6 (severe). (Figure 1). Demographics, medical history, clinical characteristics, laboratory findings, imaging data, in-hospital treatment, and outcomes were retrospectively analyzed. A composite endpoint of major adverse cardiovascular events (MACE) was defined as all - cause mortality, heart failure, acute coronary syndrome, atrial fibrillation and stroke.

Results

Two hundred eighty patients (63.2 ± 16.7 years old, 57.5% male) were included in the analysis. One hundred thirty one (46.7%) patients had a CAC score of 0. MACE rate was 21.8% (61 patients). Multivariable logistic regression showed that the absence of CAC was inversely associated with MACE (OR 0.209, 95% CI 0.052–0.833, p = 0.027), with a negative predictive value of 84.5% (sensitivity 72%, specificity 55%), independent of age, risk factors or disease severity (Figure 2).

Conclusion

The absence of CAC had a high negative predictive value for MACE in patients hospitalized with COVID-19, independent of the presence of cardiac risk factors or disease severity. These findings reinforce the idea that the assessment of CAC could be a useful marker for risk stratification and management of COVID - 19 patients. Future directions should focus on the implementation of CAC score into mid - term and long - term follow - up of this particular population, to provide a more precise and earlier estimation of cardiovascular risk. Abstract Figure.  Abstract Figure.

Prognostic value of coronary artery calcium score in hospitalized COVID-19 patients

Background

The association between known cardiovascular risk factors and poor prognosis of patients diagnosed with coronavirus disease 2019 (COVID-19) has been recently emphasized (1). Coronary artery calcium (CAC) score assessed by computed tomography (CT) is considered a risk modifier in primary prevention of cardiovascular disease and has shown to improve cardiovascular risk prediction in addition to classical risk factors (2).

Purpose

We hypothesized that the absence of CAC might have an additional predictive value for an improved cardiovascular outcome of hospitalized COVID-19 patients.

Methods

We prospectively included 310 consecutive hospitalized patients with COVID-19. Thirty patients with a history of coronary artery disease were excluded.Low dose non-contrast chest CT was performed in all patients at admission. Visual assessment of CAC in every coronary artery was obtained by using an ordinal scoring of 0, 1, 2 or 3 corresponding to absent, mild, moderate or severe CAC score. A total score was calculated by summing the score of each vessel, which was further categorized as 0 (undetectable), 1–3 (mild), 4–5 (moderate) and ≥6 (severe). (Figure 1). Demographics, medical history, clinical characteristics, laboratory findings, imaging data, in–hospital treatment and outcomes were retrospectively analyzed. A composite endpoint of major adverse cardiovascular events (MACE) was defined as all-cause mortality and cardiovascular events (heart failure, myocarditis, arrhythmia, acute coronary syndrome, stroke, pulmonary embolism).

Results

Two-hundred eighty patients (63.2±16.7 years old, 57.5% male) were included in the analysis. One hundred thirty one (46.7%) patients had a CAC score of zero. MACE-rate was 24.2% (68 patients). Multivariate logistic regression showed that the absence of CAC was inversely associated with MACE (OR 0.264, 95% 0.071–0.981, p=0.047), with a negative predictive value (NPV) of 81.4%, sensitivity 70%, specificity 55%, independent of age, risk factors or disease severity (Table 1).

Conclusion

The absence of CAC translated into a low risk for MACE in COVID-19 patients, even in the presence of cardiac risk factors, which reinforces the idea that the assessment of CAC score in COVID-19 patients could be a useful marker for patients risk stratification and management. Future directions should focus on the implementation of CAC score into mid-term and long-term follow-up of this particular population, to provide a more precise and earlier estimation of cardiovascular risk

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

Which Criteria are Considered and How are They Evaluated in Health Technology Assessments? A Review of Methodological Guidelines Used in Western and Asian Countries

OBJECTIVES

This study aimed to provide an exhaustive description of criteria and methodological recommendations for evaluating them in health technology assessment (HTA) in Western and Asian countries.

