Baseline characteristics and outcome of stroke patients after endovascular therapy according to previous symptomatic vascular disease and sex

Aim

The aim of this study was to investigate baseline characteristics and outcome of patients after endovascular therapy (EVT) for acute large vessel occlusion (LVO) in relation to their history of symptomatic vascular disease and sex.

Methods

Consecutive EVT-eligible patients with LVO in the anterior circulation admitted to our stroke center between 04/2015 and 04/2020 were included in this observational cohort study. All patients were treated according to a standardized acute ischaemic stroke (AIS) protocol. Baseline characteristics and successful reperfusion, recurrent/progressive in-hospital ischaemic stroke, symptomatic in-hospital intracranial hemorrhage, death at discharge and at 3 months, and functional outcome at 3 months were analyzed according to previous symptomatic vascular disease and sex.

Results

995 patients with LVO in the anterior circulation (49.4% women, median age 76 years, median admission NIHSS score 14) were included. Patients with multiple vs. no previous vascular events showed higher mortality at discharge (20% vs. 9.3%, age/sex - adjustedOR = 1.43, p = 0.030) and less independency at 3 months (28.8% vs. 48.8%, age/sex - adjustedOR = 0.72, p = 0.020). All patients and men alone with one or multiple vs. patients and men with no previous vascular events showed more recurrent/progressive in-hospital ischaemic strokes (19.9% vs. 6.4% in all patients, age/sex - adjustedOR = 1.76, p = 0.028) (16.7% vs. 5.8% in men, age-adjustedOR = 2.20, p = 0.035). Men vs. women showed more in-hospital symptomatic intracranial hemorrhage among patients with one or multiple vs. no previous vascular events (23.7% vs. 6.6% in men and 15.4% vs. 5.5% in women, OR = 2.32, p = 0.035/age - adjustedOR = 2.36, p = 0.035).

Conclusions

Previous vascular events increased the risk of in-hospital complications and poorer outcome in the analyzed patients with EVT-eligible LVO-AIS. Our findings may support risk assessment in these stroke patients and could contribute to the design of future studies.

Efficacy and safety of ocrelizumab in patients with relapsing multiple sclerosis: Real-world experience of two Swiss multiple sclerosis centers

BACKGROUND

Ocrelizumab (OCR) is a humanized monoclonal antibody directed against CD-20 positive lymphocytes, mainly B-lymphocytes. OCR is approved for treatment of primary progressive (PPMS) and relapsing multiple sclerosis (RMS). This study aims to provide real-world safety and efficacy data of people with RMS treated with OCR in two Swiss Multiple Sclerosis (MS) centers.

METHODS

We have conducted a retrospective data analysis using the patient cohorts from the Cantonal Hospital Aarau and Bern University Hospital (RMS: n = 235). Statistical analyses were performed with Mann-Whitney U-Test, Chi-squared test and Spearman-Rho-Correlation. Adjustment for multiple testing was performed by Bonferroni procedure.

RESULTS

After initiation of OCR, there was a decrease in disease activity in RMS patients. In our study, 152/190 (80.0 %) RMS patients fulfilled the criteria for NEDA-3 12 months and 88/104 (84.6 %) showed NEDA-3 24 months after OCR initiation. The most frequent adverse events (AEs) in our study were infections, taking place in 78/235 (33.2 %) RMS patients. COVID-19 was the most common infection, followed by urinary infections and other respiratory infections and infectious adverse events occurred significantly more frequent in patients with reduced IgG serum concentration.

CONCLUSIONS

Our real-world study showed OCR being associated with low rates of any type of MS disease activity as indicated by NEDA-3. The adverse event profile is comparable to the known events especially infections and an association between infections and reduced IgG serum concentration was found.

Sex differences in multiple sclerosis relapse presentation and outcome: a retrospective, monocentric study of 134 relapse events

Background

Reporting of sex-specific analyses in multiple sclerosis (MS) is sparse. Disability accrual results from relapses (relapse-associated worsening) and independent thereof (progression independent of relapses).

Objectives

A population of MS patients during relapse treated per standard of care was analyzed for sex differences and short-term relapse outcome (3-6 months) as measured by Expanded Disability Status Scale (EDSS) change.

Design

Single-center retrospective study.

Methods

We analyzed 134 MS relapses between March 2016 and August 2020. All events required relapse treatment (steroids and/or plasma exchange). Demographic, disease, and paraclinical characteristics [cerebrospinal fluid (CSF) and magnetic resonance imaging (MRI)] were displayed separated by sex. Multivariable linear regression was run to identify factors associated with short-term EDSS change.

