Outcome measures of the surgery first approach for orthognathic correction of dentofacial deformities

In the surgery-first approach (SFA), orthognathic surgery is performed without the need for presurgical orthodontic treatment. This study was aimed at assessing the treatment durations and occlusal outcomes for a consecutive cohort of patients, with a range of dentofacial deformities, who had completed orthognathic treatment using SFA. The duration of orthognathic treatment was measured. The overall change in occlusion, and the quality of the final occlusion, were evaluated using the patients' study casts. A single, independent, calibrated operator carried out the occlusal scores, using the validated Peer Assessment Rating (PAR) index. This was repeated to test intraoperator reliability. A total of 51 patients completed surgery-first treatment during the study period. The mean (range) age at surgery was 23.3 (15-47) years. The pre-treatment skeletal jaw relationship was Class III in 39 cases, and Class II in 12 cases. The mean (SD) overall treatment duration was 11.7 (5.7) months. The intraexaminer reliability of assessing the occlusion was high. The PAR scores confirmed a significant improvement in the quality of occlusion at the completion of treatment, which compares favourably with previous studies on the conventional orthodontics-first approach. The surgery first approach can be effective at correcting both Class II and Class III malocclusion types with reduced treatment times.

Dosimetry Reconstruction in Radiopharmaceutical Therapy Using a Sparse Network of External γ-Sensors

PURPOSE/OBJECTIVE(S)

Radiopharmaceutical therapy (RPT) has demonstrated promise in the treatment of neuroendocrine and prostate cancer. Due to the highly varied biodistribution and non-homogeneity of total integrated dose across cancer patients, a system for real-time dosimetry based on continuous measurement is desirable to deliver sufficient dose for tumor ablation while preventing toxicity from off-target uptake by organs at risk (OAR). Single time point imaging (mostly SPECT)-based dosimetry offers a snapshot of the body-wide dose distribution at a given time point, but even single SPECT imaging is generally limited in availability, often leading to significant inaccuracies in estimating total integrated dose. Therefore, accurate personalized dosimetry in RPT is an unmet need and requires continuous dosimetry measurements of tumors and OARs across multiple half-lives of the therapeutic radiopharmaceutical. Using a priori knowledge of tumor and OAR locations from pretherapy imaging, we have developed a novel algorithm that utilizes a network of custom uncollimated, optical fiber-based γ-counting probes to isolate the real-time in vivo tumor and OAR uptake in 177Lu-PSMA-617 and 225Ac-MACROPA-YS5 therapy.

MATERIALS/METHODS

The proposed system was successfully validated in athymic mice models bearing varying numbers of tumors from two human prostate cancer cell lines (PC3-pip, PC3-flu). Uncollimated γ counts using the developed probes were acquired outside of the mice for 10 minutes, starting at 0 hr, 6 hrs, 12 hrs, 24 hrs, and 48 hrs after the injection of 177Lu-PSMA-617. The percent injected activity per mL of tissue (%IA/mL) of each tumor and OAR was reconstructed at every time point and compared to the %IA/mL extracted from SPECT/CT immediately after the recording.

RESULTS

The developed system's %IA/mL reconstruction in PC3-pip tumors, PC3-flu tumors, kidneys, and bladders is highly correlative with the %IA/mL extracted from state-of-art in vivo dosimetry techniques, with %IA/mL ranging from 0.1% to 160% assuming a 29.6 MBq 177Lu-PSMA-617 administration. The least squares linear regression fit between the reconstructed activity and the activity measured from SPECT/CT is given by Estimated %IA/mL = 0.91 x SPECT %IA/mL, with an R2 of 0.991, and Pearson's r of 0.9975. There is a nearly 1:1 mapping between the proposed model and SPECT/CT.

CONCLUSION

A novel dose reconstruction algorithm for personalized dosimetry in RPT that utilizes a sparse set of external γ-counters and a priori knowledge of tumor and OAR locations was developed and validated in in vivo human prostate cancer murine models. The proposed system enables continuous dosimetry measurements of multiple tumors and OAR noninvasively, with high accessibility, high temporal resolution, and across multiple classes of ɑ and β-based RPT. Similar experiments using 225Ac-MACROPA-YS5 are ongoing and additional results will be reported.