METHODS

We conducted a system literature review of HTA-related guidelines by searching the websites of HTA agencies and related data sources. The guidelines, reports, or recommendations introducing the HTA evaluation methods, processes, decision-making frameworks, and criteria for priority setting were eligible to be included. The review was limited to guidelines from countries belonging to the European Network for Health Technology Assessment (EUnetHTA) and HTAsiaLink organisations and other countries with well-established available guidelines.

RESULTS

A total of 52 guidelines from 24 countries were identified, including 13 countries from the EUnetHTA organisation, 9 countries from the HTAsiaLink organisation and 2 other countries (Canada and the USA). A strong consensus was observed among the HTA agencies on the core set of criteria including efficacy or effectiveness, cost-effectiveness, safety, and budget impact. More similarities were observed than differences in methodological recommendations for clinical and economic evaluations among the agencies.

CONCLUSIONS

Substantial convergence is seen in the criteria included in the HTA process, as well as the methods to evaluate and quantify them. Further efforts are needed to verify whether the criteria identified from the guidelines are incorporated in real HTA decisions, and how they are assessed and weighted in practice.

Search for Electron Antineutrino Appearance in a Long-Baseline Muon Antineutrino Beam

Electron antineutrino appearance is measured by the T2K experiment in an accelerator-produced antineutrino beam, using additional neutrino beam operation to constrain parameters of the Pontecorvo-Maki-Nakagawa-Sakata (PMNS) mixing matrix. T2K observes 15 candidate electron antineutrino events with a background expectation of 9.3 events. Including information from the kinematic distribution of observed events, the hypothesis of no electron antineutrino appearance is disfavored with a significance of 2.40σ and no discrepancy between data and PMNS predictions is found. A complementary analysis that introduces an additional free parameter which allows non-PMNS values of electron neutrino and antineutrino appearance also finds no discrepancy between data and PMNS predictions.

[Proposal of guidelines for antibiotic prophylaxis in plastic, reconstructive, and aesthetic surgery]

BACKGROUND

In plastic surgery, guidelines about antibiotic prophylaxis are inaccurate and incomplete, due to result the absence of high-level studies on this subject. The main aim is to establish national common recommendations for plastic surgery antibiotic prophylaxis.

MATERIALS AND METHODS

A working group will discuss and validate a multi-center analysis of practices in three University Hospital Centers compared to an interdisciplinary analysis of recommendations to the French Society of Anaesthesia and Intensive Care Medicine and scientific literature. This working group is composed of plastic surgeon members of the French Society of Aesthetic Reconstructive Plastic Surgery, infectious disease physicians, and anaesthesiologists to define clear and precise antibiotic prophylaxis recommendations.

RESULTS

Antibiotic prophylaxis with cefazoline (or clindamycine±gentamicine in case of allergy), has been recommended for general surgery with flap or implants, for breast surgery, lipofilling, and rhinoplasty. In other plastic surgery, no antibiotic prophylaxis has been recommended.

CONCLUSION

We established common recommendations for plastic surgery antibiotic prophylaxis that is the first step to update these recommendations. Now, they can be evaluated in clinical situation to validate them.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.

Claudin-1, miR-122 and apolipoprotein E transductions improve the permissivity of SNU-182, SNU-398 and SNU-449 hepatoma cells to hepatitis C virus

Hepatitis C virus (HCV) is a human hepatotropic virus, but many hepatoma cell lines are not permissive to this virus. In a previous study, we observed that SNU-182, SNU-398 and SNU-449 hepatoma cell lines were nonpermissive to HCV. To understand the nonpermissivity, we evaluated the ability of each cell line to support the different steps of HCV life cycle (entry, replication and production of infectious particles). Using retroviral pseudoparticles pseudotyped with HCV envelope proteins and recombinant HCV produced in cell culture, we observed that low level or absence of claudin-1 (CLDN1) expression limited the viral entry process in SNU-182 and SNU-398 cells, respectively. Our results also showed that supplementation of the three cell lines with miR-122 partly restored the replication of a JFH1 HCV replicon. Finally, we observed that expression of apolipoprotein E (ApoE) was very low or undetectable in the three cell lines and that its ectopic expression permits the production of infectious viral particles in SNU-182 and SNU-398 cells but not in SNU-449 cells. Nevertheless, the supplementation of SNU-182, SNU-398 and SNU-449 cells with CLDN1, miR-122 and ApoE was not sufficient to render these cells as permissive as HuH-7 cells. Thus, these cell lines could serve as cell culture models for functional studies on the role of CLDN1, miR-122 and ApoE in HCV life cycle but also for the identification of new restriction and/or dependency host factors essential for HCV infection.

