The development and testing of a smart sensorized guide wire for catheterization in a "blood" vessel phantom to support aortic valve implementation

PURPOSE

Heart valve disease is commonly treated by minimally invasive procedures with guide wires and catheterization. The main purpose of this study is to find out whether an extension of the guide wire with a sensor can support the surgeon within the blood vessel to reduce X-ray necessity.

METHODS

A smart guide wire is developed by an extension with a flex-bending sensor to evaluate the sensor signal with and without "blood" flow at a constant compression force. Various surgically relevant investigations are performed. For assessment, the mean temporal average of the moving averaged filtered ADC signal and a subsequent FFT are carried out.

RESULTS

Results show that there is a smaller sensor signal when the applied force or bending at the sensor is higher. In all investigations, there was a different sensor signal. The flex-bending sensor can detect the effect of pulsatile flow. The smallest temporal averaged signal difference between reference and clamp in the front wire's tip is 1.09%. For example, the mean temporal average of the filtered ADC signal for different clinically relevant scenarios is between 2550 and 2900.

CONCLUSIONS

The results show that the sensorized guide wire developed for catheterization can support aortic valve implementation. The sensor sensitivity is sufficient to detect even very small variations within the blood vessel and therefore is promising to support catheterization heart valve surgeries in future.

Characteristics and burden of acute COVID-19 and long-COVID: Demographic, physical, mental health, and economic perspectives

BACKGROUND

COVID-19 infection and its associated consequence, known as long-COVID, lead to a significant burden on the global healthcare system and limitations in people's personal and work lives. This study aims to provide further insight into the impact of acute and ongoing COVID-19 symptoms and investigates the role of patients' gender and vaccination status.

METHODS

416 individuals (73.9% female) between the ages of 16 and 80 years (M = 44.18, SD = 12.90) with self-reported symptoms of long-COVID participated in an online survey conducted between March and May 2022.

RESULTS

6.0%, 74.3%, and 19.7% of all respondents reported having had an asymptomatic, mild, or severe acute illness, respectively. Out of all participants, 7.8% required hospitalization. The most prevalent symptoms during the acute infection (Mdn = 23.50 symptoms, IQR = 13-39) included fatigue, exhaustion, cough, brain fog, and memory problems. The median long-COVID disease duration was 12.10 months (IQR = 2.8-17.4). Among 64 inquired long-COVID symptoms (Mdn = 17.00 symptoms, IQR = 9-27), participants reported fatigue, exhaustion, memory problems, brain fog, and dyspnea as the most common ongoing symptoms, which were generally experienced as fluctuating and deteriorating after physical or cognitive activity. Common consequences of long-COVID included financial losses (40.5%), changes in the participants' profession (41.0%), stress resistance (87.5%), sexual life (38.1%), and mood (72.1%), as well as breathing difficulties (41.3%), or an increased drug intake (e.g., medicine, alcohol; 44.6%). In addition, vaccinated individuals exhibited a shorter acute illness duration and an earlier onset of long-COVID symptoms. In general, women reported more long-COVID symptoms than men.

CONCLUSION

Long-COVID represents a heterogeneous disease and impacts multiple life aspects of those affected. Tailored rehabilitation programs targeting the plurality of physical and mental symptoms are needed.

Anatomy and physiology of the autonomic nervous system: Implication on the choice of diagnostic/monitoring tools in 2023

The autonomic nervous system (ANS) harmoniously regulates all internal organic functions (heart rate, blood pressure, vasomotion, digestive tract motility, endocrinal secretions) and adapts them to the needs. It's the control of so-called vegetative functions, which allows homeostasis but also allostasis of our body. ANS is divided into two systems often understood as antagonistic and complementary: the sympathetic and the parasympathetic systems. However, we currently know of many situations of co-activation of the two systems. Long seen as acting through "reflex" control loops passing through the integration of peripheral information and the efferent response to the peripheral organ, more recent electrophysiological and brain functional imaging knowledge has been able to identify the essential role of the central autonomic network. This element complicates the understanding of the responses of the reflex loops classically used to identify and quantify dysautonomia. Finding the "ANS" tools best suited for the clinician in their daily practice is a challenge that we will attempt to address in this work.