Human macrophages are immunoprofiled by pericardial fluid small extracellular vesicles modulating lipid metabolism mechanisms

Background

The incidence and severity of ischemic heart disease (IHD) is exacerbated by coronary artery disease (CAD). Monocytes and macrophages are central to atherosclerosis. Endogenous small extracellular vesicles (sEVs) can shuttle microRNAs and other molecular cargos from cell to cell, mediating expressional and functional response in the recipient cells. Recent evidence supports a role for sEVs in modulating macrophage phenotype. The pericardial fluid (PF) is in direct contact with the epicardium and contain sEVs. We recently showed that human PF-sEVs are capable to modulate cardiovascular cells via microRNA shuttling.

Purpose

This study sought to investigate whether PF-sEVs regulate macrophages, contributing to a specific immunophenotype in CAD patients.

Methods

PF was collected from either CAD patients undergoing coronary bypass surgery (CABG) or non-atherosclerotic patients operated for mitral valve repair (non-CAD control group). sEVs were isolated using size exclusion chromatography and characterised for size (Nanosight tracking analysis; NTA), tetrasapanin content (by Nanoview chips), microRNA content by RNA seq and proteomic analysis. Monocytes from healthy donors were isolated from buffy coats and differentiated into macrophages following established protocols. Macrophages were incubated with either CAD-sEVs or non-CAD sEVs for 24h at 37oC. The cells were collected and processed for mRNA analyses (qRT-PCR) and flow cytometry. Human PF-cells were isolated and analysed to be compared with the in vitro setting. Further bioinformatics were employed to understand functional pathways and validated in PF from patients.

Results

Exposure to CAD-sEVs induces a proinflammatory profile of human macrophages. CAD-sEVs treated macrophages showed a CD36+low, CD206+low CD40+high profile. While non-CAD-sEVs did not statistically differ from PBS nor untouched groups, CAD-sEVs increased the mRNA level of IL1a, IL1b, TNFa and decreased MRC1. Proteomics revealed that PF-sEVs from CAD patients carried higher amounts of pro-inflammatory molecules (ICAM-1 and IL18) compared to NonCAD control. Bioinformatics analysis showed that 861 miRNAs were decreased in the PF-sEVs from CAD patients compared to non-CAD. miRNA targets prediction and pathway analyses reported that clusters of deregulated miRNAs could regulate CD36 and SRB1 which were shown to be decreased in CAD-sEVs treated macrophages. Human PF-cells revealed a reduced expression of CD36 on PF-macrophages.

Conclusions

We demonstrate, for the first time, that sEVs isolated from the PF of CAD patients induce a proinflammatory profile of human macrophages and that target crucial lipid metabolism pathways. These clinically relevant results could drive to decipher improved therapeutics able modulate the epicardial/myocardial immune response in CAD patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart Fundation

Molecular and haemodynamic interplay in bicuspid aortic valve aortopathy: segmental differences across the aortic circumference

Background

Bicuspid aortic valve (BAV) patients develop ascending aortic (AAo) dilation. The pathogenesis of BAV-aortopathy (genetic vs. hemodynamic) remains unclear.

Purpose

To identify regional changes around the AAo wall in BAV patients with aortopathy integrating clinical imaging and molecular data.

Methods

BAV patients with aortopathy (n=20) were recruited prospectively to surgically collect aortic tissue and perform four-dimensional cardiac magnetic resonance (CMR) scans. Molecular markers were measured analysing the tissue biopsies (n=15) and wall shear stress (WSS) across the AAo circumference was calculated from the 4D CMR data (n=11 patients, and n=7 additional healthy volunteers for comparison). Dilated (anterior/right) vs. non-dilated (posterior/left) circumferential segments were profiled for whole genomic microRNAs (Next Generation RNA-Sequencing, miRCURY LNA PCR), proteins content (Tandem Mass Spectrometry) and elastin fragmentation and degeneration (histomorphometric analysis). Picture 1 summarises the study approach (including a map of the AAo divided in the following segments: A=anterior, AR=anterior-right, PR=posterior-right, P=posterior, PL=posterior-left, AL=anterior-left).

Results

Integrated bioinformatic analyses of RNA-sequencing and proteomic datasets identified 5 microRNAs (miR-128-3p, miR-210-3p, miR-150-5p, miR-199b-5p, and miR-21-5p) differentially expressed across the AAo circumference. Among them, three miRNAs (miR-128-3p, miR-150-5p, and miR-199b-5p) were predicted to have an effect on eight common target genes, whose expression was dysregulated according to proteomic analyses and involved in vascular endothelial growth factor signalling, hippo signaling and arachidonic acid pathway. Decreased elastic fibre levels and elastic layer thickness were observed in the dilated segments in the histomorphometric analysis. Increased WSS and flow-velocity, helical streamlines and asymmetrical flow were observed at the anterior/right wall in asymmetrically and symmetrically dilated patients (the latter exhibiting higher WSS), compared to healthy volunteers.