[Secondary megaureter: A rare complication of Deflux® endoscopic management of vesicoureteral reflux in children]

Endoscopic management is the gold standard for symptomatic low-grade vesicoureteral reflux (VUR) in children. Deflux^® (hyaluronic acid/dextranomer) injection is highly effective and has very few complications. We report on two cases of secondary megaureter after Deflux^® injections. In the first case, a boy presented with Grade 4 VUR. He received a bilateral Deflux^® injection with a total of three syringes. The postoperative ultrasound was normal. However, a check-up ultrasound 3 years later showed a significant ureteropyelocalyceal dilatation, with stasis and decreased renal function on scintigraphy, the reason why antireflux surgery (Cohen procedure) was performed. In the second case, a girl diagnosed with bilateral VUR at birth received bilateral injections with one syringe on each side at the age of 12 months. One month later, the ultrasound showed a dilation of the distal ureters (diameter of the right ureter, up to 10mm; left ureter, up to 6.7mm). The child underwent surgery 8 months later (Cohen procedure) because of iterative pyelonephritis and persistent ureter dilatation. Only one previous case has been described in the literature. In our experience, this complication has occurred only twice in 452 injections (4‰). In conclusion, endoscopic treatment with hyaluronic acid/dextranomer injection is a minimally invasive procedure that improves the situation in cases of VUR. It has few complications. Other than failure, there is a low risk of secondary expansion requiring, in our opinion, ultrasound verification over the long term.

[Umbilicus in children]

The umbilicus is our first scar. It is the last remain of our life in utero. Besides the umbilical hernia, a common pathology during the first three years of life that rarely requires surgery, there are some rare congenital abnormalities such as gastroschisis and omphalocele, which occur in about 1-5/10,000 births. Gastroschisis is a birth defect of the anterior abdominal wall, through which the fetal intestines freely protrude and are not covered by any membranes. During the 13th week prenatal ultrasound, the umbilical cord can be seen to be properly attached while the intestines float freely in the amniotic fluid. This defect is most common in young women who smoke and/or use cocaine and is not typically associated with genetic disorders. Omphalocele is an average coelosomy, in which a visceral hernia protrudes into the base of the umbilical cord. Omphalocele is typically diagnosed during the prenatal phase, and occurs most commonly in older mothers. It is frequently associated with genetic and morphologic abnormalities, therefore a karyotype should automatically be performed. For these two pathologies, the surgical problem lies in managing, during the reintegration, the conflict container/content responsible to lower vena cava syndrome and disorders ventilatory. Deciding on the technique will depend on the clinical form, and on the tolerance to reinsertion. The success of the surgery is directly linked to the postoperative emergence care for the pre-, per- and postnatal phases. The umbilical cord is preserved in the case of a gastroschisis. A primary or secondary umbilicoplasty will be performed for an omphalocele closure. The umbilicoplasty aims to create an umbilicus in a good position by giving it a shape, ideally oval, but also and especially an umbilication. The primary or secondary umbilicoplasty remains a challenge in a growing abdomen (change in position, deformation, loss of intussusception with growth). Many techniques are described: cutaneous flaps randomly placed, excision and skin plasty, resection and controlled wound healing. The choice of technique is a matter of practice but must be done in a rational way, depending on the scar condition when secondary reconstruction, and with minimal scarring, for primary reconstruction. To avoid morphological changes associated with growth, secondary umbilicoplasty should be proposed after the age of five.