Platelets from patients with chronic inflammation have a phenotype of chronic IL-1β release

Background

Chronic inflammation is a cardiovascular risk factor, and interleukin-1β (IL-1β) is central to the inflammatory host response. Platelets contain the NLRP3 inflammasome and are able to translate IL-1β messenger RNA (mRNA) and secrete mature IL-1β upon activation. However, the role of a chronic inflammatory environment in platelet IL-1β mRNA and protein content remains unclear.

Objectives

The aim of the current study was to investigate intracellular platelet IL-1β and IL-1β mRNA in a chronic inflammatory state.

Methods

Sixty-five patients with stable inflammation (ie, high-sensitivity C-reactive protein within predefined margins in 2 separate measurements) were stratified according to high-sensitivity C-reactive protein levels in low (0.0-0.9 mg/L), medium (1.0-2.9 mg/L), and high (3.0-9.9 mg/L) risk groups. Platelet reactivity as well as platelet IL-1β protein synthesis were studied.

Results

The highest risk group was characterized by a distinct cardiovascular risk profile and approximately 20% higher platelet counts. While platelet reactivity was not different, a reduction in intracellular platelet IL-1β mRNA and IL-1β protein levels was observed in the highest risk group and was linked to decreased platelet size and granularity. This signature suggests a phenotype of chronic IL-1β secretion and could be experimentally phenocopied by stimulation of platelets from healthy volunteers with either TRAP-6 or collagen related peptide (CRP-XL).

Conclusion

Our data suggest a phenotype of chronic IL-1β secretion by platelets in patients with chronic sterile inflammation.

EVALUATION OF A MODIFIED EPWORTH SLEEPINESS SCALE TO RELIABLY ASSESS EXCESSIVE DAYTIME SLEEPINESS IN LOW-INCOME COUNTRIES: RESULTS FROM THE BENIN SOCIETY AND SLEEP (BESAS) STUDY

Background

The Epworth Sleepiness Scale (ESS) is a tool widely used to assess excessive daytime sleepiness. Unfortunately, it is not reliable in low-income countries where situations such as reading a book, watching TV or driving a car are not common. The aim of this study was thus to assess the performance of a modified version of the Epworth scale in a low-income country.

Methods

We used data from the Benin Society and Sleep (BeSAS) study where the ESS and a modified ESS (mESS) were administered to participants. In the mESS, questions four questions over eight were redesigned to reflect common living situations in Benin. The internal coherence of the mESS was assessed using the Cronbach alpha coefficient (CAC). The discriminatory ability of the scale was assessed by comparing the mean scores according to reported sleep quality, insomnia complaints and apnea-hypopnea index (AHI).

Results

A total of 2909 participants were recruited, 1129 were male (38.9%) with a mean age (SD) of 44.7 (14.5) y. Overall, 52.4% (1526) completed all the mESS questions while 453 (15.6%) completed the standard ESS. The CAC of the mES was 0.86 showing good internal coherence. Concerning the discriminatory ability, mean scores for mESS were 7.8 for participants with ISI < 8 vs 9.2 for participants with ISI≥8 (p<0.001), 7.8 for participants withPSQI<5 vs 8.3 for participants with PSQI≥5 (p=0.03). No difference was found when comparing the participants participants using different cut-offs of AHI (15 and 30).

Conclusion

The mES is more reliable than ES in the Beninese population. mESS shows good internal coherence and differentiates between insomniacs vs non-insomniacs and between good and poor sleepers. Although the mES is not a perfect score, it appears more relevant in the Benin population than the original Epworth scale but needs further validation/improvement in other low-income countries.

PERFORMANCE OF SIX SCREENING SCORES FOR OBSTRUCTIVE SLEEP APNOEA IN AN AFRICAN POPULATION

Introduction

A screening tool for obstructive sleep apnoea (OSA) is useful in low-income countries where it may be difficult to access sleep recordings. The objective of this study was to assess the performance of six screening scores compared with objective sleep recording in an African population sample.