Conclusion

This study has newly revealed concomitant expressional dysregulation of miRNAs, proteins, and elastic fibres on the anterior/right wall in dilated BAV patients, corresponding to regions of elevated WSS, contributing to advance the understanding of the interplay of genetic and hemodynamic factors underpinning BAV aortopathy.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation and Above & Beyond

Human pericardial fluid exosomes regulate macrophage immunophenotype: new prospective for cardiovascular immune response in coronary artery disease

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation (BHF) Project Grant

Background

The incidence and severity of ischemic heart disease(IHD) is exacerbated by coronary artery disease (CAD). Monocytes and macrophages are central to atherosclerosis. Endogenous small extracellular vesicles(sEVs) can shuttle microRNAs and other molecular cargos from cell to cell, mediating expressional and functional response in the recipient cells. Recent evidence supports a role for sEVs in modulating macrophage phenotype. The pericardial fluid(PF) is in direct contact with the epicardium and contain sEVs. We recently showed that human PF-sEVs are capable to modulate cardiovascular cells via microRNA shuttling. Moreover, pericardial cells reportedly cross-talk with the myocardium to regulate immune response to IHD.

Purpose

This study sought to investigate whether PF-sEVs regulate macrophages, contributing to a specific immunophenotype in CAD patients.

Methods

PF was collected from either CAD patients undergoing coronary bypass surgery(CABG) or non-atherosclerotic patients operated for mitral valve repair(non-CAD control group).sEVs were isolated using size exclusion chromatography and characterised for size(Nanosight tracking analysis; NTA), tetrasapanin content(by Nanoview chips),microRNA content by RNA seq and proteomic analysis. Monocytes from healthy donors were isolated from buffy coats and differentiated into macrophages following established protocols. Macrophages were incubated with either CAD-sEVs or non-CAD sEVs for 24h at 37oC.The cells were collected and processed for mRNA analyses(qRT-PCR) and flow cytometry.Conditioned medium from sEVs treated macrophages was used to further analyse downstream effect on T cells.Further bioinformatics were employed to understand functional pathways and validated in PF from patients.

Results

Exposure to CAD-sEVs induces a proinflammatory profile of human macrophages.CAD-sEVs treated macrophages showed a CD36+low,CD206+low,CD40+high profile.While non-CAD-sEVs did not statistically differ from PBS nor untouched groups, CAD-sEVs increased the mRNA level of IL1a,IL1b,TNFa and decreased MRC1.Proteomics revealed that PF-sEVs from CAD patients carried higher amounts of pro-inflammatory molecules(ICAM-1 and IL18)compared to non-CAD control.Bioinformatics analysis showed that 861 miRNAs were decreased and 482 increased in the PF-sEVs from CAD patients compared to non-CAD.miRNA targets prediction and pathway analyses reported that clusters of deregulated miRNAs could regulate CD36 and SRB1 which were shown to be decreased in CAD-sEVs treated macrophages.In addition,media from CAD-sEVs treated macrophages induced a higher T cell activation profile.

Conclusions

We demonstrate, for the first time, that sEVs isolated from the PF of CAD patients induce a proinflammatory profile of human macrophages and that target crucial lipid metabolism pathways.These clinically relevant results could drive to decipher improved therapeutics able modulate the epicardial/myocardial immune response in CAD patients

222 Robotic Surgery: Public Perceptions and Current Misconceptions

Aim

While surgeons and robotic companies are key stakeholders involved in the adoption of Robotic Surgery (RS), the public's role is often overlooked. However, given that patients hold ultimate power over their healthcare decisions, public acceptance of RS is crucial. This study aims to identify public understanding, opinions and misconceptions on RS and present solutions to facilitate its wider integration.

Method

An online questionnaire distributed via social media platforms between February and May 2021 identified the views of UK adults on RS. The data was evaluated using thematic analysis, descriptive statistics, and statistical analysis. Statistical differences in age, gender, education level, and presence in the medical field were also sought.

Results

263 responses were obtained, with 216 (82.1%) analysed. Demographic differences provided significantly different results. Participants were relatively uninformed about RS, with a median knowledge score of 4.00(2.00–6.00) on a 10-point likert scale. Fears surrounding increased risk, reduced precision and technological failure were identified, alongside misconceptions on what RS entails, including it being autonomous. However, providing factual information in the survey about RS statistically increased participant comfort (p=<0.0001). Most (61.8%) participants believed robot manufacturers were responsible for malfunctions, but doctors were held accountable more by older, less educated, and non-medical participants.