Results

Mean age at relapse was 38.4 years (95% confidence interval: 36.3-40.4) with a proportion of 71.6% women in our cohort. Smoking was more than twice as prevalent in men (65.8%) than women (32.3%). In- and after-relapse EDSSs were higher in men [men: 3.3 (2.8-3.9), women: 2.7 (2.4-3.0); men: 3.0 (1.3-3.6); women: 1.8 (1.5-2.1)] despite similar relapse intervention. Paraclinical parameters revealed no sex differences. Our primary model identified female sex, younger age, and higher EDSS at relapse to be associated with EDSS improvement. A higher immunoglobulin G (IgG) quotient (CSF/serum) was associated with poorer short-term outcome [mean days between first relapse treatment and last EDSS assessment 130.2 (79.3-181.0)].

Conclusion

Sex and gender differences are important in outcome analyses of MS relapses. Effective treatment regimens need to respect putative markers for a worse outcome to modify long-term prognosis such as clinical and demographic variables, complemented by intrathecal IgG synthesis. Prospective trials should be designed to address these differences and confirm our results.

Socioeconomic and Regional Disparities in Industry-Sponsored Clinical Trials in Multiple Sclerosis

This cross-sectional study examines the geographical and socioeconomic factors associated with trial distribution and outcome of treatment for multiple sclerosis (MS).

Anti-neurochondrin antibody as a biomarker in primary autoimmune cerebellar ataxia-a case report and review of the literature

BACKGROUND AND PURPOSE

Neuronal autoantibodies can support the diagnosis of primary autoimmune cerebellar ataxia (PACA). Knowledge of PACA is still sparce. This article aims to highlight the relevance of anti-neurochondrin antibodies and possible therapeutical consequences in people with PACA.

METHODS

This is a case presentation and literature review of PACA associated with anti-neurochondrin antibodies.

RESULTS

A 33-year-old man noticed reduced control of the right leg in May 2020. During his first clinic appointment at our institution in September 2021, he complained about gait imbalance, fine motor disorders, tremor, intermittent diplopia and slurred speech. He presented a pancerebellar syndrome with stance, gait and limb ataxia, scanning speech and oculomotor dysfunction. Within 3 months the symptoms progressed. An initial cerebral magnetic resonance imaging, June 2020, was normal, but follow-up imaging in October 2021 and July 2022 revealed marked cerebellar atrophy (29% volume loss). Cerebrospinal fluid analysis showed lymphocytic pleocytosis of 11 x 10³ /L (normal range 0-4) and oligoclonal bands type II. Anti-neurochondrin antibodies (immunoglobulin G) were detected in serum (1:10,000) and cerebrospinal fluid (1:320, by cell-based indirect immunofluorescence assay and immunoblot, analysed by the EUROIMMUN laboratory). After ruling out alternative causes and neoplasia, diagnosis of PACA was given and immunotherapy (steroids and cyclophosphamide) was started in January 2022. In March 2022 a stabilization of disease was observed.

CONCLUSION

Cerebellar ataxia associated with anti-neurochondrin antibodies has only been described in 19 cases; however, the number of unrecognized PACAs may be higher. As anti-neurochondrin antibodies target an intracellular antigen and exhibit a mainly cytotoxic T-cell-mediated pathogenesis, important therapeutic implications may result. Because of the severe and rapid clinical progression, aggressive immunotherapy was warranted. This case highlights the need for rapid diagnosis and therapy in PACA, as stabilization and even improvement of symptoms are attainable.

Anti-kelchlike protein 11 antibody-associated encephalitis: Two case reports and review of the literature

BACKGROUND AND PURPOSE

Kelchlike protein 11 antibodies (KLHL11-IgGs) were first described in 2019 as a marker of paraneoplastic neurological syndromes (PNSs). They have mostly been associated with testicular germ cell tumors (tGCTs).

METHODS

Two patients with KLHL11-IgG encephalitis are reported, and the literature is comprehensively reviewed.

RESULTS

Patient 1 had been in remission from a tGCT 10 years prior. He developed episodic vertigo and diplopia progressing over a few days. Treatment with corticosteroids (CSs) was started a few days after symptom onset. Patient 2 had transient diplopia, which resolved spontaneously. Visual problems persisted for 7 months, when he additionally developed a progressive cerebellar syndrome. One year after onset, CS treatment was started. Initial magnetic resonance imaging was unremarkable in both patients, but analysis of cerebrospinal fluid (CSF) revealed chronic inflammation. KLHL11-IgG was positive in both patients (Patient 1 only in CSF, Patient 2 in serum). Neoplastic screening has so far not revealed any signs of active underlying malignancy. We found 15 publications of 112 patients in total with KLHL11-IgG encephalitis. Most patients (n = 82) had a cerebellar syndrome with or without signs of rhombencephalitis. The most common symptoms were ataxia (n = 82) and vertigo (n = 47), followed by oculomotor disturbances (n = 35) and hearing disorders (n = 31). Eighty of 84 patients had a GCT as an underlying tumor.

