Component separation repair of incisional hernia: evolution of practice and review of long-term outcomes in a single center

PURPOSE

To review the long-term outcomes of complex abdominal wall reconstruction using anterior and posterior component separation (CS) techniques in our center.

METHODS

This was a descriptive analytical study. Analysis of data from a prospectively collected database of patients who had undergone Component Separation (CS) repair of incisional hernias was performed. Two techniques were used. Anterior component separation (ACS) and posterior component separation with transversus abdominis release (PCS/TAR). Follow-up was clinical review at 6 weeks, 6 months, and 12 months with direct access telephone review thereafter. Long-term outcome data was obtained from electronic records and based on either clinical or CT assessment. Minimum physical follow-up was 6 months for all patients.

RESULTS

89 patients with large incisional hernias underwent CS repair. 29 patients had ACS while 60 underwent PCS/TAR. Mean follow-up was 60 months (range 6-140 months) in the ACS group and 20 months (range 6-72 months) in the PCS group. Twenty-five patients (28%) had simultaneous major procedures including 21 intestinal anastomoses. Twenty-six (29%) of patients had associated stomas. Twenty-seven (30.3%) of the patients had undergone previous hernia repairs. Seromas occurred in 24 (26.97%) patients. Wound infections were more common after ACS. There have been 10 (11.2%) recurrences to date.

CONCLUSION

Component separation repair techniques result in good long-term outcomes with acceptable complication rates. They can be performed simultaneously with gastrointestinal procedures with low morbidity. Appropriate patient selection and use of appropriate mesh are important.

QRS complex and T wave planarity for the efficacy prediction of automatic implantable defibrillators

OBJECTIVE

To test the hypothesis that in recipients of primary prophylactic implantable cardioverter-defibrillators (ICDs), the non-planarity of ECG vector loops predicts (a) deaths despite ICD protection and (b) appropriate ICD shocks.

METHODS

Digital pre-implant ECGs were collected in 1948 ICD recipients: 21.4% females, median age 65 years, 61.5% ischaemic heart disease (IHD). QRS and T wave three-dimensional loops were constructed using singular value decomposition that allowed to measure the vector loop planarity. The non-planarity, that is, the twist of the three-dimensional loops out of a single plane, was related to all-cause mortality (n=294; 15.3% females; 68.7% IHD) and appropriate ICD shocks (n=162; 10.5% females; 87.7% IHD) during 5-year follow-up after device implantation. Using multivariable Cox regression, the predictive power of QRS and T wave non-planarity was compared with that of age, heart rate, left ventricular ejection fraction, QRS duration, spatial QRS-T angle, QTc interval and T-peak to T-end interval.

RESULTS

QRS non-planarity was significantly (p<0.001) associated with follow-up deaths despite ICD protection with HR of 1.339 (95% CI 1.165 to 1.540) but was only univariably associated with appropriate ICD shocks. Non-planarity of the T wave loop was the only ECG-derived index significantly (p<0.001) associated with appropriate ICD shocks with multivariable Cox regression HR of 1.364 (1.180 to 1.576) but was not associated with follow-up mortality.

CONCLUSIONS

The analysed data suggest that QRS and T wave non-planarity might offer distinction between patients who are at greater risk of death despite ICD protection and those who are likely to use the defibrillator protection.

In vitro comparative evaluation of physical and chemical properties of surface enamel after using APF and SDF with or without laser activation

PURPOSE

To evaluate and compare the changes in physical and chemical properties of the enamel surface after application of Silver Diamine Fluoride (SDF), Acidulated Phosphate Fluoride (APF), LASER activated SDF and LASER activated APF.

METHODS

Sample consisted of 72 freshly extracted healthy human premolar teeth, extracted for orthodontic purpose, free from caries, fracture or any anomalies. The selected samples were randomly divided into four groups (n = 18): Group 1 (SDF); Group 2 (APF); Group 3 (LASER activated SDF) and Group 4 (LASER activated APF). All samples were evaluated for values of DIAGNOdent at baseline, after demineralisation and after remineralisation. They were further divided and assessed for colour changes, surface alterations and fluoride content of surface enamel using Spectrophotometer, Scanning Electron Microscopy and Energy Dispersive X-ray Spectrometry respectively. The statistical analysis was done using One-Way ANOVA, Tukey's HSD test, Mann-Whitney U test and Kruskal-Wallis Test.

RESULTS

Highest remineralising potential and maximum colour changes of surface enamel was exhibited by Group 3. Scanning Electron Micrographs of Group 3 and Group 4 exhibited regular globular structures of enamel whereas Group 1 and Group 2 showed irregular globular surface of the enamel at 2000× and 5000× magnification. Maximum fluoride uptake on the surface enamel was seen in Group 4 followed by Group 3.

CONCLUSION

Use of LASER activated topical fluorides helps to achieve superior caries prevention. LASER activated APF can be used as an aesthetic alternative to SDF, as LASER activated APF showed higher uptake of fluoride on the enamel surface without discoloration effect.

Association between pulmonary embolism and COVID-19 disease

OBJECTIVES

The current retrospective study focused on evaluation of the relationship between pulmonary embolism during COVID-19 pandemic and demographic, presenting symptoms, comorbidities and laboratory results in patients who underwent CT angiography of the pulmonary arteries.

METHODS

The study enrolled all adult patients with suspected acute pulmonary embolism (PE) who underwent computed tomography pulmonary angiography (CTPA) between March 1, 2020, and April 30, 2022, during the SARS-CoV-2 pandemic. 1698 CTPAs were reviewed and various data were collected. Based on examination results, patients were divided into 4 groups: a group with positive PE and a group with negative PE for both COVID-19 and non-COVID-19 patients.

RESULTS

When comparing different predictors of COVID-19 patients and non-COVID-19 patients we noticed lower probability of PE in female gender (OR 0.77, 95% CI: 0.60-1.00, p = 0.052) and in chronic obstructive pulmonary disease (COPD) patients (OR 0.6, 95% CI: 0.38-0.90, p = 0.017). Higher probability of PE was in cases of older age (OR 1.02, 95% CI: 1.01-1.02, p < 0.001), increased heart rate (OR 1.01, 95% CI: 1.01-1.02, p < 0.001) and increased D-dimer levels (OR 1.03, 95% CI: 1.02-1.04, p < 0.001).

CONCLUSION

Considering predictors of PE there was a significantly lower risk of PE in the female gender and COPD, and a higher risk with increasing age, heart rate, and D-dimer levels.

Efficacy of spinal manipulations and Schroth exercises on psychological parameters in patients with functional scoliosis: a randomised controlled trial

Functional scoliosis is defined as the reversible and temporary lateral spinal curvature that mainly occurs due to abnormal postural habits that leads to non-structural and compensatory changes in spine. Functional scoliosis can lead to the development of mental health issues, such as stress, anxiety and depression. The purpose of the present study was to evaluate the effects of spinal manipulation techniques and Schroth exercises on psychological parameters in patients with functional scoliosis. The subjects were randomly allocated into experimental (n=31) and control group (n=31). Spinal manipulation techniques and Schroth exercises were given to the patients of experimental group, while only Schroth exercises were given to the patients of control group. Outcome measures were Depression, Anxiety & Stress Score that was examined by using ‘DASS-21 questionnaire’. Treatment was given for four weeks, thrice weekly. After the completion of four weeks, DASS scores were obtained from the participants. Patients were followed up after 2 months and data was collected again. Repeated measures ANOVA were used to compare the mean changes within-group. Independent t-test was used to analyse the mean improvement between-group. Results suggested that there was a statistically significant difference between pre-/post and pre-/follow-up scores of the DASS, but there was statistical non-significant difference between post-/follow-up scores of the DASS. Results also suggested that experimental group showed better improvement compared to the control group. This study concluded that the combine use of spinal manipulation techniques and Schroth exercise protocol can significantly reduce the psychosomatic symptoms in functional scoliosis.