Methods

This analysis is based on the "Benin Sleep and Society" (BeSAS) populational study in which respiratory polygraphy (PG) was performed using a type III device and OSA screening questionnaires (STOP, STOP-Bang, Berlin, NOSAS [≥ 8 and ≥ 5), No-Apnea, GOAL) were administered to participants. PG-defined OSA severity categories were defined according to the apnoea-hypopnoea index (AHI): mild (AHI 5 to <15/h), moderate (AHI 15 to <30/h) or severe (AHI≥30/h), and these were compared to score findings.

Results

A total of 1810 subjects (mean age 45.4±14.6 years; 57.3% women) were included. For moderate to severe OSA, the area under the receiving operating characteristic (ROC) curve was greatest for GOAL and No-Apnea (0.70), followed by NoSAS5 (0.69). The highest sensitivity values were for NoSAS5 (0.73), No-Apnea (0.72), and GOAL (0.69), while NoSAS8 had the highest specificity (0.91), followed by Berlin (0.88) and GOAL (0.71). All scores performed poorly with respect to the positive predictive value (PPV), which was highest with NoSAS8 (0.38). Conclusion: This study provides the first comparison of the performance of screening scores for OSA in an African population. Although still low, PPV was highest with NoSAS8. Hence, NoSAS8 would be the screening method of choice for OSA in resource-constrained settings where formal sleep recordings are not accessible.

Short-course subcutaneous treatment with PQ Grass strongly improves symptom and medication scores in grass allergy

BACKGROUND

A modified grass allergen subcutaneous immunotherapy (SCIT) product with MicroCrystalline Tyrosine and monophosphoryl lipid-A as an adjuvant system (Grass MATA MPL [PQ Grass]) is being developed as short-course treatment of grass-pollen allergic rhinitis (SAR) and/or rhinoconjunctivitis. We sought to evaluate the combined symptom and medication score (CSMS) of the optimized cumulative dose of 27,600 standardized units (SU) PQ Grass in a field setting prior to embarking on a pivotal Phase III trial.

METHODS

In this exploratory, randomized, double-blind, placebo-controlled trial subjects were enrolled across 14 sites (Germany and the United States of America). Six pre-seasonal subcutaneous injections of PQ Grass (using conventional or extended regimens) or placebo were administered to 119 subjects (aged 18-65 years) with moderate-to-severe SAR with or without asthma that was well-controlled. The primary efficacy endpoint was CSMS during peak grass pollen season (GPS). Secondary endpoints included Rhinoconjunctivitis Quality of Life Questionnaire standardized (RQLQ-S) and allergen-specific IgG4 response.

RESULTS

The mean CSMS compared to placebo was 33.1% (p = .0325) and 39.5% (p = .0112) for the conventional and extended regimens, respectively. An increase in IgG4 was shown for both regimens (p < .01) as well as an improvement in total RQLQ-S for the extended regimen (mean change -0.72, p = .02). Both regimens were well-tolerated.

CONCLUSIONS

This trial demonstrated a clinically relevant and statistically significant efficacy response to PQ Grass. Unprecedented effect sizes were reached for grass allergy of up to ≈40% compared to placebo for CSMS after only six PQ Grass injections. Both PQ Grass regimens were considered equally safe and well-tolerated. Based on enhanced efficacy profile extended regime will be progressed to the pivotal Phase III trial.

Methods for think-aloud interviews in health-related resource-use research: the PECUNIA RUM instrument

BACKGROUND

The think-aloud (TA) approach is a qualitative research method that allows for gaining insight into thoughts and cognitive processes. It can be used to incorporate a respondent's perspective when developing resource-use measurement (RUM) instruments. Currently, the application of TA methods in RUM research is limited, and so is the guidance on how to use them. Transparent publication of TA methods for RUM in health economics studies, which is the aim of this paper, can contribute to reducing the aforementioned gap.