CONCLUSIONS

Our cases demonstrate classical symptoms of KLHL11-IgG encephalitis. Early diagnosis and therapy are imperative. As with other PNSs, clinical awareness is needed and further studies are required especially in regard to therapeutic management.

Hypogammaglobulinemia: A contributing factor to multiple sclerosis fatigue?

OBJECTIVE

Fatigue is one of the most disabling and difficult to treat symptoms of autoimmune diseases and frequently presents in people with multiple sclerosis (PwMS). Hypogammaglobulinemia for immunoglobulin G (IgG) affects approximately 8-25% of PwMS. We performed a retrospective analysis to investigate the association of MS-fatigue and IgG hypogammaglobulinemia.

METHODS

PwMS, treated at Eginition University Hospital Athens or at the University Hospital Bern, were included (n = 134 patients (Bern n = 99; Athens n = 35)). Mann Whitney U-test (MWT), ANOVA test, Chi² test and multivariable linear regression models were run.

RESULTS

97/134 (72.4%) PwMS reported fatigue. In the multivariable linear regression analysis, IgG serum concentration (-1.6, 95%CI -2.7 - -0.5, p = 0.006), daytime sleepiness (0.8, 95%CI 0.2-1.4, p = 0.009), and a depressive mood (1.1, 95%CI 0.8-1.4, p < 0.001) were significantly associated with fatigue. The impact of IgG serum concentration (-2.9 95%CI -4.7 - -1.1, p = 0.002) remained significant also in the subcohort of PwMS without depressive symptoms or daytime sleepiness.

CONCLUSIONS

We found an association between IgG hypogammaglobulinemia and fatigue in PwMS (Level of Evidence IV), which might be translated to other autoimmune diseases. It bears a potential therapeutic consequence considering IgG supplementation strategies, if our finding can be validated prospectively.

Multidimensional phenotyping of the post-COVID-19 syndrome: A Swiss survey study

INTRODUCTION

Post-COVID-19 syndrome affects approximately 10-25% of people after a COVID-19 infection, irrespective of initial COVID-19 severity. The aim of this project was to assess the clinical characteristics, course, and prognosis of post-COVID-19 syndrome using a systematic multidimensional approach.

PATIENTS AND METHODS

An online survey of people with suspected and confirmed COVID-19 and post-COVID-19 syndrome, distributed via Swiss COVID-19 support groups, social media, and our post-COVID-19 consultation, was performed. A total of 8 post-infectious domains were assessed with 120 questions. Data were collected from October 15 to December 12, 2021, and 309 participants were included. Analysis of clinical phenomenology of post-COVID-19 syndrome was performed using comparative statistics.

RESULTS

The three most prevalent post-COVID-19 symptoms in our survey cohort were fatigue (288/309, 93.2%), pain including headache (218/309, 70.6%), and sleep-wake disturbances (mainly insomnia and excessive daytime sleepiness, 145/309, 46.9%). Post-COVID-19 syndrome had an impact on work ability, as more than half of the respondents (168/268, 62.7%) reported an inability to work, which lasted on average 26.6 weeks (95% CI 23.5-29.6, range 1-94, n = 168). Quality of life measured by WHO-5 Well-being Index was overall low in respondents with post-COVID-19 syndrome (mean, 95% CI 9.1 [8.5-9.8], range 1-25, n = 239).

CONCLUSION

Fatigue, pain, and sleep-wake disturbances were the main symptoms of the post-COVID-19 syndrome in our cohort and had an impact on the quality of life and ability to work in a majority of patients. However, survey respondents reported a significant reduction in symptoms over 12 months. Post-COVID-19 syndrome remains a significant challenge. Further studies to characterize this syndrome and to explore therapeutic options are therefore urgently needed.

Sex and gender differences in autoimmune demyelinating CNS disorders: Multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD) and myelin-oligodendrocyte-glycoprotein antibody associated disorder (MOGAD)