Conclusions

This study highlights the role of negative and inaccurate public perceptions surrounding RS in impeding its widespread adoption. Greater emphasis must be placed on patient education in RS to mitigate misconceptions and ensure greater diffusion of its benefits

219 The Opportunities and Challenges of Robotic Surgery: A Surgeon and Robotic Company Perspective

Introduction

As an increasing number of specialties have begun to adopt robotic surgery (RS), its prevalence within the NHS is continually rising. This study aims to establish stakeholders’ opinions on the opportunities and challenges of the widespread adoption of RS.

Method

Participants were recruited through social media platforms such as LinkedIn or via university affiliations and current RS research. Semi-structured interviews of eight surgeons and five company representatives were conducted online. Transcripts were analysed to formulate themes surrounding the opportunities and challenges of RS.

Results

This study identified six common themes amongst shareholders: Perspective, Ethics, Impact of Robotics, Training, Adoption and Finances. The success rates and quality of results offered by RS make it a recognised future surgical staple amongst interviewees. However, the technology remains a contentious subject amongst surgeons, with many doubting whether the benefits outweigh the costs associated with implementation. Such reservations are further exacerbated by the absence of a formal training pathway. National guidelines are necessary to embed RS within the NHS infrastructure, allowing greater standardisation for patients and surgeons. The importance of patient education to address misconceptions was emphasised. Despite current high costs, robotic technology is forecasted to become cheaper with greater use and increased market competition. Interviewees stressed that responsibility for errors lies with the surgeon, but with the manufacturer for instrument malfunctions.

Conclusions

This study highlights stakeholders’ views on the opportunities and challenges of RS. The identified themes should form the basis of the proposed recommendations to facilitate a more widespread adoption of RS.

Severe isolated mitral stenosis: are we facing different phenotypes?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Rheumatic mitral valve stenosis (MS) causes progressive left atrial (LA) fibrosis and functional impairment, pulmonary artery systolic hypertension and right ventricular (RV) dysfunction.

Purpose

The aim of the study was the evaluate the different characteristics between high gradients (HG) and low gradient (LG) MS and, within the LG group those with high (LG-HF) or low flow (LG-LF). Moreover, we wanted to evaluate if there was any difference in overall complications and atrial fibrillation (AF) incidence.

Methods

A total of 147 patients with isolated severe MS were retrospectively enrolled from the institutional echo database.  Echocardiograms were read offline and clinical information were obtained from patients` records. Patients were divided into a group with HG (31 patients, mean MS gradient > 10 mmHg) and LG (116 patients, mean MS gradient ≤ 10 mmHg). The group of LG was then divided in low flow (Stroke volume index (SVi) ≤ 35 ml/m2, LF-LG: 68 patients) and in high flow (SVi > 35 ml/m2, HF-LG: 48 patients).

Results

The HG group was younger, although the difference did not reach statistical significance, higher percent of males (45% M vs 22% F, p = 0.02), higher heart rate (HR), left atrial volume, higher tricuspid regurgitation velocity (TVR) and derived pulmonary artery systolic pressure (PASP), RV fractional area changes (RV FAC) but similar RV longitudinal contraction. Moreover, the HG group had more severe MS calculated according to PHT.  The group of LG was divided according to SVi:  LF-LG group compare to HG-MS had higher percent of females (45% F vs 13% M, p < 0.001), similar AF (43% vs 32%, p = ns) and pre surgical complications (19% vs 16%, p = ns). LF-LG group had smaller LA systolic volume (117 ± 51 51 ml vs 148.6 ± 38 ml, p < 0.0001), lower LV-S` (5.3 ± 1.4 vs 6 ± 1.6 cm/s, p = 0.004), lower TRV (2.47 ± 0.5 vs 3.24 ± 0.7 m/s, p < 0.0001), higher TAPSE/PASP (0.64 ± 0.3  vs 0.45 ± 0.29, p < 0.001), lower RV S` (9.79 ± 2.01m/s vs 11.25 ± 3.1 m/s, p = 0.01), higher RVFAC (38.5 ± 9.6% vs 30.9 ± 9.2%, p = 0.0005). The group of LG-LF had also less severe MS (1.3 ± 0.6 cm2 vs 1.15 ± 0.3 cm2, p < 0.01).

Conclusion

Patients with HG MS were those with worst left ventricular involvement, higher PASP and lower RV function. The LF-LG MS were older, and more females were included and even though they had smaller LA, lower values of PASP they had significantly higher percent of AF and similar pre surgical complications.  It could be speculated that LF-LG severe MS patients could be a different phenotype of the disease.