Clinical Trial Registry of India: CTRI/2020/02/023221

The role of computed tomography pulmonary angiography in COVID-19 patients with suspected pulmonary embolism

OBJECTIVES

This study is aimed to determine the location and distribution of pulmonary embolism (PE) and presence of signs potentially indicative of right heart overload on computed tomography pulmonary angiography (CTPA) in COVID-19 and non-COVID-19 patients. We also evaluated the extent and severity of COVID-19-associated lung changes in relation to PE.

METHODS

The total number of 1,698 patients with CTPA included in the study were divided into 2 groups according to their COVID-19 status and each group was divided into 2 subgroups based on their PE status. These groups and subgroups were compared in terms of location of PE, diameter of pulmonary artery, right heart strain, ground-glass opacities (GGO), consolidations and other imaging features.

RESULTS

In COVID-19 patients, there was a significant predominance of PE in peripheral branches of pulmonary artery (p < 0.001). There was an increased right-to-left ratio of ventricular diameters in cases with PE (p = 0.032 in patients with COVID-19 and p < 0.001 in non-COVID-19 patients). There was no association between the extent and severity of the disease and distribution of PE.

CONCLUSION

COVID-19 is associated with a higher incidence of peripheral location of PE and presence of GGO. There were signs indicative of right heart overload in cases with PE regardless of COVID-19 (Tab. 3, Fig. 1, Ref. 29) Keywords: COVID-19, computed tomography, CTPA, pneumonia, pulmonary embolism.

QRS micro-fragmentation as a mortality predictor

AIMS

Fragmented QRS complex with visible notching on standard 12-lead electrocardiogram (ECG) is understood to represent depolarization abnormalities and to signify risk of cardiac events. Depolarization abnormalities with similar prognostic implications likely exist beyond visual recognition but no technology is presently suitable for quantification of such invisible ECG abnormalities. We present such a technology.

METHODS AND RESULTS

A signal processing method projects all ECG leads of the QRS complex into optimized three perpendicular dimensions, reconstructs the ECG back from this three-dimensional projection, and quantifies the difference (QRS 'micro'-fragmentation, QRS-μf) between the original and reconstructed signals. QRS 'micro'-fragmentation was assessed in three different populations: cardiac patients with automatic implantable cardioverter-defibrillators, cardiac patients with severe abnormalities, and general public. The predictive value of QRS-μf for mortality was investigated both univariably and in multivariable comparisons with other risk factors including visible QRS 'macro'-fragmentation, QRS-Mf. The analysis was made in a total of 7779 subjects of whom 504 have not survived the first 5 years of follow-up. In all three populations, QRS-μf was strongly predictive of survival (P < 0.001 univariably, and P < 0.001 to P = 0.024 in multivariable regression analyses). A similar strong association with outcome was found when dichotomizing QRS-μf prospectively at 3.5%. When QRS-μf was used in multivariable analyses, QRS-Mf and QRS duration lost their predictive value.

CONCLUSION

In three populations with different clinical characteristics, QRS-μf was a powerful mortality risk factor independent of several previously established risk indices. Electrophysiologic abnormalities that contribute to increased QRS-μf values are likely responsible for the predictive power of visible QRS-Mf.

T-wave alternans poorly prognostic in primary prophylactic ICD patients: a prospective EU-CERT-ICD study

Background

New methods to identify patients who truly benefit from primary prophylactic implantable cardioverter defibrillation (ICD) are urgently needed. T-wave alternans (TWA) represents a beat-to-beat fluctuation in the morphology of the ST-segment and T-wave. It has been shown to associate with arrhythmogenesis of heart and sudden cardiac death [1]. We hypothised that TWA might associate with benefit from ICD implantation in primary prevention.

Methods

In EU-CERT-ICD study, we prospectively enrolled 2327 primary prophylactic ICD candidates from 15 European countries. A 24-hours Holter-monitoring was taken from all recruited patients at enrolment. TWA was assessed from Holter-monitoring using MMA method with Getemed Cardioday software. To assess the benefit from ICD treatment, we used outcomes all-cause mortality, appropriate shock and survival benefit. We conducted Cox regression model, competing risk regression model and propensity score adjusted Cox regression model. TWA was assessed both as contiguous variable and with cut-off points &lt;47 μV and &lt;60 μV.

Results

Final cohort included 1,734 valid T-wave alternans samples, 1,211 patients with ICD and 523 control patients with conservative treatment, with mean follow-up time 2.3 years. TWA &lt;60 μV predicted lower all-cause mortality in ICD patients in univariate cox regression model (HR 1.484, 95% CI 1.024–2.151, p=0.0374). In multivariate models, TWA did not predict death or appropriate shocks in ICD patients. In addition, TWA did not predict death in control patients. In propensity score adjusted Cox regression model, TWA did not predict ICD benefit.

Conclusion

T-wave alternans is poorly prognostic in primary prophylactic ICD patients. Altough it may predict life-threatening arrhythmias and sudden cardiac death in several patient populations, it cannot be used in assessing benefit from implantable cardioverter defibrillator in primary prevention among patients with ejection fraction ≤35%.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Community's 7th Framework Program FP7/2007-2013

Adherence and discontinuation of sglt2-inhibitors and glp1-r agonists in patients with type 2 diabetes with and without cardiovascular disease

Background

Sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucacon-like-peptide-1 receptor (GLP-1R) agonists are two novel therapies in type 2 diabetes (T2D) that are recommended in patients with manifestations of cardiovascular disease or high risk of cardiovascular disease due to their cardioprotective benefits. Despite the increasing use of these drugs, there is still limited knowledge on the adherence patterns and the risk of discontinuation, according to the presence or absence of different cardiovascular conditions.

Purpose

To investigate the adherence and estimate the risk of discontinuation of SGLT2 inhibitors and GLP1-R agonists in patients with T2D with and without cardiovascular disease.

Methods

From Danish nationwide registers, we included all individuals &gt;40 years with T2D who redeemed the first prescription of a SGLT2 inhibitor or GLP1-R agonist, between December, 2012 and December, 2018. Patients were divided into subgroups according to the presence or absence of different cardiovascular conditions (heart failure, ischemic heart disease, peripheral artery disease, atrial fibrillation), at the time of inclusion. Adherence over the course of one year after initiation of treatment was estimated by the proportion of days covered (PDC) for each subgroup, and adherence was defined as PDC 80%. The risk of discontinuation was estimated using multivariable cause-specific Cox regression models, and was defined as a break in treatment of 90 days. The Aalen-Johansen estimator was used to account for censoring and competing risks. Patients were followed until date of emigration, death or study end (December 31, 2019).

Results

We included 24,061 patients with T2D who initiated treatment with a SGLT2 inhibitor, and 13,899 patients with T2D who initiated treatment with a GLP1-R agonist, for the first time between December 10, 2012 and December 31, 2018. Median age at inclusion was 62 years (IQR 54–70) and 40% were female. In the analyses, 67% of the patients treated with SGLT2 inhibitors were adherent to therapy throughout the first year, whereas the same proportion of patients, 67%, were adherent to therapy with GLP-1R agonists. Mean PDC was 77% (SD 33) and 79% (31) for patients in therapy with SGLT2 inhibitors and GLP1-R agonists, respectively. No significant difference was observed related to the presence or absence of cardiovascular disease (SGLT2 inhibitor: mean PDC 77 (33) vs. 77 (33), GLP1-R agonist: 78 (32) vs. 79 (31)).