Relative efficacy and tolerability of vortioxetine versus selected antidepressants by indirect comparisons of similar clinical studies

INTRODUCTION

Vortioxetine is an antidepressant with multimodal activity which has shown efficacy in major depressive disorder (MDD) patients in six of ten short-term, randomized, placebo-controlled trials (completed end 2012).

METHODS

We performed meta-regression analyses to indirectly compare vortioxetine to seven marketed antidepressants with different mechanisms of action. To ensure study comparability, only experimental drug and placebo arms from placebo-controlled registration studies were included in primary analyses. The main outcomes were efficacy (standardized mean difference in change from baseline to 2 months on primary endpoint [MADRS/HAM-D]), and tolerability (withdrawal rate due to adverse events).

RESULTS

For efficacy, estimates of treatment effect (negative estimates favor vortioxetine) for vortioxetine versus comparators were: agomelatine, -0.16 (p = 0.11); desvenlafaxine, 0.03 (p = 0.80); duloxetine, 0.09 (p = 0.42); escitalopram, -0.05 (p = 0.70); sertraline, -0.04 (p = 0.83); venlafaxine IR/XR, 0.12 (p = 0.33); and vilazodone, -0.25 (p = 0.11). For tolerability, all but one combination was numerically in favor of vortioxetine (odds ratio < 1), although not all differences were statistically significant: agomelatine, 1.77 (p = 0.03); desvenlafaxine, 0.58 (p = 0.04); duloxetine, 0.75 (p = 0.26); escitalopram, 0.67 (p = 0.28); sertraline, 0.30 (p = 0.01); venlafaxine, 0.47 (p = 0.01); and vilazodone, 0.64 (p = 0.18). Sensitivity analyses did not significantly alter antidepressant effect estimates or relative ranking.

CONCLUSION

These meta-regression data show that vortioxetine offers a comparable or favorable combination of efficacy (measured by MADRS/HAM-D) and tolerability (measured by withdrawal rate due to adverse events) versus other antidepressants in registration studies in MDD. Alternative methods like mixed-treatment comparison and inclusion of all randomized studies and active reference arms may provide complementary information to this analysis (more evidence but also more heterogeneity). Key messages: Indirect comparisons based on registration studies allow a useful comparison between a recently approved antidepressant and an approved drug. Vortioxetine offers a comparable or favorable combination of efficacy (measured by MADRS/HAM-D assessments) and tolerability (measured by withdrawal rate due to adverse events) versus other antidepressants in registration studies in MDD.

ω6/ω3 Polyunsaturated fatty acid supplementations in renal cell model lead to a particular regulation through lipidome for preserved ω6/ω3 ratios

Polyunsaturated fatty acids (PUFA) supplementations modify cell lipid composition leading to a change in cell function. However, the effect of PUFA supplementations in renal model cell on the kidney epithelial cells membrane fatty acid profile is not known. Therefore, the purpose of this study was to determine the effects of PUFAs with different ω6/ω3 ratios supplementations in the kidney epithelial cells and the type of supplementation that can be used as cellular protection during kidney transplantation. For that, we used as model the LLCPK1 cell and determined their membrane fatty acid (FA) composition after supplementation with three different commercial food supplements. These supplements consist of S1: docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) with ω6/ω3 ratio = 0.1, S2: DHA, EPA, linoleic acid (LA) and γ-linoleic acid (GLA) with ω6/ω3 ratio = 2.5, or S3: α-linolenic acid (ALA) and LA with ω6/ω3 ratio near 1. Cells were incubated for 24 hr with 30 μM of ω3 fatty acids from each supplement. Fatty acid composition of control and experimental groups was analysed by gas chromatography after extraction of lipids and fatty acids methylation. The efficiency of cell PUFA supplementation was achieved by showing 2 to 4 fold increases in cell PUFA incorporation. Whatever the supplementation used, the cell saturated fatty acids (SFA) were decreased by 50% following the three supplementations used (p<0.001) as compared to control group. These decreases in SFA were compensated in part by increasing monounsaturated fatty acid levels. All these changes were observed with constant of cell ω6/ω3 ratio whatever the supplementations used. These data suggest that the supplements, with long chain polyunsaturated fatty acids or their precursors, lead to important regulation in the lipidome (desaturases and elongases) associated to preserved ω6/ω3 ratios. The fatty acids remodeling may represent an interesting new mechanism by which renal FA homoestasis could occurred.