Stuck mechanical valve complication in non-COVID-19 patients during COVID-19 pandemic: single center experience

Funding Acknowledgements

Type of funding sources: None.

Background

Stuck valve is a very rare and severe complication that occurs in mechanical valve replacement patients with ineffective anticoagulation. However, with COVID-19 restriction measures, it became challenging to regularly assess INR to make sure it falls within the target therapeutic range to prevent this complication.

Purpose

We wanted to explore how did the COVID-19 pandemic restrictions impacted mechanical valve replacement patients on chronic anticoagulation and the long-term consequences of limiting their access to health service.

Methods

We present a series of 10 patients on warfarin anticoagulation therapy who either underwent transthoracic echocardiography for a suspected stuck valve or were seen at the outpatient valve clinic with the residual consequences of a stuck valve during the COVID-19 restriction measures in our institute.

Results

Eight patients were female, two of whom were pregnant at the first trimester and eventually went on to receive an abortion; six patients received urgent valve replacement cardiac surgery; four patients were managed medically e.g. with heparin; none had thrombolytic therapy. Stuck prosthetic valves incident has increased significantly during this period, particularly those in the mitral position for which urgent replacement and prolonged hospitalization including intensive care admission, with high in-hospital mortality rates and high costs were necessary. Mean hospital admission time was 27.5 ± 18.5 days.  The cost of treatment, as average estimated reimbursement, was 11,000 USD for medical admission only, and 43,200 USD when surgery was required, up to 64,000 USD when ECMO was part of patient management.

Conclusion

Despite governments’ efforts to implement telemedicine and virtual clinics, COVID-19 restrictions and health-messaging affected the routine follow-up of non-COVID-19 patients. We report dramatic consequences to this drastic change in healthcare: clinical complications, lost lives and inflated healthcare costs in patients with a prosthetic valve. We believe that non-COVID-19 patients have paid, and will continue to pay in the future, a price that is much greater than those patients who have suffered from COVID-19. Active engagement of patients should be implemented in a time of emergencies, and further studies should address the efficacy and cost-effectiveness of public policies aimed to decrease the burden of avoidable complications and missed diagnoses. Abstract Figure. Fluoroscopy in a 70 years old patient

Machine learning to aid in the diagnosis of acute heart failure in the emergency department

Background

B-type natriuretic peptide (BNP) and mid-regional pro-atrial natriuretic peptide (MRproANP) testing are recommended to aid in the diagnosis of acute heart failure. However, the application of these biomarkers for optimal diagnostic performance is uncertain.

Methods

We performed a systematic review and harmonised individual patient-level data to evaluate the diagnostic performance of BNP and MRproANP for the diagnosis of acute heart failure using random-effects meta-analysis. We subsequently developed and externally validated a decision-support tool called CoDE-HF for both BNP and MRproANP that combines the natriuretic peptide concentrations with clinical variables using machine learning to report the probability of acute heart failure for an individual patient.

Results

Fourteen studies from 12 countries provided individual patient-level data in 8,493 patients for BNP and 3,847 patients for MRproANP, in whom, 48.3% (4,105/8,493) and 41.3% (1,611/3899) had an adjudicated diagnosis of acute heart failure, respectively. The negative and positive predictive values of guideline-recommended thresholds for BNP (100 pg/mL) and MR-proANP (120 pg/mL) were 93.6% (95% confidence interval 88.4–96.6%) and 68.8% (62.9–74.2%), and 95.6% (92.2–97.6%) and 64.8% (56.3–72.5%), respectively. However, we observed significant heterogeneity in the diagnostic performance across important patient subgroups (Figure 1). In the external validation cohort, CoDE-HF was well calibrated with excellent discrimination in those without prior acute heart failure for both BNP and MRproANP (area under the curve of 0.946 [0.933–0.958] and 0.943 [0.921–0.964], and Brier scores of 0.105 and 0.073, respectively). CoDE-HF performed consistently across all subgroups for both BNP and MRproANP, and identified 30% and 65.7% at low-probability (negative predictive value of 99.1% [98.8–99.3%] and 99.1% [98.8–99.4%]), and 30% and 17.3% at high-probability (positive predictive value of 91.3% [90.7–91.9%] and 70.0% [68.5–71.4%]) in those without prior heart failure, respectively (Figure 2).