METHODS

Methods for conducting TA interviews were iteratively developed by a multi-national working group of health economists and additional qualitative research expertise was sought. TA interviews were conducted in four countries to support this process. A ten-step process was outlined in three parts: Part A 'before the interview' (including translation, recruitment, training), Part B 'during the interview' (including setting, opening, completing the instrument, open-ended questions, closing), and part C 'after the interview' (including transcription and data analysis, trustworthiness).

CONCLUSIONS

This manuscript describes the step-by-step approach for conducting multi-national TA interviews with potential respondents of the PECUNIA RUM instrument. It increases the methodological transparency in RUM development and reduces the knowledge gap of using qualitative research methods in health economics.

Effect of oxybutynin and reboxetine on obstructive sleep apnea: a randomized, placebo-controlled, double blind, crossover trial

STUDY OBJECTIVES

Although recent investigations combining noradrenergic and antimuscarinic drugs have shown promising short-term results to treat obstructive sleep apnea (OSA), the mid-term effect and optimal dosage remain uncertain. The present study aimed to evaluate the effect of one week of 5 mg oxybutynin and 6 mg reboxetine (oxy-reb) on OSA versus placebo.

METHODS

We performed a randomized, placebo-controlled, double-blind, crossover trial comparing the effect of one week of oxy-reb versus one week of placebo on OSA severity. At-home polysomnography was performed at baseline and after each week of intervention.

RESULTS

Fifteen participants (male 66.7%) aged 59 [44-62] years (median [interquartile range]) with a mean body mass index of 33.1 ± 6.6 kg.m -2 were included. No significant difference in apnea-hypopnea index (AHI) was observed between conditions (estimated marginal means (95% confidence interval) at baseline: 39.7 (28.5-55.3); oxy-reb: 34.5 (22.7-52.3); placebo: 37.9 (27.1-52.9); p=0.652), but oxy-reb improved average oxygen desaturation (p=0.016) and hypoxic burden (p=0.011) and lowered sleep efficiency (p=0.019) and rapid eye movement (REM) sleep (p=0.002). Moreover, participants reported reduced sleep quality during the week of oxy-reb compared to the week of placebo (4.7 (3.5; 5.9) vs. 6.5 (5.5; 7.5) on a 0-10 visual analogic scale, respectively; p=0.001). No significant differences in sleepiness, vigilance and fatigue were observed. No serious adverse events occurred.

CONCLUSION

Administration of oxybutynin 5 mg and reboxetine 6 mg did not improve OSA severity assessed by AHI, but did alter sleep architecture and sleep quality. Reduced average oxygen desaturation and hypoxic burden were also observed.

The experiences of pediatric nurses deployed to adult COVID-19 wards

BACKGROUND

The coronavirus pandemic created an unprecedented deployment of health professionals. The objective of this study was to describe the experiences of pediatric nurses transferred to adult COVID-19 wards during the first wave of the pandemic.

METHODS

We performed a qualitative study using a phenomenological approach. Nurses were recruited on a voluntary basis. All participants moved from a pediatric ward and were redeployed to an adult COVID-19 ward in another hospital. Interviews were carried out face to face in line with social-distancing guidelines. We used a script of open-end questions. The interviews were recorded and transcribed in full and qualitative data were analyzed using NVivo software.

RESULTS AND CONCLUSIONS

In total, 23 nurses were interviewed. Our analysis revealed positive and negative experiences given the different types of support the nurses received, individual attitudes that promoted resilience in a crisis situation, ethical conflicts linked to end-of-life care, and their perspectives on the next wave of the pandemic. The main difficulties encountered by the transferred nurses were related to their working conditions and safety, communication about working practices, and end-of-life patient care. In most cases, the individual resilience strategies put in place and the different forms of social support enabled them to cope with stress and maintain their commitment. However, some interviewees would have benefited from improved managerial support. For all participants, their perception of this support and the benefits of their experience influenced their willingness to be transferred to an adult ward again during a future wave of the pandemic.