Relation between α-isoform and phosphatase activity of Na+,K+-ATPase in rat skeletal muscle fiber types

In skeletal muscle the relationship between Na+,K+-ATPase activity and isoform content remains controversial (9,6). It could be due to the fiber-type content, membrane isolation and analytical methods. We investigated the distribution of subunit α1 and α2 Na+,K+-ATPase catalytic isoforms and the Na+,K+-ATPase activity in isolated membranes from white ( type I and glycolitic fibers) and red (type II and oxidative fibers) skeletal muscles. Red Gastrocnemius and White Gastrocnemius muscles were sampled from 8 week-old female Wistar rats and crude membranes were performed. The Na+,K+-ATPase activity and membrane distribution of Na+,K+-ATPase α1 and α2 isoforms were assessed by ouabain sensitive K-phosphatase (Kpase) measurements and Western Blot respectively. The Na+,K+-ATPase activity was 6 fold lower in White Gastrocnemius membranes than in Red Gastrocnemius membranes. The α1 and α2-isoform levels are higher in RG than in White Gastrocnemius. The α1 and α2-subunit Red Gastrocnemius content was significantly higher than in WG. The correlation between crude membrane Kpase activity and both catalytic α-subunit of the Na+,K+-ATPase exist.These data suggest that the Na+,K+-ATPase phosphatase activity correlates with the α1 and α2 isoforms levels in Red Gastrocnemius and White Gastrocnemius and confirms the fiber-specific Na+,K+-ATPase catalytic α-subunits and α2-isoform as the major catalytic isoform in rat skeletal muscle.

Maternal nutrient restriction during late gestation and early postnatal growth in sheep differentially reset the control of energy metabolism in the gastric mucosa

Fetal growth restriction followed by accelerated postnatal growth contributes to impaired metabolic function in adulthood. The extent to which these outcomes may be mediated centrally within the hypothalamus, as opposed to in the periphery within the digestive tract, remains unknown. In a sheep model, we achieved intrauterine growth restriction experimentally by maternal nutrient restriction (R) that involved a 40% reduction in food intake through late gestation. R offspring were then either reared singly to accelerate postnatal growth (RA) or as twins and compared with controls also reared singly. From weaning, all offspring were maintained indoors until adulthood. A reduced litter size accelerated postnatal growth for only the first month of lactation. Independently from postnatal weight gain and later fat mass, R animals developed insulin resistance as adults. However, restricted accelerated offspring compared with both the control accelerated and restricted restricted offspring ate less and had higher fasting plasma leptin as adults, an adaptation which was accompanied by changes in energy sensing and cell proliferation within the abomasum. Additionally, although fetal restriction down-regulated gene expression of mammalian target of rapamycin and carnitine palmitoyltransferase 1-dependent pathways in the abomasum, RA offspring compensated for this by exhibiting greater activity of AMP-activated kinase-dependent pathways. This study demonstrates a role for perinatal nutrition in the peripheral control of food intake and in energy sensing in the gastric mucosal and emphasizes the importance of diet in early life in regulating energy metabolism during adulthood.

Musical expertise boosts implicit learning of both musical and linguistic structures

Musical training is known to modify auditory perception and related cortical organization. Here, we show that these modifications may extend to higher cognitive functions and generalize to processing of speech. Previous studies have shown that adults and newborns can segment a continuous stream of linguistic and nonlinguistic stimuli based only on probabilities of occurrence between adjacent syllables or tones. In the present experiment, we used an artificial (sung) language learning design coupled with an electrophysiological approach. While behavioral results were not clear cut in showing an effect of expertise, Event-Related Potentials data showed that musicians learned better than did nonmusicians both musical and linguistic structures of the sung language. We discuss these findings in terms of practice-related changes in auditory processing, stream segmentation, and memory processes.