Conclusions

In this nationwide cohort study, we found that patients with T2D who initiated therapy with a SGLT2 inhibitor and those who initiated therapy with a GLP1-R agonist were almost equally adherent to therapy throughout the first year. Adherence in both treatment groups did not differ according to the presence or absence of cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.

Intra-subject stability of different expressions of spatial QRS-T angle and their relationship to heart rate

Three-dimensional angle between the QRS complex and T wave vectors is a known powerful cardiovascular risk predictor. Nevertheless, several physiological properties of the angle are unknown or poorly understood. These include, among others, intra-subject profiles and stability of the angle relationship to heart rate, characteristics of angle/heart-rate hysteresis, and the changes of these characteristics with different modes of QRS-T angle calculation. These characteristics were investigated in long-term 12-lead Holter recordings of 523 healthy volunteers (259 females). Three different algorithmic methods for the angle computation were based on maximal vector magnitude of QRS and T wave loops, areas under the QRS complex and T wave curvatures in orthogonal leads, and weighted integration of all QRS and T wave vectors moving around the respective 3-dimensional loops. These methods were applied to orthogonal leads derived either by a uniform conversion matrix or by singular value decomposition (SVD) of the original 12-lead ECG, giving 6 possible ways of expressing the angle. Heart rate hysteresis was assessed using the exponential decay models. All these methods were used to measure the angle in 659,313 representative waveforms of individual 10-s ECG samples and in 7,350,733 individual beats contained in the same 10-s samples. With all measurement methods, the measured angles fitted second-degree polynomial regressions to the underlying heart rate. Independent of the measurement method, the angles were found significantly narrower in females (p &lt; 0.00001) with the differences to males between 10o and 20o, suggesting that in future risk-assessment studies, different angle dichotomies are needed for both sexes. The integrative method combined with SVD leads showed the highest intra-subject reproducibility (p &lt; 0.00001). No reproducible delay between heart rate changes and QRS-T angle changes was found. This was interpreted as a suggestion that the measurement of QRS-T angle might offer direct assessment of cardiac autonomic responsiveness at the ventricular level.

AB1510 INFLAMMATORY MYOSITIS – FINAL ANSWER?

Background

Motor neurone disease may mimic inflammatory myositis. There is an overlap in clinical symptoms (such as muscle weakness, dysphagia and respiratory involvement) which may pose a diagnostic challenge. Careful history, thorough clinical examination and appropriate investigations can help to distinguish between the two. Monitoring the response to treatment is also crucial. We present a case that presented to rheumatology with progressive muscle weakness, she was investigated and treated for inflammatory myositis but was later diagnosed with motor neurone disease.

Objectives

To illustrate the need for thorough clinical assessment and investigations in patients with suspected inflammatory myositis and consider alternative diagnoses as clinical picture evolves.

Methods

A 68 year old lady, presented with 6 months history of progressive proximal muscle weakness. She also reported weakness of grip, affecting activities of daily life. She was finding it difficult to get up from chair. There was no swallowing difficulty, respiratory symptoms and skin rash. She had no weight loss or constitutional symptoms. She did not have any joint pain or features of connective tissue disease. She had history of hypertension. On clinical examination, she did not have any features of connective tissue disease. There was no evidence of joint synovitis or skin rash. Proximal power in upper and lower limbs noted to be 4/5 with intact reflexes. Initial investigations revealed mildly raised CPK at 287 with normal thyroid function and inflammatory markers. Immunological tests including ANA and myositis panel were requested alongside EMG, MRI thighs and CT chest/abdomen/pelvis. Myositis panel was positive for anti-MDA-5 antibodies (in the absence of any skin or respiratory symptoms). There was no evidence of malignancy on CT imaging. MRI thighs revealed fluid in the trochanteric bursae. She was trialled on oral prednisolone in view of her clinical features and positive anti-MDA5 antibody. However, there was no improvement in her symptoms or functional status. EMG revealed widespread neurogenic process affecting upper and lower limbs on both sides, without significant evidence of acute myopathy. The progressive nature of symptoms with the upper motor neurone signs raised the possibility of an evolving anterior horn cell disorder. She was referred to neurology and was subsequently diagnosed to have Motor Neurone Disease. The steroids were rapidly tapered off and stopped.

Results

Motor neurone disease is an important differential when considering inflammatory myopathy, particularly inclusion body myositis which causes more progressive muscle weakness. It is a neurological disorder characterised by degeneration of neurons. There is no clear cause identified. MND causes both upper and lower motor neurone signs. Symptoms include limb weakness, bulbar weakness that can affect speech and swallowing, muscle twitching and fasciculation. Respiratory weakness may occur. Thorough clinical examination and EMG findings help identify the diagnosis. Imaging may be needed. There is no cure. Management requires an MDT approach, primarily guided by neurology, including physiotherapy, occupational therapy, speech and language therapy and respiratory support.

Conclusion

This lady was initially treated for inflammatory myositis based on her symptoms, mildly raised CK and positive anti-MDA5 antibodies. On review of her clinical progress, we noted poor response to steroids and EMG results pointing at an alternative diagnosis of MND. This case highlights the importance of EMG in the assessment and management of patients with suspected inflammatory myositis as well as the need to closely monitor progress and re-evaluation where needed. Although she had anti-MDA-5 antibodies and mildly raised CK, she did not have any skin disease or other systemic features, inflammatory markers and muscle imaging was normal. Response to steroids was inadequate.

References

[1]Turner MR, Talbot K. Mimics and chameleons in motor neurone disease. Pract Neurol. 2013

[2]Ryan A, Nor AM, Costigan D, et al. Polymyositis Masquerading as Motor Neuron Disease. Arch Neurol. 2003

Disclosure of Interests

None declared

QRS duration as an independent risk factor for appropriate shocks and mortality in patients with prophylactic implantable cardioverter-defibrillator

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Community’s 7th Framework Programme FP7/2007-2013

Background

The implantable cardioverter defibrillator (ICD) is an established therapy for the prevention of sudden cardiac death (SCD) in high-risk heart failure patients. However, improvements in risk stratification are necessary to increase the efficiency of ICD use. We performed an analysis of the retrospective EU-CERT-ICD registry with respect to QRS duration and effects of cardiac resynchronisation therapy (CRT) on outcomes.

Methods/Results

A total of 5033 patients (81% males) from 14 European centres had an ICD implanted for primary prophylaxis. Mean age at the time of ICD implantation was 64±11 years and ischemic cardiomyopathy was the underlying pathology in 65% of patients. CRT was used in 43% of the patients. The median follow-up was 2.7 years (IQR 1.4-4.6 years). Predefined primary endpoints were all-cause mortality, first appropriate and first inappropriate shocks. The effect of covariates on the cumulative primary endpoints were assessed through hazard ratios in the Fine and Gray subdistributional hazard models (accounting for the competing risks) stratified by centres.

Because of resynchronization by the device, the analysis considered a different influence of QRS on outcomes in the CRT-D and the ICD groups. We observed an increase in the cumulative incidence of the first appropriate shock with increasing QRS values for patients implanted with only an ICD (HR 1.12 per 10ms increase, p&lt;0.001). In patients with CRT-D, increasing QRS values related to a (statistically non-significant) decrease in the cumulative incidence of the first appropriate shocks (HR 0.96 per 10ms, p=0.299).