Intravenous iron supplementation in heart failure patients induces temporary endothelial dysfunction with release of endothelial microvesicles

Background

Intravenous iron supplementation is an established therapy for patients with heart failure (HF) and concomitant iron deficiency reducing the risk of HF hospitalization. However, concerns persist regarding potential adverse vascular effects, since iron may induce oxidative stress, inflammation, and apoptosis of endothelial cells. To assess endothelial health following ferric carboxymaltose (FCM) administration, we analyzed the profile of circulating endothelial microvesicles (EMVs) and endothelial progenitor cells (EPCs) in a cohort of 23 HF patients using flow cytometry.

Results

Compared to healthy subjects, baseline levels of CD31+/CD41- EMVs were higher and EMVs featured a more apoptotic phenotype in HF patients. Following FCM administration, EMV levels showed a rapid but transient increase and displayed an altered phenotype profile with dominant augmentation of EMVs expressing inducible markers CD62E and CD54, indicating endothelial inflammatory activation and injury. Levels of circulating vasoregenerative CD45lowCD34+KDR+ EPCs were lower in HF patients and FCM application resulted in an early decrease of EPCs followed by substantial mobilization into the circulation after one week. Levels of EMVs and EPCs returned to baseline values within two and four weeks, respectively. HF patients with additional chronic kidney disease showed an elevated EMV/EPC ratio and diminished EPC mobilization, suggesting impaired vascular repair capacity. Providing a mechanistic link, in vitro experiments with cultured endothelial cells revealed that FCM dose-dependently promotes endothelial apoptosis, increases expression of adhesion molecules and CXCL12, and triggers generation of EMVs.

Conclusion

Intravenous iron supplementation with FCM in HF patients induces a biphasic response with initial increased release of CD62E+ and CD54+ enriched EMVs and subsequent mobilization of EPCs, indicating endothelial dysfunction upon FCM and suggesting consecutive engagement of a defense program aimed to reconstitute vascular health.

Clinical implications and risk factors for QRS prolongation over time in heart failure patients

BACKGROUND

QRS prolongation is an established prognostic marker in heart failure (HF). In contrast, the role of QRS width progression over time has been incompletely explored. The current study investigates the role of QRS width progression over time on clinical status and identifies underlying predictors.

METHODS

Datasets of ≥ 2 consecutive visits from 100 attendees to our HF clinic between April and August 2021 were analysed for changes in QRS complex duration.

RESULTS

In total 240 datasets were stratified into tertiles based on change in QRS duration (mm/month) (1st tertile: - 1.65 [1.50] 'regression'; 2nd tertile 0.03 [0.19] 'stable', 3rd tertile 3.57 [10.11] 'progression'). The incidence of the combined endpoint HF hospitalisation and worsening of symptomatic heart failure was significantly higher in the group with QRS width progression (3rd tertile) compared with the stable group (2nd tertile; log-rank test: p = 0.013). These patients were characterised by higher plasma NT-pro-BNP levels (p = 0.008) and higher heart rate (p = 0.007). A spline-based prediction model identified patients at risk of QRS width progression when NT-pro-BNP and heartrate were > 837 pg/ml and > 83/bpm, respectively. These markers were independent of guideline-directed medical HF therapy. Patients beyond both thresholds had a 14-fold increased risk of QRS width progression compared to those with neither or either alone (HR: 14.2 [95% 6.9 - 53.6]; p < 0.0001, p for interaction = 0.016).

CONCLUSIONS

This pilot study demonstrates that QRS width progression is associated with clinical deterioration of HF. NTproBNP plasma levels and heart rate indicate patients at risk QRS width progression, independently of HF therapy.

International comparability of reference unit costs of education services: when harmonizing methodology is not enough (PECUNIA project)

BACKGROUND

Health problems can lead to costs in the education sector. However, these costs are rarely incorporated in health economic evaluations due to the lack of reference unit costs (RUCs), cost per unit of service, of education services and of validated methods to obtain them. In this study, a standardized unit cost calculation tool developed in the PECUNIA project, the PECUNIA RUC Template for services, was applied to calculate the RUCs of selected education services in five European countries.

METHODS

The RUCs of special education services and of educational therapy were calculated using the information collected via an exploratory gray literature search and contact with service providers.