Conclusion

In an international collaborative analysis, we observed that guideline-recommended thresholds for BNP and MRproANP to diagnose acute heart failure varied significantly across patient subgroups. A decision-support tool using machine learning to combine natriuretic peptides as a continuous measure and other clinical variables provides a more accurate and individualised approach.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Medical Research Council and British Heart Foundation Figure 1. NPV of BNP threshold (100 pg/mL)Figure 2. NPV of the CoDE-HF rule-out score

Human pericardial fluid exosomes regulate macrophage immunophenotype: new prospective for cardiovascular myocardium-epicardium crosstalk in coronary artery disease

Background

The incidence and severity of ischemic heart disease (IHD) is exacerbated by coronary artery disease (CAD). Monocytes and macrophages are central to atherosclerosis. Endogenous small extracellular vesicles (sEVs) can shuttle microRNAs and other molecular cargos from cell to cell, mediating expressional and functional response in the recipient cells. Recent evidence supports a role for sEVs in modulating macrophage phenotype. The pericardial fluid (PF) is in direct contact with the epicardium and contain sEVs of myocardial origin (C. Beltrami et.al 2017). We recently showed that human PF-sEVs are capable to modulate cardiovascular cells via microRNA shuttling (C.Beltrami et.al. 2017). Moreover, epicardial cells reportedly cross-talk with the myocardium to regulate immune response to IHD (V.Ramjee et.al 2017).

Purpose

This study sought to investigate whether PF-sEVs regulate macrophages, contributing to a specific immunophenotypes in CAD patients.

Methods

PF was collected from either CAD patients undergoing coronary bypass surgery (CABG) or non-atherosclerotic patients operated for mitral valve repair (non-CAD control group). sEVs were isolated using size exclusion chromatography and characterised for size (Nanosight tracking analysis; NTA) and microRNA content (Exiqon miR-array). Monocytes from healthy donors were isolated from buffy coats and differentiated into macrophages following established protocols. Macrophages were incubated with either CAD-sEVs or non-CAD sEVs for 24h at 37oC. PBS and sEV-free serum were used as negative controls and LPS as a proinflammatory control. The cells were collected and processed for mRNA analyses (qRT-PCR) and Flow cytometry (FACS).

Results

Twenty-four-hour exposure to CAD-sEVs induces a proinflammatory profile of human macrophages. While non-CAD-sEVs did not statistically differ from PBS nor Exo-free groups, CAD-sEVs increased the mRNA level of IL1a, NOS3, TNFa, CCL2 and IL6 (comparison to both non-CAD and negative controls). These data were not associated with changes in apoptosis. Bioinformatics analysis showed that 11 miRNAs where consistently increased, and 67 miRNAs decreased in the PF-sEVs from all CAD patients compared to non-CAD. miRNA targets prediction and pathway analyses (R-Project) revealed that the deregulated miRNAs could regulate macrophage motility and cytokine signalling.

Conclusions

We demonstrate, for the first time, that sEVs isolated from the PF of CAD patients induce a proinflammatory profile of human macrophages. These clinically relevant results could drive to decipher improved therapeutics able to modulate the epicardial/myocardial immune response in CAD patients.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Biritish Heart Fundation grant to Prof. Costanza Emanueli

The Efficacy of Pyrotinib as a Third- or Higher-Line Treatment in HER2-Positive Metastatic Breast Cancer Patients Exposed to Lapatinib Compared to Lapatinib-Naive Patients: A Real-World Study

Background: Pyrotinib is a novel irreversible pan-ErbB receptor tyrosine kinase inhibitor. Evidence of the efficacy of pyrotinib-based treatments for HER2-positive metastatic breast cancer (MBC) in patients exposed to lapatinib is limited.

Methods: Ninety-four patients who received pyrotinib as a third- or higher-line treatment for HER2-positive MBC were included in this retrospective study. The primary and secondary endpoints were overall survival (OS) and progression‐free survival (PFS). Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) analysis were implemented to balance important patient characteristics between groups.

Results: Thirty (31.9%) patients were pretreated with lapatinib and subsequently received pyrotinib as an anti-HER2 treatment, and 64 (68.1%) patients did not receive this treatment. The OS and PFS indicated a beneficial trend in lapatinib-naive group compared to lapatinib-treated group in either the original cohort (PFS: 9.02 vs 6.36 months, p = 0.05; OS: 20.73 vs 14.35 months, p = 0.08) or the PSM (PFS: 9.02 vs 6.08 months, p = 0.07; OS: 19.07 vs 18.00 months, p = 0.61) or IPTW (PFS: 9.90 vs 6.17 months, p = 0.05; OS: 19.53 vs 15.10 months, p = 0.08) cohorts. Subgroup analyses demonstrated lapatinib treatment-related differences in PFS in the premenopausal subgroup and the no prior trastuzumab treatment subgroup, but no significant differences were observed in OS.