Multiple sclerosis (MS), Neuromyelitis optica spectrum disorder (NMOSD) and Myelin-Oligodendrocyte-Glycoprotein antibody associated disorder (MOGAD) are demyelinating disorders of the central nervous system (CNS) of autoimmune origin. Here, we summarize general considerations on sex-specific differences in the immunopathogenesis and hormonal influences as well as key clinical and epidemiological elements. Gender-specific issues are widely neglected starting with the lacking separation of sex as a biological variable and gender comprising the sociocultural components. As for other autoimmune diseases, female preponderance is common in MS and NMOSD. However, sex distribution in MOGAD seems equal. As in MS, immunotherapy in NMOSD and MOGAD is crucial to prevent further disease activity. Therefore, we assessed data on sex differences of the currently licensed disease-modifying treatments for efficacy and safety. This topic seems widely neglected with only fragmented information resulting from post-hoc analyses of clinical trials or real-world post-marketing studies afflicted with lacking power and/or inherent sources of bias. In summary, biological hypotheses of sex differences including genetic factors, the constitution of the immune system and hormonal influences are based upon human and preclinical data, especially for the paradigmatic disease of MS whereas specific data for NMOSD and MOGAD are widely lacking. Epidemiological and clinical differences between men and women are well described for MS and to some extent for NMOSD, yet, with remaining contradictory findings. MOGAD needs further detailed investigation. Sex-specific analyses of safety and efficacy of long-term immunotherapies need to be addressed in future studies designed and powered to answer the pressing questions and to optimize and individualize treatment.

P-243 Automating tracking of cell division for human embryo development in time lapse videos

Study question

Can tracking cell division and predicting human embryo cleavage stages be automated in time-lapse videos (TLV) using AI object detection methods?

Summary answer

We developed software predicting blastomere count and tracking cell cleavages up until 4-5 stage. The software employs object detection technique called YOLOv5 to detect cells.

What is known already

Embryo morphology plays an important part in determining viability. Parameters such as number of cells present following fertilization, abnormal cell division (reverse/direct) and evaluating cleavage stages have correlation with pregnancy rates. However, continuous manual evaluation can be time-consuming, and automation will assist in embryo viability assessment. YOLOv5 has proven to accurately detect objects in videos. YOLOv5 uses mean average precision (mAP) as a metric to quantify the portions of frames in videos having the correct count of the objects.

Study design, size, duration

We have developed a software that uses YOLOv5 to detect cells present in frames of TLV, then marks each cell boundary with different colored circular overlays using OpenCV. We trained YOLOv5 to detect objects: cell, morula and blastocyst using 150 images of different cell-stages, morula, blastocyst. For object cell mAP was 0.65. Annotated location of objects in images and YOLOv5 predictions were reviewed by embryologists. We evaluated the software on TLV from 11 patients.

Participants/materials, setting, methods

After YOLOv5 detects cells in frames of TLV, our software computes cell count and assigns each cell a different color which is maintained until cell division into daughter cells. Later, daughter cells were also assigned different colors. If the frame has a preceding frame, software calculates detected cells' proximity with each cell in the preceding frame and copies color scheme provided proximity is within some threshold. The software provides TLV with colored overlays as output.

Main results and the role of chance

In starting frames of TLV with single cell, software accurately detected 1-cell (high precision=0.99, high recall=0.83, high F1-score=0.90). We observed some misclassification between 1-cell and morula. The reason could be that compacted morula looks like 1-cell. Best performance is observed for 2-cells (high precision=0.91, high recall=0.98, high F1-score=0.95). 4-cells were sometimes misclassified with 3 or 5-cells (high precision=0.88, low recall=0.59, high F1-score=0.71). One reason for the misclassification can be that overlapping between cells increases with number of cells. 3-cell and 5-cell are confused with other stages, still cleavage stage detection is better than random: 3-cell (average precision=0.43, high recall=0.83, average F1-score=0.49), 5-cell (average precision=0.44, average recall=0.40, average F1-score=0.40). For cell-stages&gt;5, YOLOv5 detects less cells than actual count and software predicts cleavage later than actual by 9-10 frames on average. The proximity threshold used was 0.10 for cell-count&lt;4 and 0.05 for count&gt;4.

In 5 TLV, overlay color for cells changes abruptly between frames, possibly because once YOLOv5 detected a stage, in consecutive frames less cell-number was recorded, and then again reported correct count. Sometimes, software selected the wrong parent for daughter cells (incorrect colored overlay). 2 TLV had direct and reverse cleavages and software could detect these two patterns.

Limitations, reasons for caution

Overall, our software can precisely detect cells, cell divisions and cleavage stages up to 4-cell stages. We hypothesize that training YOLOv5 on a bigger dataset and including several focal plane information will enable our software to detect overlapping cells and cleavage stages &gt; =5.

Wider implications of the findings

Object detection proved to be pragmatic for ART and tracking cell division using our software will reduce time consumed in manual annotations, easier prediction of abnormal cleavages and more objective assessments. Qualitative evaluation by embryologists resulted in the overall verdict that this is useful and promising for further development.