Since a wide QRS is an indication for CRT-D therapy, high QRS values cluster among those patients with implanted CRT-D, while among patients with QRS under 130ms standard ICD implantations are more frequent. This can explain the observed increase in the cumulative incidence of the first appropriate shocks for increasing QRS values up to 130ms in the ICD-group and its decrease for increasing QRS values over 130ms in the CRT-D group.

Regarding all-cause mortality, hazard ratios for age, LVEF, NYHA, ICM, AF, diabetes and sex category agreed with the results obtained in previously published meta-analyses.

Increased QRS values are associated with higher mortality in the ICD group (HR 1.09 per 10ms increase, p&lt;0.001), but not in the CRT-D group (HR 0.99 per 10ms increase, p=0.695).

Conclusion

In our study, we confirmed QRS duration as an independent risk factor for appropriate ICD shocks and all-cause mortality in patients with ICD for primary prophylaxis. However, this was only observed in patients with single- or dual-chamber ICD, while there was no correlation in CRT-D patients. The findings suggest that CRT-D exerts a protective effect regarding the occurrence of first appropriate shock and all-cause mortality for patients with QRS values higher than 130 ms and indication for resynchronization.

Short-Term Beat-to-Beat QT Variability Appears Influenced More Strongly by Recording Quality Than by Beat-to-Beat RR Variability

Increases in beat-to-beat variability of electrocardiographic QT interval duration have repeatedly been associated with increased risk of cardiovascular events and complications. The measurements of QT variability are frequently normalized for the underlying RR interval variability. Such normalization supports the concept of the so-called immediate RR effect which relates each QT interval to the preceding RR interval. The validity of this concept was investigated in the present study together with the analysis of the influence of electrocardiographic morphological stability on QT variability measurements. The analyses involved QT and RR measurements in 6,114,562 individual beats of 642,708 separate 10-s ECG samples recorded in 523 healthy volunteers (259 females). Only beats with high morphology correlation (r &gt; 0.99) with representative waveforms of the 10-s ECG samples were analyzed, assuring that only good quality recordings were included. In addition to these high correlations, SDs of the ECG signal difference between representative waveforms and individual beats expressed morphological instability and ECG noise. In the intra-subject analyses of both individual beats and of 10-s averages, QT interval variability was substantially more strongly related to the ECG noise than to the underlying RR variability. In approximately one-third of the analyzed ECG beats, the prolongation or shortening of the preceding RR interval was followed by the opposite change of the QT interval. In linear regression analyses, underlying RR variability within each 10-s ECG sample explained only 5.7 and 11.1% of QT interval variability in females and males, respectively. On the contrary, the underlying ECG noise contents of the 10-s samples explained 56.5 and 60.1% of the QT interval variability in females and males, respectively. The study concludes that the concept of stable and uniform immediate RR interval effect on the duration of subsequent QT interval duration is highly questionable. Even if only stable beat-to-beat measurements of QT interval are used, the QT interval variability is still substantially influenced by morphological variability and noise pollution of the source ECG recordings. Even when good quality recordings are used, noise contents of the electrocardiograms should be objectively examined in future studies of QT interval variability.

3D Finite Element Simulation of Processing of Generalized Newtonian Fluids in Counter-rotating and Tangential TSE and Die Combination

A full three-dimensional finite element analysis of the nonisothermal flow of generalized non-Newtonian fluids in counter-rotating tangential twin screw extruder is presented. Previous studies of the simulation of processing in tangential twin screw extruders have focused solely on the twin screw extruder, whereas here the coupled flow and heat transfer occurring in the integrated geometry of the extruder, connected to a die are considered. The FEM based numerical simulation of the coupled momentum-mass-energy conservation equations allowed the determination of the effects of some of the important system parameters, including the power law index and the staggering angle of the screws, on the pumping and pressurization capability of the extruder and the associated degree of fill in the extruder.

Vraag & Antwoord

- Intestinaal microbioom/dysbiose-index bij chronische darmproblemen bij kleine huisdieren - Effect of anemia on performance and immune response in piglets - Behandeling van FIP bij katten

Sex and Rate Change Differences in QT/RR Hysteresis in Healthy Subjects

While it is now well-understood that the extent of QT interval changes due to underlying heart rate differences (i.e., the QT/RR adaptation) needs to be distinguished from the speed with which the QT interval reacts to heart rate changes (i.e., the so-called QT/RR hysteresis), gaps still exist in the physiologic understanding of QT/RR hysteresis processes. This study was designed to address the questions of whether the speed of QT adaptation to heart rate changes is driven by time or by number of cardiac cycles; whether QT interval adaptation speed is the same when heart rate accelerates and decelerates; and whether the characteristics of QT/RR hysteresis are related to age and sex. The study evaluated 897,570 measurements of QT intervals together with their 5-min histories of preceding RR intervals, all recorded in 751 healthy volunteers (336 females) aged 34.3 ± 9.5 years. Three different QT/RR adaptation models were combined with exponential decay models that distinguished time-based and interval-based QT/RR hysteresis. In each subject and for each modelling combination, a best-fit combination of modelling parameters was obtained by seeking minimal regression residuals. The results showed that the response of QT/RR hysteresis appears to be driven by absolute time rather than by the number of cardiac cycles. The speed of QT/RR hysteresis was found decreasing with increasing age whilst the duration of individually rate corrected QTc interval was found increasing with increasing age. Contrary to the longer QTc intervals, QT/RR hysteresis speed was faster in females. QT/RR hysteresis differences between heart rate acceleration and deceleration were not found to be physiologically systematic (i.e., they differed among different healthy subjects), but on average, QT/RR hysteresis speed was found slower after heart rate acceleration than after rate deceleration.

Assessment of land use cover changes, carbon sequestration and carbon stock in dry temperate forests of Chilas watershed, Gilgit-Baltistan

Abstract Land use and land cover change are affecting the global environment and ecosystems of the different biospheres. Monitoring, reporting and verification (MRV) of these changes is of utmost importance as they often results in several global environmental consequences such as land degradation, mass erosion, habitat deterioration as well as micro and macro climate of the regions. The advance technologies like remote sensing (RS) and geographical information system (GIS) are helpful in determining/ identifying these changes. In the current study area, changes in carbon stocks, notably in forest areas, are resulting in considerable dynamics of carbon stocks as a result of climate change and carbon sequestration. This study was carried out in the Diamer district of the Gilgit Baltistan (GB) Pakistan to investigate the change in cover change/land use change (particularly Forest Land use) as well as carbon sequestration potential of the forests in the district during almost last 25years. The land cover, temporal Landsat data (level 1, LIT) were downloaded from the USGS EROS (2016), for 1979-1989, 1990-2000 and 2001-2012. Change in land uses, particularly forest cover was investigated using GIS techniques. Forest inventory was carried out using random sampling techniques. A standard plot of size 0.1 ha (n=80) was laid out to determine the tree density, volume, biomass and C stocks. Simulation of C stocks was accomplished by application of the CO2FIX model with the data input from inventory. Results showed a decrease in both forest and snow cover in the region from 1979-2012. Similarly decrease was seen in tree volume, tree Biomass, dynamics of C Stocks and decrease was in occur tree density respectively. It is recommended we need further more like project such as BTAP (Billion Tree Afforestation Project) and green Pakistan project to increase the forest cover, to control on land use change, protect forest ecosystem and to protect snow cover.