Time perspective and quality of life among HIV-infected patients in the context of HAART

We explored associations between time perspective (TP) and quality of life (QOL) among HIV-infected patients. With the French validated version of the Zimbardo Time Perspective Inventory, we evaluated the TP of patients. A self-administered questionnaire gathered information about QOL (WHOQOL-HIV), TP, relationship with medical staff and self-reported side effects of HAART. Six scores of QOL - physical, psychological, social relationship, environment, patient independence and spirituality were used as dependent variables in the linear regressions to identify factors associated with QOL. The sample (n=72) for this study was recruited from a hospital department specialising in HIV care and consisted of 48 (67%) HIV-infected women and 24 (33%) HIV-infected men with a mean age of 42 years. Using hierarchical regression analysis adjusted on socio-demographic characteristics, clinical characteristics and co-factors, significant relationships were observed between the several TP orientations and an impaired physical, environmental QOL as well as level-of-independence QOL. Specific dimensions of QOL are influenced by specific orientations of TP, which provides information on self-perception and subjective evaluation of QOL. The TP construct provides keys to managing HIV infection in order to improve QOL.

Evaluation of the cost effectiveness of escitalopram versus venlafaxine XR in major depressive disorder

AIM

To assess the relative cost effectiveness of escitalopram compared with venlafaxine XR in patients with major depressive disorder (MDD).

METHODS

An economic evaluation was conducted alongside a double-blind, multinational, randomised clinical trial and examined the costs and quality of life of 251 patients taking escitalopram versus venlafaxine. Outpatients fulfilling criteria for MDD were randomised to receive oral escitalopram 10-20 mg/day or venlafaxine 75-150 mg/day for 8 weeks. Patient-reported outcomes (EuroQOL questionnaire, Quality of Life Depression Scale), use of medical services and absence from work (relating to the previous 3 months) were recorded at baseline, with repeated measurements at week 8. Unit costs in year values were applied to the resource utilisation data. A cost-effectiveness analysis was performed using the EuroQOL score as the effectiveness measure. The perspective was that of the healthcare payer, with a societal perspective considered in a sensitivity analysis.

RESULTS

Statistically significant improvements in patient-reported outcomes (vs baseline) were observed in both groups after 8 weeks' treatment. Patients treated with escitalopram tended to report fewer problems on the EuroQOL dimensions than venlafaxine recipients. Mean per-patient costs in euros (euro, year 2003 values) for the escitalopram group, compared with the venlafaxine group, were 32% lower (110 euros vs 161euros) from a healthcare perspective, although this was not a statistically significant difference. Differences were related to lower drug acquisition costs and fewer hospitalisations for escitalopram than venlafaxine recipients. A multivariate model adjusting for baseline characteristics showed that escitalopram reduced direct costs compared with venlafaxine (p = 0.007). Bootstrapped distributions of the incremental cost-effectiveness ratios also showed similar effectiveness but lower costs for escitalopram compared with venlafaxine. Inclusion of indirect costs led to similar results.

CONCLUSION

This prospective economic analysis suggests that escitalopram has similar effectiveness to venlafaxine in the treatment of MDD, but may be associated with lower healthcare costs. These findings are consistent with previously published economic evaluations.