Trial registration number

not applicable

Fatigue in Post-COVID-19 Syndrome: Clinical Phenomenology, Comorbidities and Association With Initial Course of COVID-19

Introduction

Post-COVID-19 syndrome affects approximately 10-25% of people suffering from COVID-19 infection, irrespective of initial COVID-19 severity. Fatigue is one of the major symptoms, occurring in 30-90% of people with post-COVID-19 syndrome. This study aims at describing factors associated with fatigue in people with Post-COVID-19 seen in our newly established Post-Covid clinic.

Methods

This retrospective single center study included 42 consecutive patients suffering from Post-COVID-19 syndrome treated at the Department of Neurology, University Hospital Bern, between 11/2020 and05/2021. Clinical phenomenology of Post-COVID-19 syndrome with a special focus on fatigue and risk factor identification was performed using Mann-Whitney U Test, Pearson Correlation, and Chi-Quadrat-Test.

Results

Fatigue (90.5%) was the most prevalent Post-COVID-19 symptom followed by depressive mood (52.4%) and sleep disturbance (47.6%). Fatigue was in mean severe (Fatigue severity scale (FSS) mean 5.5 points (95% Confidence interval (95CI) 5.1 - 5.9, range .9 - 6.9, n = 40), and it was unrelated to age, COVID-19 severity or sex. The only related factors with fatigue severity were daytime sleepiness and depressed mood.

Conclusion

Fatigue is the main symptom of the Post-COVID-19 syndrome in our cohort. Further studies describing this syndrome are needed to prepare the healthcare systems for the challenge of treating patients with Post-COVID-19 syndrome.

[Primary CNS Vasculitis - An Overview]

Primary CNS Vasculitis - An Overview Abstract. Cerebral vasculitis, especially the primary vasculitis of the central nervous systems (primary CNS vasculitis), are rare inflammatory diseases of the small- and medium-sized vessels of the CNS. The pathogenesis of primary CNS vasculitis is unclear. Infectious triggers are hypothesized to induce an activation of the immune system with resulting inflammation of the blood vessels within the CNS. Clinically, primary CNS vasculitis presents heterogeneously with leading symptoms such as headache, memory impairment and other neurological deficits. A broad diagnostic work-up prior to treatment initiation is crucial. Treatment consists of immunotherapy (pulse and maintenance therapy) and requires long-term neurological treatment and follow-up due to the increased risk of recurrence of the disease.

P–260 Towards better explainable deep learning models for embryo selection in ART

Study question

Can heatmaps generated by occlusion explain the patterns learned by deep learning (DL) models classifying the embryo viability in ART?

Summary answer

Occlusion experiments generate heatmaps that reveal which regions in frames of time-lapse video (TLV) are more discriminative for classification and prediction by the DL models.

What is known already

DL has widely been explored in ART for embryo selection. Depending upon input (video or image), different DL models classifying embryo viability are developed. However, whether the prediction is based on actual input features or random guessing is unknown. The embryo selection in ART is subjective. If the intention is using DL models’ prediction to transfer, freeze or discard the embryo, explanations of how they interpret embryonic development features brings transparency and trust. In other areas, heatmaps are used for explaining DL predictions. The heatmaps can be a tool to understand patterns learned by DL models for embryo selection.

Study design, size, duration

We trained two separate DL models for predicting the presence of fetal heartbeat for the transferred embryos. We further used occlusion generated heatmaps to explain the predictions. For training, retrospective data was used. The input dataset consisted of 136 TLVs and corresponding patient data for 132 participants (128: single embryo transfers and 8: double embryo transfer) from both IVF and ICSI treatment. Each video was assessed by an embryologist.

Participants/materials, setting, methods

DL models (A as ResNet–18, B as VGG16) are trained for predicting the presence of fetal heartbeat on a single frame extracted from TLV after day three or later. Model A has a better recall (0.7) compared to B (0.5). Heatmaps explain the reason behind models’ recall rate by visually representing patterns learned by them. Using occlusion filter size 30*30 with stride 14 and size 50*50 with stride 25, we generate heatmaps for both models.

Main results and the role of chance

The heatmaps generated using occlusion can represent visually the patterns discovered by the DL models when predicting the presence of a fetal heartbeat. Using occlusion filter size 30*30 with stride 14, we verified that Model B has lower recall because the heatmaps show that the model finds redundant features present outside the embryo region in many input frames. It could be interpreted that either the model has not learned relevant patterns or is more robust to noise. This representation of DL models equips us in better decision-making, whether to consider or discard the prediction or rather train the model further, preprocess training data or change network architecture. The heatmaps revealed that for frames where significant patterns learned by the models are within the embryo region, more weight was given to specific features like the inner cell mass, trophectoderm and some parts within the zona pellucida. Moreover, the heat maps generated using occlusion are independent of the underlying model’s architecture as the same experiment settings were used for both models. For occlusion filter size 50*50 with stride 25, the expanse of input regions (in or outside the embryo) considered relevant could be visualized for both models A and B.