U-Shaped Association of the Heart Rate Variability Triangular Index and Mortality in Hemodialysis Patients With Atrial Fibrillation

Background: Atrial fibrillation (AF) is common in hemodialysis patients and contributes to increased mortality. We aimed to examine heart rate variability triangular index (HRVI) in hemodialysis patients with AF as it has recently been reported to predict mortality in AF patients without kidney disease.

Methods: A total of 88 patients on hemodialysis with a medical history of AF or newly diagnosed AF underwent 24-h electrocardiography recordings. The primary endpoint of cardiovascular mortality was recorded during a median follow up of 3.0 years. Risk prediction was assessed by Cox regression, both unadjusted and adjusted for the Charlson Comorbidity Index and the Cardiovascular Mortality Risk Score.

Results: Median age was 76 years, median dialysis vintage was 27 months. Altogether, 22 and 44 patients died due to cardiovascular and non-cardiovascular causes. In 55% of patients AF was present during the recording. Kaplan-Meier plots of HRVI quartiles suggested a non-linear association between HRVI, cardiovascular, and all-cause mortality which was confirmed in non-linear Cox regression analysis. Adjusted linear Cox regression revealed a hazard ratio of 6.2 (95% CI: 2.1–17.7, p = 0.001) and 2.2 (95% CI: 1.3–3.8, p = 0.002) for the outer quartiles (combined first and fourth quartile) for cardiovascular and all-cause mortality, respectively. Patients in the first quartile were more likely to have sinus rhythm whereas patients in the fourth quartile were more likely to have AF.

Conclusions: We found a U-shaped association between HRVI and mortality in hemodialysis AF patients. The results might contribute to risk stratification independent of known risk scores in hemodialysis AF patients.

Lung ultrasound could reduce X-ray after major lung resection

OBJECTIVES

This study evaluated the role of ultrasound in postoperative care after major lung resection.

BACKGROUND

High accuracy of lung ultrasound imaging was proved in various medical fields. The experience with ultrasound after thoracic surgery is limited.

METHODS

Patients scheduled for major lung resection were consecutively included in a prospective study comparing two modalities of imaging examinations, namely those employing ultrasound and X-ray in the diagnoses of pneumothorax and pleural effusion. Two examinations were performed. One after recovery from anaesthesia, the second before chest tube removal.

RESULTS

Forty-eight patients underwent 87 examinations. X-ray and ultrasound examinations showed substantial and fair agreements for pneumothorax (Cohen's kappa coefficients 0.775 and 0.397) and slight and substantial agreements for pleural effusion (Cohen's kappa coefficients 0.036 and 0.611). The sensitivity bounds for pneumothorax were 45.5-58.5 % at the first and 29.7-59.4 % at the second examination. Sensitivity bounds for pleural effusion were 0-86.2 % at the first and 32.6-36.9 % at the second examination. Except for two cases of pneumothorax being missed by X-ray imaging, the rest of mismatches were clinically irrelevant conditions with no impact on clinical decision and patient's outcome.

CONCLUSION

The use of ultrasound can reduce the number of X-ray examinations and thus lower the radiation exposure after major lung resections (Tab. 4, Ref. 30).

Q waves are the strongest electrocardiographic variable associated with primary prophylactic implantable cardioverter-defibrillator benefit: a prospective multicentre study

AIM

The association of standard 12-lead electrocardiogram (ECG) markers with benefits of the primary prophylactic implantable cardioverter-defibrillator (ICD) has not been determined in the contemporary era. We analysed traditional and novel ECG variables in a large prospective, controlled primary prophylactic ICD population to assess the predictive value of ECG in terms of ICD benefit.

METHODS AND RESULTS

Electrocardiograms from 1477 ICD patients and 700 control patients (EU-CERT-ICD; non-randomized, controlled, prospective multicentre study; ClinicalTrials.gov Identifier: NCT02064192), who met ICD implantation criteria but did not receive the device, were analysed. The primary outcome was all-cause mortality. In ICD patients, the co-primary outcome of first appropriate shock was used. Mean follow-up time was 2.4 ± 1.1 years to death and 2.3 ± 1.2 years to the first appropriate shock. Pathological Q waves were associated with decreased mortality in ICD patients [hazard ratio (HR) 0.54, 95% confidence interval (CI) 0.35-0.84; P < 0.01] and patients with pathological Q waves had significantly more benefit from ICD (HR 0.44, 95% CI 0.21-0.93; P = 0.03). QTc interval increase taken as a continuous variable was associated with both mortality and appropriate shock incidence, but commonly used cut-off values, were not statistically significantly associated with either of the outcomes.

CONCLUSION

Pathological Q waves were a strong ECG predictor of ICD benefit in primary prophylactic ICD patients. Excess mortality among Q wave patients seems to be due to arrhythmic death which can be prevented by ICD.

The Haleem-Marks-Botchu classification: a novel CT-based classification for intracanal rib head penetration

PURPOSE

Intracanal rib head penetration is a well-known entity in dystrophic scoliotic curves in neurofibromatosis type 1. There is potential for spinal cord injury if this is not recognised and managed appropriately. No current CT-based classification system is currently in use to quantify rib head penetration. This article aims to propose and evaluate a novel CT-based classification for rib head penetration primarily for neurofibromatosis but which can also be utilised in other conditions of rib head penetration.

MATERIALS AND METHODS

The grading was developed as four grades: normal rib head (RH) position-Grade 0, subluxed extracanal RH position-Grade 1, RH at pedicle-Grade 2, intracanal RH-Grade 3. Grade 3 was further classified depending on the head position in the canal divided into thirds. Rib head penetration into proximal third (from ipsilateral side)-Grade 3A, into the middle third-Grade 3B and into the distal third-Grade 3C. Seventy-five axial CT images of Neurofibromatosis Type 1 patients in the paediatric age group were reviewed by a radiologist and a spinal surgeon independently to assess interobserver and intraobserver agreement of the novel CT classification. Agreement analysis was performed using the weighted Kappa statistic.

RESULTS

There was substantial interobserver correlation with mean Kappa score (k = 0.8, 95% CI 0.7-0.9) and near perfect intraobserver Kappa of 1.0 (95% CI 0.9-1.0) and 0.9 (95% CI 0.9-1.0) for the two readers.

CONCLUSION

The novel CT-based classification quantifies rib head penetration which aids in management planning.

1576 Safeguarding Tools in Paediatric Burns

Introduction

When assessing paediatric patients presenting with burns, non-accidental injury always has to be considered. In our department, local policy dictates that all patients aged 18 or below should have a child safeguarding tool completed on initial clerking.

Method

A retrospective audit of all paediatric burns seen over one month was performed. Primary outcome measures included completion of a safeguarding tool and documentation of referral outcome. These results were presented locally and implementing changes were carried out. This was then re-audited over a further monthly period.

Results

Initial data collection showed a safeguarding tool completion rate of 69% and referral outcome documentation rate of 50% (n = 16). Implement changes included dissemination of initial audit results to the department, changing the layout of our clerking proformas and introducing posters in the unit which provided more information on risk assessing paediatric patients. The re-audit results showed a safeguarding tool completion rate of 100% and a referral outcome documentation rate of 100% (n = 14).

Conclusions

There was a significant improvement in both the safeguarding tool completion and referral outcome documentation rates following our interventions. Simple measures just such education and strategic adjustments of clerking proformas have been shown to be effective measures for increasing documental compliance of child safeguarding tools.