Conclusion: Pyrotinib-based therapy demonstrated promising effects in HER2-positive MBC patients in a real-world study, especially in lapatinib-naive patients, and also some activity in lapatinib-treated patients.

Seasonal distribution and habitat use preference of Barking deer (Muntiacus vaginalis) in Murree-Kotli Sattian-Kahuta National Park, Punjab Pakistan

Microhabitat factors associated with the habitat of barking deer (Muntiacus vaginalis) were examined and compared between summer and winter seasons. Habitat characteristics and preferred habitat were measured by locating direct and indirect signs. To quantify the habitat utilization of barking deer, each selected study site was sampled for floral diversity from 2015 to 2017. Quadrats were deployed along transect lines to determine seasonal distribution. Barking deer were not evenly distributed across vegetation types in the study area; they occurred more often in the broad-leaved forest than in Chir pine forest, at an elevational range of 550-850 m, in thick vegetation on steep slopes. The most preferred habitat included trees and shrubs with 30% and 69% cover, respectively. Barking deer avoided thicker tree cover, possibly as it hinders movement and escape from predators. No significant difference (χ2 = 6.37, df = 3, p = 0.19) in seasonal vegetation cover was recorded.

N-terminal pro-B-type natriuretic peptide in the diagnosis of acute heart failure

Background

N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing can aid in the evaluation of patients with suspected acute heart failure. Current approaches are based on thresholds selected to give good negative and positive predictive value, however the optimal means to utilise NT-proBNP is uncertain.

Methods

Embase, Medline and Cochrane central register of controlled trials were searched for studies evaluating NT-proBNP in patients with suspected acute heart failure. Individual patient-level data was requested and diagnostic performance for the guideline-recommended rule-out (300 pg/mL) and age-specific rule-in (450, 900 and 1,800 pg/mL) thresholds were evaluated with random-effects meta-analysis. A generalised linear mixed model was developed and validated as a decision-support tool that combines NT-proBNP with clinical characteristics to report the probability of acute heart failure (0–100) for an individual patient.

Results

Fourteen studies from 13 countries provided individual patient-level data in 10,365 patients, of which, 43.9% (4,549/10,365) had an adjudicated diagnosis of acute heart failure. At the rule-out threshold, the negative predictive value (NPV) was 94.6% (91.9%-96.4%), with significant heterogeneity across patient subgroups (see Figure). At the rule-in thresholds, the positive predictive values (PPV) for those <50 years, 50–75 years, and >75 years were 61.0% (55.3%-66.4%), 72.7% (62.1%-81.3%) and 80.5% (71.1%-87.4%), respectively. In patients without prior heart failure, our model had good discrimination and calibration (area under the curve of 0.931 [0.925–0.938], Brier score of 0.094). A score of <5.6 and ≥45.2 identified 42.3% of patients as low-probability of acute heart failure (NPV 98.5%, 97.6%-99.1%) and 30.5% as high-probability (PPV 75.1%, 67.7%-81.3%) with consistent performance across subgroups.

Conclusions

The diagnostic performance of NT-proBNP thresholds to rule-out and rule-in acute heart failure varies across patient subgroups. A model that uses NT-proBNP as a continuous measure provides a more consistent and individualised approach.

NPV of NT-proBNP threshold of 300 pg/mL

Funding Acknowledgement

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

Impact of inorganic salts on vase life and postharvest qualities of the cut flower of Perpetual Carnation

This study was carried out in the laboratory of Shangqiu Institute of Technology, Henan to investigate the effect of a different combination of inorganic salt on the quality and physiological characteristics of cut flowers (CFs) of Perpetual Carnation. Furthermore, to find out the best preservation solution of inorganic salt that can enhance the ornamental value of CFs of Carnation and prolong its vase life. Sucrose, 8-hydroxyquinoline, paclobutrazol, salicylic acid and different kinds of inorganic salts were added as a preservation solution. And the same amount of distilled water was used as control. The effects of these various inorganic salts on the morphological characteristics including vase life, changes in flower stems, fresh weight (FW) and water balance and the physiological characteristics including contents of malondialdehyde (MDA), cell membrane permeability and the contents of proline of carnation were investigated. The CFs placed in vase solution with inorganic salts showed significant changes in its morphology and physiological characteristics as compared to control. The changes in flower diameter (FD), FW, malondialdehyde and cell membrane permeability showed an increasing trend first and then decreasing. The value of water balance was observed with a downward trend. However, the vase life, FD, the contents of malondialdehyde, contents of proline and FW of CFs held in the preservative solution containing inorganic salts were increased than that of control. The fresh preservative solution contained sucrose 3% + 8-hydroxyquinoline (8-HQ) (200 mg·L‾1) + paclobutrazol (100 mg·L‾1) + salicylic acid (SA) (25 mg·L‾1) + CaCl2 (100 mg·L‾1) has the best effect on longevity (34 days), FW and FD of carnation CFs. This solution has improved the ornamental and physiological characteristics of fresh carnation CFs.