Limitations, reasons for caution

Heatmaps generated by occluding input regions give a visual representation of features in individual frames not directly on videos. Explaining DL models by heatmaps besides occlusion, other techniques (Grad-Cam) exist but were not evaluated. Furthermore, there is no quantitative measure for evaluating whether heatmaps are a good explanation or not.

Wider implications of the findings: The heatmaps make the patterns discovered by DL models visually recognized and bring forth the prominent portions of embryo regions. This will again improve understanding and trust in DL models’ predictions. Visual representation of DL models using heatmaps enables interpreting a prediction, performing model analysis and determining scope for improvement.

Trial registration number

Not applicable

[Healthy diet in primary and secondary prevention of stroke]

Healthy diet in primary and secondary prevention of stroke Abstract. An unhealthy diet is one of the modifiable risk factors for stroke. The world population's diet is suboptimal. Healthy and nutritious food such as whole grain, vegetables, fruit and fish is not consumed enough, and unhealthy food such as sweetened beverages, processed meat and salty food takes up a higher proportion of the diet than recommended. We also see this imbalance in Switzerland. After a thorough literature review, we summarize the current findings about different diets and food groups affecting the risk of stroke. Generally, a diet low in salt and rich in potassium, vegetables, fruit, whole grains and unsaturated fats, moderate consumption of fish and low intake of meat is recommended to decrease the risk of stroke. The Mediterranean diet comprises all these aspects and was shown to reduce the stroke risk considerably. Generally, a high variety of food has more impact than supplementation of vitamins, minerals and micronutrients.

Dysplastic Nevi are a Risk Factor for Uveal Melanoma

Many studies have characterized the phenotypic features of individuals who are likely to develop cutaneous melanoma. One of the major items included in melanoma risk assessment has been the presence of clinically atypical nevi (dysplastic nevi). This study assessed the number of subjects with dysplastic nevi in groups of patients with uveal melanoma or cutaneous melanoma and in a group of volunteer controls. The SPSS program was used to calculate the odds ratios (hereafter called relative risks; RR) and 95% confidence intervals (C) in melanoma patients and controls. The RR was 4.36 for uveal melanoma (95% Cl 1.84-10.36) and 4.22 for cutaneous melanoma (95% Cl 1.81-9.84). These results suggest that cutaneous dysplastic nevi are a significant risk factor for uveal melanoma.

Hemodialysis Clinic Social Networks, Sex Differences, and Renal Transplantation

This study describes patient social networks within a new hemodialysis clinic and models the association between social network participation and kidney transplantation. Survey and observational data collected between August 2012 and February 2015 were used to observe the formation of a social network of 46 hemodialysis patients in a newly opened clinic. Thirty-two (70%) patients formed a social network, discussing health (59%) and transplantation (44%) with other patients. While transplant-eligible women participated in the network less often than men (56% vs. 90%, p = 0.02), women who participated discussed their health more often than men (90% vs. 45.5%, p = 0.02). Patients in the social network completed a median of two steps toward transplantation compared with a median of 0 for socially isolated patients (p = 0.003). Patients also completed more steps if network members were closely connected (β = 2.23, 95% confidence interval [CI] 0.16-4.29, p = 0.03) and if network members themselves completed more steps (β = 2.84, 95% CI 0.11-5.57, p = 0.04). The hemodialysis clinic patient social network had a net positive effect on completion of transplant steps, and patients who interacted with each other completed a similar number of steps.

X-ray nanodiffraction analysis of stress oscillations in a W thin film on through-silicon via

X-ray nanodiffraction is used to evaluate axial and tangential residual stress distributions in a W thin film deposited on the scalloped inner wall of a through-silicon via. The results reveal oscillatory stress distributions which correlate well with the scallop wavelength and morphology.

Synchrotron X-ray nanodiffraction is used to analyse residual stress distributions in a 200 nm-thick W film deposited on the scalloped inner wall of a through-silicon via. The diffraction data are evaluated using a novel dedicated methodology which allows the quantification of axial and tangential stress components under the condition that radial stresses are negligible. The results reveal oscillatory axial stresses in the range of ∼445–885 MPa, with a distribution that correlates well with the scallop wavelength and morphology, as well as nearly constant tangential stresses of ∼800 MPa. The discrepancy with larger stress values obtained from a finite-element model, as well as from a blanket W film, is attributed to the morphology and microstructural nature of the W film in the via.