1013 Dupuytren’s Contracture Treatment with XIAPEX Injection: Reviewing A Single Surgeon's Experience

Aim

To review a single surgeon's experience for the treatment of Dupuytren's disease with XIAPEX injection and the clinical outcomes as measured by a URAM score.

Method

Retrospective review of patient notes, clinical photography and URAM scores for patients who underwent the procedure between August 2013 and October 2016.

Results

33 patients underwent the procedure. 25 patients completed pre and post URAM scores. Average pre procedure score was 19.4 and avergae post procedure score was 3.28 a difference of 16.12 (clinically important change for URAM score is 2.9). Average pre procedure MCPJ contracture was 46.67 degrees and average post procedure contracture was 3.3 degrees. Average pre procedure PIPJ contracture was 66.8 degrees and average post procedure contracture was 8.2 degrees. Where both MCPJ and PIPJ affected of the same digit average pre procedure MCPJ and PIPJ contracture was 60 degrees. The post procedure contracture was 0 degrees in the MCPJ and 29.7 degrees in the PIPJ. 1 patient underwent surgery for progressive disease.

Conclusions

XIAPEX injection has shown a clinically significant result in the treatment of Dupuytren's disease. There were minimal complications and only 1 patient needed further surgery. However, a small sample size thus conclusions have to be cautious.

1632 Improving Excision Margins in Skin Oncology

Aim

There are 152,000 new non-melanoma skin cancer (NMSC) cases in the UK every year, and excision and reconstruction of basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) form a significant part of the clinical workload in plastic surgery. In this quality improvement project, we aimed to identify and improve our unit’s compliance of guidelines for excision margins for NMSCs.

Method

A retrospective audit was undertaken in June 2020 to determine compliance with British Association of Dermatology and local guidelines on excision margins for NMSCs. A repeat audit was undertaken in October 2020 following quality improvement interventions.

Results

The first audit cycle examined 66 lesions in total. Guidelines were met in 53% (BCCs) and 50% (SCCs) of lesions. 12% of lesions had unclear documentation of margins. 16 lesions had margins that were too small as according to the risk factors present. These findings were presented to the department, and a new operative note template specifically designed for skin oncology was launched. Key audit findings were displayed along with the guidelines on posters. A repeat cycle was undertaken in October 2020, which examined 52 lesions. Significant improvement was seen with 100% documentation, and excision margin guideline compliance rate of 71% (BCCs) and 79% (SCCs).

Conclusions

Adequate excision margins in skin oncology is vital to ensure complete excision and to minimise the risk of recurrence. Our project demonstrates significant improvement in excision margin compliance through the launch of a specific operative note template and information posters.

Conventional oxygen therapy versus CPAP as a ceiling of care in ward-based patients with COVID-19: a multi-centre cohort evaluation

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is commonly used for respiratory failure due to severe COVID-19 pneumonitis, including in patients deemed not likely to benefit from invasive mechanical ventilation (nIMV). Little evidence exists demonstrating superiority over conventional oxygen therapy, whilst ward-level delivery of CPAP presents practical challenges. We sought to compare clinical outcomes of oxygen therapy versus CPAP therapy in patients with COVID-19 who were nIMV.

METHODS

This retrospective multi-centre cohort evaluation included patients diagnosed with COVID-19 who were nIMV, had a treatment escalation plan of ward-level care and clinical frailty scale ≤ 6. Recruitment occurred during the first two waves of the UK COVID-19 pandemic in 2020; from 1^st March to May 31^st, and from 1^st September to 31^st December. Patients given CPAP were compared to patients receiving oxygen therapy that required FiO₂ ≥0_.4 for more than 12 hours at hospitals not providing ward-level CPAP. Logistic regression modelling was performed to compare 30-day mortality between treatment groups, accounting for important confounders and within-hospital clustering.

FINDINGS

Seven hospitals provided data for 479 patients during the UK COVID-19 pandemic in 2020. Overall 30-day mortality was 75.6% in the oxygen group (186/246 patients) and 77.7% in the CPAP group (181/233 patients). A lack of evidence for a treatment effect persisted in the adjusted model (adjusted odds ratio 0.84 95% CI 0.57-1.23, p=0.37). 49.8% of patients receiving CPAP-therapy (118/237) chose to discontinue it.

INTERPRETATION

No survival difference was found between using oxygen alone or CPAP to treat patients with severe COVID-19 who were nIMV. A high patient-initiated discontinuation rate for CPAP suggests a significant treatment burden. Further reflection is warranted on the current treatment guidance and widespread application of CPAP in this setting.

FUNDING

L Pearmain is supported by the MRC (MR/R00191X/1). TW Felton is supported by the NIHR Manchester Biomedical Research Centre.

Polyscore of autonomic parameters for risk stratification of the elderly general population: the Polyscore study

Aims

Present society is constantly ageing and elderly frequently suffer from conditions that are difficult and/or costly to treat if detected late. Effective screening of the elderly is therefore needed so that those requiring detailed clinical work-up are identified early. We present a prospective validation of a screening strategy based on a Polyscore of seven predominantly autonomic, non-invasive risk markers.

Methods and results

Within a population-based survey in Germany (INVADE study), participants aged ≥60 years were enrolled between August 2013 and February 2015. Seven prospectively defined Polyscore components were obtained during 30-min continuous recordings of electrocardiogram, blood pressure, and respiration. Out of 1956 subjects, 168 were excluded due to atrial fibrillation, implanted pacemaker, or unsuitable recordings. All-cause mortality over a median 4-year follow-up was prospectively defined as the primary endpoint. The Polyscore divided the investigated population (n = 1788, median age: 72 years, females: 58%) into three predefined groups with low (n = 1405, 78.6%), intermediate (n = 326, 18.2%), and high risk (n = 57, 3.2%). During the follow-up, 82 (4.6%) participants died. Mortality in the Polyscore-defined risk groups was 3.4%, 7.4%, and 17.5%, respectively (P < 0.0001). The Polyscore-based mortality prediction was independent of Framingham score, diabetes, chronic kidney disease, and major stroke and/or myocardial infarction history. It was particularly effective in those aged <75 years (n = 1145).

Conclusion

The Polyscore-based mortality risk assessment from short-term non-invasive recordings is effective in the elderly general population, especially those aged 60–74 years. Implementation of a comprehensive Polyscore screening of this age group is proposed to advance preventive medical care.

Influence of heart rate correction formulas on QTc interval stability

Monitoring of QTc interval is mandated in different clinical conditions. Nevertheless, intra-subject variability of QTc intervals reduces the clinical utility of QTc monitoring strategies. Since this variability is partly related to QT heart rate correction, 10 different heart rate corrections (Bazett, Fridericia, Dmitrienko, Framingham, Schlamowitz, Hodges, Ashman, Rautaharju, Sarma, and Rabkin) were applied to 452,440 ECG measurements made in 539 healthy volunteers (259 females, mean age 33.3 ± 8.4 years). For each correction formula, the short term (5-min time-points) and long-term (day-time hours) variability of rate corrected QT values (QTc) was investigated together with the comparisons of the QTc values with individually corrected QTcI values obtained by subject-specific modelling of the QT/RR relationship and hysteresis. The results showed that (a) both in terms of short-term and long-term QTc variability, Bazett correction led to QTc values that were more variable than the results of other corrections (p < 0.00001 for all), (b) the QTc variability by Fridericia and Framingham corrections were not systematically different from each other but were lower than the results of other corrections (p-value between 0.033 and < 0.00001), and (c) on average, Bazett QTc values departed from QTcI intervals more than the QTc values of other corrections. The study concludes that (a) previous suggestions that Bazett correction should no longer be used in clinical practice are fully justified, (b) replacing Bazett correction with Fridericia and/or Framingham corrections would improve clinical QTc monitoring, (c) heart rate stability is needed for valid QTc assessment, and (d) development of further QTc corrections for day-to-day use is not warranted.