P6309Impaired secretion of clusterin in pericardial fluid of diabetics, a deleterious outcome for the cardiac micro-vasculature

Background

Extracellular vesicles are vital mediators of cell-to-cell communications. We previously demonstrated that in the adult heart, exosomes released in the pericardial fluid (PF) have the functional capability to induce cell survival and angiogenesis in recipient endothelial cells. It has previously been shown that PF exosomes from patients with an existing myocardial infarction (MI) contain clusterin (CLU). Remarkably, secreted CLU is cardio-protective as evidenced by enhanced arteriogenesis and reduced apoptosis in animal models of MI. We hypothesize that type 2 Diabetes Mellitus (T2DM) along with ischemic heart disease (IHD) alters PF EV content impairing its reparative angiogenic potential.

Aim

To investigate the role of T2DM in modulating human PF exosomal content and its vascular action.

Methods and results

PF samples were collected from 3 different groups of patients (N=3): 1) Ischemic heart disease (IHD) with or 2) without T2DM, and 3) non-ischaemic, non-diabetic controls operated for mitral valve repair.

The impact of PF exosomes on human coronary microvascular ECs (HCMECs) was evaluated by cell based functional assays for measuring apoptosis, proliferation and angiogenesis. Interestingly, unlike PF exosomes from control patients, PF exosomes from DM patients with IHD promoted EC apoptosis and impaired angiogenesis.

To investigate the effect of T2DM on PF content, we performed high throughput proteomic and metabolomic analysis of whole PF and PF EVs. We identified proteins and metabolites that were differentially expressed under T2DM condition by using the R package Limma. Employing a network approach, protein and metabolic data were integrated by using our newly developed inhouse R package Metabosignal. This networks approach revealed an interesting interaction circuit involving protein CLU. The T2DM-associated reduction of CLU level in the PF, identified from the “omics” analyses was confirmed by ELISA (n=8 patients per group).

To examine the effects of DM and ischemia on CLU intracellular expression and secretion, HCMECs were exposed to high D-glucose (HG, 25 mM) and hypoxia (1%O2). In line with our PF data, HCMECs exposed to HG and hypoxia showed lower levels of both CLU mRNA and secreted CLU (ELISA). Importantly, recombinant CLU (rCLU) treatment on HCMECs rescued their angiogenic potential, induced cell proliferation and protected them from apoptosis under both HG and hypoxia conditions. In addition, silencing of endogenous levels of CLU in HCMECs impaired angiogenesis, suggesting that CLU might be an inherent component of the angiogenesis machinery in ECs.

Conclusions

This study suggests that DM reduces the level of secreted CLU in the PF, depriving myocardial micro-vessels of this protective and regenerative mediator. Restoring diminished CLU levels in the diabetic heart could be a possible therapeutic approach for contrasting diabetic micro-angiopathy.

Acknowledgement/Funding

British Heart Foundation Program Grant

Colostrum oxytocin modulates cellular stress response, inflammation, and autophagy markers in newborn rat gut villi

Little is known about the role of oxytocin (OT) in colostrum during early gut colonization. We previously showed that transient OT receptor (OTR) expression on newborn rat enterocytes coincides with the milk-suckling period, and that OT activates endoplasmic reticulum stress sensors in cultured enterocytes. Here, we explored whether colostrum-OT attenuates stress in newborn villi primed and unprimed by colostrum by measuring levels of stress markers including BiP (an ER chaperone), eIF2a (translation initiation factor), and pPKR (eIF2a kinase). We also measured two inflammation-signaling proteins NF-κB and its inhibitor IκB. To test the impact of colostrum on autophagy, we measured a marker of autophagy initiation, LC3A. Colostrum increased inactive p-eIF2a, p-PKR and IκB and reduced p-IκB, BiP and LC3A. LPS increased and OT decreased p-IkB. BiP (GRP78) was higher in unprimed than primed villi. Together, these data suggest that colostrum OT attenuates the impact of inflammation on postnatal gut villi and that OT enhances autophagy to protect against amino acid insufficiency-induced stress during the interval between birth and the first feeding.