Microbial specialists in below-grade foundation walls in Scandinavia

Below-grade foundation walls are often exposed to excessive moisture by water infiltration, condensation, leakage, or lack of ventilation. Microbial growth in these structures depends largely on environmental factors, elapsed time, and the type of building materials and construction setup. The ecological preferences of Actinomycetes (Actinobacteria) and the molds Ascotricha chartarum, Myxotrichum chartarum (Ascomycota), Geomyces pannorum, and Monocillium sp. (Hyphomycetes) have been addressed based on analyses of 1764 samples collected in below-grade spaces during the period of 2001-2012. Our results show a significant correlation between these taxa and moist foundation walls as ecological niches. Substrate preference was the strongest predictor of taxa distribution within the wall, but the taxa's physiological needs, together with gradients of abiotic factors within the wall structure, also played a role. Our study describes for the first time how the wall environment affects microbial growth.

The orthosteric GABAA receptor ligand Thio-4-PIOL displays distinctly different functional properties at synaptic and extrasynaptic receptors

BACKGROUND AND PURPOSE

Explorations into the heterogeneous population of native GABA type A receptors (GABAA Rs) and the physiological functions governed by the multiple GABAA R subtypes have for decades been hampered by the lack of subtype-selective ligands.

EXPERIMENTAL APPROACH

The functional properties of the orthosteric GABAA receptor ligand 5-(4-piperidyl)-3-isothiazolol (Thio-4-PIOL) have been investigated in vitro, ex vivo and in vivo.

KEY RESULTS

Thio-4-PIOL displayed substantial partial agonist activity at the human extrasynaptic GABAA R subtypes expressed in Xenopus oocytes, eliciting maximal responses of up to ∼30% of that of GABA at α5 β3 γ2S , α4 β3 δ and α6 β3 δ and somewhat lower efficacies at the corresponding α5 β2 γ2S , α4 β2 δ and α6 β2 δ subtypes (maximal responses of 4-12%). In contrast, it was an extremely low efficacious agonist at the α1 β3 γ2S , α1 β2 γ2S , α2 β2 γ2S , α2 β3 γ2S , α3 β2 γ2S and α3 β3 γ2S GABAA Rs (maximal responses of 0-4%). In concordance with its agonism at extrasynaptic GABAA Rs and its de facto antagonism at the synaptic receptors, Thio-4-PIOL elicited robust tonic currents in electrophysiological recordings on slices from rat CA1 hippocampus and ventrobasal thalamus and antagonized phasic currents in hippocampal neurons. Finally, the observed effects of Thio-4-PIOL in rat tests of anxiety, locomotion, nociception and spatial memory were overall in good agreement with its in vitro and ex vivo properties.

CONCLUSION AND IMPLICATIONS

The diverse signalling characteristics of Thio-4-PIOL at GABAA Rs represent one of the few examples of a functionally subtype-selective orthosteric GABAA R ligand reported to date. We propose that Thio-4-PIOL could be a useful pharmacological tool in future studies exploring the physiological roles of native synaptic and extrasynaptic GABAA Rs.

Positive effects of early continuous positive airway pressure on pulmonary function in extremely premature infants: results of a subgroup analysis of the COIN trial

OBJECTIVE

Early continuous positive airway pressure (CPAP) may reduce lung injury in preterm infants.

PATIENTS AND METHODS

Spontaneously breathing preterm infants were randomised immediately after birth to nasal CPAP or intubation, surfactant treatment and mechanical ventilation. Pulmonary function tests approximately 8 weeks post-term determined tidal breathing parameters, respiratory mechanics and functional residual capacity (FRC).

RESULTS

Seventeen infants received CPAP and 22 mechanical ventilation. Infants with early CPAP had less mechanical ventilation (4 vs 7.5 days; p=0.004) and less total respiratory support (30 vs 47 days; p=0.017). Post-term the CPAP group had lower respiratory rate (41 vs 48/min; p=0.007), lower minute ventilation (223 vs 265 ml/min/kg; p=0.009), better respiratory compliance (0.99 vs 0.82 ml/cm H(2)O/kg; p=0.008) and improved elastic work of breathing (p=0.004). No differences in FRC were found.

CONCLUSIONS

Early CPAP is feasible, shortens the duration of respiratory support and results in improved lung mechanics and decreased work of breathing.