Development, Characterization, and Evaluation of SLN-Loaded Thermoresponsive Hydrogel System of Topotecan as Biological Macromolecule for Colorectal Delivery

BACKGROUND

Chemotherapeutic drugs cause severe toxicities if administered unprotected, without proper targeting, and controlled release. In this study, we developed topotecan- (TPT-) loaded solid lipid nanoparticles (SLNs) for their chemotherapeutic effect against colorectal cancer. The TPT-SLNs were further incorporated into a thermoresponsive hydrogel system (TRHS) (TPT-SLNs-TRHS) to ensure control release and reduce toxicity of the drug. Microemulsion technique and cold method were, respectively, used to develop TPT-SLNs and TPT-SLNs-TRHS. Particle size, polydispersive index (PDI), and incorporation efficiency (IE) of the TPT-SLNs were determined. Similarly, gelation time, gel strength, and bioadhesive force studies of the TPT-SLNs-TRHS were performed. Additionally, in vitro release and pharmacokinetic and antitumour evaluations of the formulation were done.

RESULTS

TPT-SLNs have uniformly distributed particles with mean size in nanorange (174 nm) and IE of ~90%. TPT-SLNs-TRHS demonstrated suitable gelation properties upon administration into the rat's rectum. Moreover, drug release was exhibited in a control manner over an extended period of time for the incorporated TPT. Pharmacokinetic studies showed enhanced bioavailability of the TPT with improved plasma concentration and AUC. Further, it showed significantly enhanced antitumour effect in tumour-bearing mice as compared to the test formulations.

CONCLUSION

It can be concluded that SLNs incorporated in TRHS could be a potential source of the antitumour drug delivery with better control of the drug release and no toxicity.

Electrocardiographic parameters of left ventricular hypertrophy and prediction of mortality in hemodialysis patients

Background

In hemodialysis patients, left ventricular hypertrophy (LVH) contributes to high cardiovascular mortality. We examined cardiovascular mortality prediction by the recently proposed Peguero-Lo Presti voltage since it identifies more patients with electrocardiographic (ECG) LVH than Cornell or Sokolow-Lyon voltages.

Methods

A total of 308 patients on hemodialysis underwent 24 h ECG recordings. LVH parameters were measured before and after dialysis. The primary endpoint of cardiovascular mortality was recorded during a median 3-year follow up. Risk prediction was assessed by Cox regression, both unadjusted and adjusted for the Charlson Comorbidity Index and the Cardiovascular Mortality Risk Score.

Results

The Peguero-Lo Presti voltage identified with 21% the most patients with positive LVH criteria. All voltages significantly increased during dialysis. Factors such as ultrafiltration rate, Kt/V, body mass index, sex, and phosphate were the most relevant for these changes. During follow-up, 26 cardiovascular deaths occurred. Post-dialysis Peguero-Lo Presti cut-off as well as the Peguero-Lo Presti and Cornell voltages were independently associated with cardiovascular mortality in unadjusted and adjusted analysis. The Sokolow-Lyon voltage was not significantly associated with mortality. An optimal cut-off for the prediction of cardiovascular mortality was estimated at 1.38 mV for the Peguero-Lo Presti.

Conclusions

The post-dialysis Peguero-Lo Presti cut-off as well as the Peguero-Lo Presti and Cornell voltages allowed independent risk prediction of cardiovascular mortality in hemodialysis patients. Measuring the ECG LVH parameters after dialysis might allow a standardized interpretation as dialysis-specific factors influence the voltages.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40620-021-01068-0.

Quality of life and well-being of population at the end of third phase of lockdown in india against the COVID-19 pandemic

Background. On March 24, 2020, a nationwide Lockdown for 21 days was ordered by the Government of India which was then extended till May 31, 2020. Researchers have predicted lockdown is a necessary step to prevent COVID-19 spread. However, others have also stated that it could cause serious damage to the economic, mental, social, and physical well-being of the people. Objective. The aim of the study is to evaluate the impact of lockdown on the quality of life and well-being of the Indians. Methods. It is a cross sectional prospective web-based questionnaire study. A link (https://forms.gle/pX25VuahP5NxT88QA) was created. Total 426 responses were received via that link and the data was included in the statistical analysis. Results. Our study revealed that during the lockdown 61.5% of the respondents were performing physical activities lesser than before. More than half responded they had a reduced financial satisfaction. Most answers on emotional well-being and social-family wellbeing were also positive, but some responses showed disturbing too, like 22% felt anxious and nervous over half of the days. It was found in the study that physical, financial, emotional, mental, social and family wellbeing were disturbed during the lockdown and quality of life was also hampered. Conclusion. Though, may be Nationwide Lockdown was the most required action at that point of time to prevent virus spread, but our study revealed that uncertainty regarding its cure and management guidelines like lockdown and social distancing has badly affected quality of life and wellbeing of the population.

Clinical effectiveness of primary prevention implantable cardioverter-defibrillators: results of the EU-CERT-ICD controlled multicentre cohort study

Aims

The EUropean Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter-Defibrillators (EU-CERT-ICD), a prospective investigator-initiated, controlled cohort study, was conducted in 44 centres and 15 European countries. It aimed to assess current clinical effectiveness of primary prevention ICD therapy.

Methods and results

We recruited 2327 patients with ischaemic cardiomyopathy (ICM) or dilated cardiomyopathy (DCM) and guideline indications for prophylactic ICD implantation. Primary endpoint was all-cause mortality. Clinical characteristics, medications, resting, and 12-lead Holter electrocardiograms (ECGs) were documented at enrolment baseline. Baseline and follow-up (FU) data from 2247 patients were analysable, 1516 patients before first ICD implantation (ICD group) and 731 patients without ICD serving as controls. Multivariable models and propensity scoring for adjustment were used to compare the two groups for mortality. During mean FU of 2.4 ± 1.1 years, 342 deaths occurred (6.3%/years annualized mortality, 5.6%/years in the ICD group vs. 9.2%/years in controls), favouring ICD treatment [unadjusted hazard ratio (HR) 0.682, 95% confidence interval (CI) 0.537–0.865, P = 0.0016]. Multivariable mortality predictors included age, left ventricular ejection fraction (LVEF), New York Heart Association class <III, and chronic obstructive pulmonary disease. Adjusted mortality associated with ICD vs. control was 27% lower (HR 0.731, 95% CI 0.569–0.938, P = 0.0140). Subgroup analyses indicated no ICD benefit in diabetics (adjusted HR = 0.945, P = 0.7797, P for interaction = 0.0887) or those aged ≥75 years (adjusted HR 1.063, P = 0.8206, P for interaction = 0.0902).

Conclusion

In contemporary ICM/DCM patients (LVEF ≤35%, narrow QRS), primary prophylactic ICD treatment was associated with a 27% lower mortality after adjustment. There appear to be patients with less survival advantage, such as older patients or diabetics.