Epidemiological and quantitative study of GBV-C infection in french polytransfused children

From 1999 to 2002, 246 serum samples taken from polytransfused children were tested for the presence of GB virus C (GBV-C) RNA using a real-time reverse transcription-polymerase chain reaction (RT-PCR) assay. This assay was based on the TaqMan technology and allowed viral load determination in infected children with a dynamic range from 10(3) to 10(7) genome equivalent (gEq) copies/ml. The limit of detection was estimated to 619 gEq copies/ml with a > or = 95% probability of a positive result. Thirty five sera were found to be GBV-C RNA positive, corresponding to a prevalence of GBV-C of 14.2%. The mean viral load was high, i.e., 6 +/- 1.4 log (range 3.22-7.42) gEq copies/ml, but low viral loads were also detected. Sequencing of the 5'-untranslated region (UTR) identified a majority of genotype 2 strains (82%) distributed into two subtypes, 88.5% genotype 2a and 11.5% genotype 2b. In conclusion, GBV-C active infection is very frequent in exposed populations such as polytransfused children. GBV-C RNA quantitation using real-time assay may be useful for diagnosis and follow-up of the natural history of GBV-C infection.

Arterialized venous free flaps for soft-tissue reconstruction of digits: a 40-case series

When there is not sufficient local tissue available for reconstruction of one or multiple digital defects, distant flap reconstructions are required. Available thin flaps with defined arterial inflow and venous outflow are limited and require the sacrifice of an arterial pedicle. In addition, a functional limitation can occur at the donor site. During the last decades, experimental and clinical attempts have been made in using venous flaps, based just on the venous network for in- and outflow. A 40-case series of arterialized venous free flaps in soft-tissue reconstruction of the digits and hand is presented. Neovessel formation induced by an intact venous plexus within the flap proved clinically to be the survival mechanism. Postoperative congestion was present in all flaps and subsided within 14 days; 92 percent of all flaps eventually survived. In 57.5 percent of cases, total flap survival was observed; in 17.5 percent of flaps, a superficial epidermolysis occurred, not requiring further surgery; in 17.5 percent of flaps, a full-thickness skin necrosis developed, requiring grafting (minor complication); in 7.5 percent of reconstructions, total flap necrosis was observed. Thus, in the authors' experience, when conventional local flaps are not available, arterialized venous free flaps proved to be a successful solution for soft-tissue reconstruction in digits and hands. The authors present the main indications and advantages of arterialized venous free flaps, emphasizing the essential technical steps and the most frequent pitfalls in treatment.

Early detection of myocardial ischaemia in the emergency department by rest or exercise (99m)Tc tracer myocardial SPET in patients with chest pain and non-diagnostic ECG

Chest pain (CP) represents a frequent reason for presentation at the emergency department (ED). A large proportion of patients have non-diagnostic ECG on presentation, and in many cases several hours have elapsed since onset of symptoms. Acute rest myocardial scintigraphy (rest SPET) has been shown to have a relevant role in the detection of patients at risk for coronary events, but its sensitivity and negative predictive value are optimal only within the first 3 h following onset of symptoms. In those with delayed presentation, exercise SPET alone, as a screening approach, appears more promising, but its feasibility and diagnostic role in the ED are still unresolved. A total of 231 consecutive patients with a recent-onset (<24 h) first episode of CP had a negative first-line work-up including ECG, troponins, creatine kinase-MB and echocardiography. These patients were considered at low risk for short-term coronary events. Patients were studied with rest SPET if they presented <3 h after onset of CP and exercise SPET if they presented after > or =3 h. The end-points of the study were detection of significant coronary artery disease (CAD) by angiography and major coronary events or cardiac death at 6 months. Eighty patients (35%) underwent rest SPET, while 151 (65%) underwent exercise SPET. Two of the 159 patients with negative SPET had evidence of critical CAD at 6-month follow-up (one patient in the rest SPET group and one in the exercise SPET group; P=NS). Of the 72 patients (31%) with a positive scan, 34 (15%) had documented CAD (16 patients in the rest SPET group and 18 in the exercise SPET group; P=NS). Sensitivity, specificity, accuracy and predictive value were not statistically different between the two groups. In conclusion, the accuracy of exercise SPET in patients with CP and delayed presentation to the ED is comparable to that of validated rest SPET in patients with early presentation. Owing to the high negative predictive value (99%), exercise SPET is especially valuable as a screening tool for the exclusion of CAD in low-risk patients and implementation of early discharge.