Lack of listing status awareness: results of a single-center survey of hemodialysis patients

This study surveyed hemodialysis patients in an urban transplant center serving a predominantly African American population to identify existing and potential barriers to transplantation. The survey used the Dialysis Patient Transplant Questionnaire (DPTQ) to collect self-reported data including interest in a deceased donor kidney transplant and self-reported listing status. We compared patients' survey data to their UNOS listing and computerized medical record at time of interview. Among the 116 patients surveyed, 83 (71.6%) reported interest in a deceased donor kidney transplant. Eighteen (52.9%) of the 34 patients undergoing pretransplantation workup were unaware of their true listing status, and 88.9% of these patients mistakenly believed they were wait listed. All of the patients who mistakenly thought they were listed were undergoing workup. Finding that a significant number of hemodialysis patients who want a deceased donor kidney transplant mistakenly think they are listed when they are not is a documentable deficiency in communication and a potential barrier to transplantation. The finding highlights a correctable problem in communication and work flow that could help to improve transplant center effectiveness. It also reveals that self-reported waiting list status significantly overestimated true waiting list status for our patients at time of interview.

Delivery room management of very low birth weight infants in Germany, Austria and Switzerland--a comparison of protocols

BACKGROUND

Surveys from the USA, Australia and Spain have shown significant inter-institutional variation in delivery room (DR) management of very low birth weight infants (VLBWI, <1500g) at birth, despite regularly updated international guidelines.

OBJECTIVE

To investigate protocols for DR management of VLBWI in Germany, Austria and Switzerland and to compare these with the 2005 ILCOR guidelines.

METHODS

DR management protocols were surveyed in a prospective, questionnaire-based survey in 2008. Results were compared between countries and between academic and non-academic units. Protocols were compared to the 2005 ILCOR guidelines.

RESULTS

In total, 190/249 units (76%) replied. Protocols for DR management existed in 94% of units. Statistically significant differences between countries were found regarding provision of 24 hr in house neonatal service; presence of a designated resuscitation area; devices for respiratory support; use of pressure-controlled manual ventilation devices; volume control by respirator; and dosage of Surfactant. There were no statistically significant differences regarding application and monitoring of supplementary oxygen, or targeted saturation levels, or for the use of sustained inflations. Comparison of academic and non-academic hospitals showed no significant differences, apart from the targeted saturation levels (SpO2) at 10 min. of life. Comparison with ILCOR guidelines showed good adherence to the 2005 recommendations.

SUMMARY

Delivery room management in German, Austrian and Swiss neonatal units was commonly based on written protocols. Only minor differences were found regarding the DR setup, devices used and the targeted ranges for SpO2 and FiO2. DR management was in good accordance with 2005 ILCOR guidelines, some units already incorporated evidence beyond the ILCOR statement into their routine practice.

Patients with type 2 diabetes inadequately controlled on premixed insulin: effect of initiating insulin glargine plus oral antidiabetic agents on glycaemic control in daily practice

AIM

Premixed insulin regimens are commonly used for type 2 diabetes mellitus (T2DM) patients. However, there is limited information regarding next-step therapy options in cases where premixed insulin does not provide adequate glycaemic control. This 12-week observational study of everyday clinical practice evaluated the efficacy and safety of insulin glargine (glargine) plus oral antidiabetic drugs (OADs) in T2DM patients previously treated with premixed insulin.

METHODS

Type 2 diabetes mellitus patients taking premixed insulin were identified from German clinics and were eligible to switch to glargine plus OADs at the physicians' and patients' discretion, as part of routine clinical practice. The study design and conduct was in accordance with German regulations. Fasting blood glucose (FBG), 2-h postprandial blood glucose (PPBG) and glycosylated haemoglobin (HbA(1c)) were measured at the start and after a 12-week observation period.

RESULTS

A total of 5045 patients were followed-up and received glargine plus OADs. FBG [start to end-point: 9.9 +/- 2.7 to 6.9 +/- 1.5 mmol/l (178 +/- 48 to 124 +/- 26 mg/dl); p < or = 0.001], 2-h PPBG [10.8 +/- 2.8 to 7.8 +/- 1.5 mmol/l (195 +/- 50 to 140 +/- 27 mg/dl)] and HbA(1c) (8.3 +/- 1.2 to 7.2 +/- 0.8%; p < or = 0.001) improved significantly from start to end-point, respectively. A total of 48.9%, 38.4% and 73.9% of patients had FBG < 6.7 mmol/l (< 120 mg/dl), 2-h PPBG < 7.2 mmol/l (< 130 mg/dl) or HbA(1c) < 7.5%, respectively, after 12 weeks. Significant reductions in body weight were observed between the start and end of the observation period. A total of 71 adverse events were reported by 38 patients. Hypoglycaemia was the most common event (n = 16).

CONCLUSIONS

This observational study shows that, in T2DM patients inadequately controlled with premixed insulin, switching therapy to glargine plus OADs is associated with significant improvements in FBG and HbA(1c), and is well tolerated in everyday clinical practice. Further intensification of insulin therapy, perhaps by adding one or more injections of prandial insulin, would help provide further improvements in glycaemic control in these patients.