In Comparison to Pathological Q Waves, Selvester Score is a Superior Diagnostic Indicator of Increased Long-Term Mortality Risk in ST Elevation Myocardial Infarction Patients Treated with Primary Coronary Intervention

The development of pathological Q waves has long been correlated with worsened outcome in patients with ST elevation myocardial infarction (STEMI). In this study, we investigated long-term mortality of STEMI patients treated by primary percutaneous coronary intervention (PPCI) and compared predictive values of Q waves and of Selvester score for infarct volume estimation. Data of 283 consecutive STEMI patients (103 females) treated by PPCI were analysed. The presence of pathological Q wave was evaluated in pre-discharge electrocardiograms (ECGs) recorded ≥72 h after the chest pain onset (72 h Q). The Selvester score was evaluated in acute ECGs (acute Selvester score) and in the pre-discharge ECGs (72 h Selvester score). The results were related to total mortality and to clinical and laboratory variables. A 72 h Q presence and 72 h Selvester score ≥6 was observed in 184 (65.02%) and 143 (50.53%) patients, respectively. During a follow-up of 5.69 ± 0.66 years, 36 (12.7%) patients died. Multivariably, 72 h Selvester score ≥6 was a strong independent predictor of death, while a predictive value of the 72 h Q wave was absent. In high-risk subpopulations defined by clinical and laboratory variables, the differences in total mortality were highly significant (p < 0.01 for all subgroups) when stratified by 72 h Selvester score ≥6. On the contrary, the additional risk-prediction by 72 h Q presence was either absent or only borderline. In contemporarily treated STEMI patients, Selvester score is a strong independent predictor of long-term all-cause mortality. On the contrary, the prognostic value of Q-wave presence appears limited in contemporarily treated STEMI patients.

Heart Rate and Heart Rate Variability Changes Are Not Related to Future Cardiovascular Disease and Death in People With and Without Dysglycemia: A Downfall of Risk Markers? The Whitehall II Cohort Study

OBJECTIVE

Higher resting heart rate (rHR) and lower heart rate variability (HRV) are associated with increased risk of cardiovascular disease (CVD) and all-cause mortality in people with and without diabetes. It is unknown whether temporal changes in rHR and HRV may contribute to this risk. We investigated associations between 5-year changes in rHR and HRV and risk of future CVD and death, taking into account participants' baseline glycemic state.

RESEARCH DESIGN AND METHODS

In this prospective, population-based cohort study we investigated 4,611 CVD-free civil servants (mean [SD] age, 60 [5.9] years; 70% men). We measured rHR and/or six indices of HRV. Associations of 5-year change in 5-min rHR and HRV with fatal and nonfatal CVD and all-cause mortality or the composite of the two were assessed, with adjustments made for relevant confounders. Effect modification by glycemic state was tested.

RESULTS

At baseline, 63% of participants were normoglycemic, 29% had prediabetes, and 8% had diabetes. During a median (interquartile range) follow-up of 11.9 (11.4; 12.3) years, 298 participants (6.5%) experienced a CVD event and 279 (6.1%) died of non-CVD-related causes. We found no association between 5-year changes in rHR and HRV and future events. Only baseline rHR was associated with all-cause mortality. A 10 bpm-higher baseline HR level was associated with an 11.4% higher rate of all-cause mortality (95% CI 1.0-22.9%; P = 0.032). Glycemic state did not modify associations.

CONCLUSIONS

Changes in rHR and HRV and possibly also baseline values of these measures are not associated with future CVD or death in people with or without dysglycemia.

Prescription understanding among out-patients in government and private hospitals: A cross-sectional study in Lahore, Pakistan

INTRODUCTION

Like many other countries, Pakistan's healthcare system is divided into the public and the private sector. According to some studies and the mindset of many Pakistani people, private hospitals provide better services than government hospitals.

PURPOSE

The paucity of research studies compelled us to compare the understanding of prescription among outpatients of the government and private hospitals since the understanding of prescription by the patient is an important patient care indicator according to WHO.

METHOD

A cross sectional study was conducted by virtue of convenience sampling. The study included 365 patients; 182 from the government sector and 183 from the private sector. The study was conducted over a period of 3 months. A structured questionnaire was prepared to gather data that was analyzed using SPSS Version 22.0.

RESULTS

Patients from both government and private hospitals got no counseling while only 45.9% of the government hospital patients and 65.9% of private hospital patients were satisfied with the counseling they received. Our study concluded that the role of a pharmacist must be extended besides dispensing only, in counseling and educating patients to reduce the burden on the physicians and hospitals as well.

CONCLUSION

It was concluded that although the patients of private hospitals scored somewhat better at answering the questions than the government hospital patients but they failed to hit the benchmark. Their slightly better results were attributed to higher education levels and better socioeconomic status rather than better services of the hospital.

Quantitative analysis of myocardial metabolic heterogeneity is superior to visual assessment for the detection of active cardiac sarcoidosis by F-18 FDG PET-CT imaging

Funding Acknowledgements

Type of funding sources: None.

Background

Myocardial inflammation may occur in the context of a multisystem disease such as sarcoidosis, adversely affecting prognosis. A definitive diagnosis of cardiac sarcoidosis (CS) is essential to implementing life-saving treatment but this is complicated by the invasive nature of endomyocardial biopsy (EMB) and its low accuracy. Positron emission tomography (PET) assists in diagnosis, which relies on visual interpretation of myocardial F-18 FDG uptake. The value of quantitative analysis and its application to clinical practice remain uncertain.

Purpose

To investigate the power of quantitative F-18 FDG PET-CT imaging analysis for detecting CS in patients with suspected disease.

Methods

All patients underwent F-18 FDG PET-CT after a 24-hour low-carbohydrate diet and 15-hour fasting as part of their diagnostic work-up for suspected cardiac inflammation. Cardiovascular magnetic resonance acted as gatekeeper to PET-CT in 8 of every 10 scans. Myocardial F-18 FDG uptake was assessed qualitatively and quantitatively using both manually drawn regions of interest and automatic polar maps to measure global and segmental standardised F-18 FDG uptake values (SUV).  The coefficient of variation (CoV) was calculated to determine uptake heterogeneity. To confirm diagnosis, follow-up data regarding disease progression, further testing and treatment were collected. To allow for sufficient follow-up time, the first 40 consecutive patients from a prospective registry (n= 214; Sep 2017-Jun 2020) were included.

Results

A comprehensive clinical picture was obtained successfully in 37 patients (median [IQR], 17 [13.5] months) and a final diagnosis of CS reached in 7 (disease prevalence, 19%). EMB was performed in 2 patients only while 3 underwent PPM/ICD implantation. Significant predictors of CS were fulfilment of Japanese Ministry of Health and Welfare criteria (Wald, 6.44; p = 0.01) and left ventricular dysfunction (Wald 6.72; p = 0.01). Qualitative F-18 FDG PET-CT had a high negative (95%) but low positive (45%) predictive value for CS (sensitivity, 83%; specificity, 77%). F-18 FDG SUV CoV was the strongest imaging predictor (Wald, 6.77; p = 0.009) and was significantly higher in CS than non-CS (CoV median [quartiles], 0.26 [0.21, 0.36] and 0.12 [0.11, 0.14] respectively; p = 0.004). As per ROC curve analysis (AUC, 0.84), a CoV threshold of 0.20 was highly specific (93%) and sensitive (86%) for CS.

Conclusion

In a referring population with a low prevalence of cardiac sarcoidosis, F-18 FDG PET-CT imaging is sensitive for the detection of myocardial inflammation with active disease unlikely in patients with a negative scan. Quantitative evaluation of metabolic heterogeneity within the myocardium provides a strong, independent marker of active disease and should be considered alongside visual assessment.