RESULTS

The RUCs of special education services ranged from €55 to €189 per school day. The RUCs of educational therapy ranged from €6 to €25 per contact and from €5 to €35 per day. Variation was observed in the type of input data and measurement unit, among other.

DISCUSSION

The tool helped reduce variability in the RUCs related to costing methodology and gain insights into other aspects that contribute to the variability (e.g. data availability). Further research and efforts to generate high quality input data are required to reduce the variability of the RUCs.

Retrospective study on the pharyngeal airspace in the lateral cephalogram - A mathematical model to predict changes due to bimaxillary orthognathic surgery

The aim of this study was the development of a statistical model for reliable prediction of Posterior Airway Space (PAS) changes in lateral cephalograms (LCR) of patients after bimaxillary orthognathic surgery. The LCRs of patients who underwent bimaxillary orthognathic surgery were retrospectively analyzed. The anteroposterior dimension of the PAS was measured at three levels in the pre-operative and postoperative LCR: On the nasopharyngeal (SPAS), oropharyngeal (MAS), and hypopharyngeal level (IAS). The data of 139 patients were collected. The following changes of the PAS were measured: in class II patients SPAS: 0.291 mm (SD = 2.570 mm); MAS: 2.444 mm (SD = 2.986 mm); IAS: 0.750 mm (SD = 3.017 mm); in class III patients SPAS: 1.377 mm (SD 3.212 mm); MAS: 0.962 (SD: = 3.135 mm); IAS: 0.370 mm (SD = 3.468 mm). Linear regression analysis showed for class II patients, a significant influence of mandibular movement on MAS (p = 0.049) and a significant effect of maxillary and mandibular movements on SPAS (p = 0.001) and MAS (p = 0.022) in class III patients. The other jaw displacements had no significant impact on the investigated PAS levels. While the presented method does not permit exact prediction of the dimension of the PAS, it is still an easily accessible method of orientation for the surgeon. The surgeon can initiate three-dimensional examinations to provide exact three-dimensional prediction based on this calculation.

Clinical implications and risk factors for QRS width progression in heart failure patients

Background

QRS complex prolongation is an established prognostic marker in patients with heart failure, (HF) and identifies patients for whom standard treatment includes cardiac resynchronization therapy (CRT). In contrast, the role of QRS width progression over time on clinical status and whether it can be predicted has been incompletely explored.

Purpose

To provide pilot data that could help to identify features associated with QRS progression and deteriorating clinical status.

Methods

The present retrospective analysis relates to 100 consecutive attendees to our HF clinic between April and August 2021. Each patient with a least one past visit including an ECG was included and a maximum of 4 past visits were assessed per patient.

Results

In total 240 datasets were generated from at least two consecutive visits and included clinical status, electrocardiographic (ECG), laboratory and echocardiographic data. Mean age and left ventricular ejection fraction were 58±13 years and 36±10%. The mean time between visits was 227 days. Datasets were stratified into tertiles based on change in QRS duration (mm/month). These were labelled as “QRS width regression” (&gt;−0.34 ms/month), “QRS stability” (−0.33 to 0.49 ms/month and “QRS width progression” (&gt;0.50 ms/month).

The incidence of the combined endpoint of worsening symptomatic HF (deterioration in NYHA class by at least one grade) and HF hospitalisation was significantly higher in the QRS progression group compared with the stable group (Log Rank test: progression v stability p=0.013). In addition, patients with QRS progression had a higher baseline plasma NT-pro-BNP levels (p=0.008) and higher baseline heart rate (p=0.007). To explore whether patients at higher risk of QRS progression could be identified at baseline, we built a prediction model based upon baseline NTproBNP levels and baseline heart rate. We determined that an NT-pro-BNP &gt;837 pg/ml and a heart rate &gt;83/bpm were reliable thresholds for greater risk of QRS progression (Figure 1A & B). Both of these variables were independent of guideline-directed medical HF therapy (including beta-antagonist use and dose). An interaction analysis revealed that combining these two risk factors was associated with a 14-fold increased risk of QRS progression compared with neither or either alone, suggesting synergism between these variables (HR: 14.2 [95% 6.9–53.6]; p&lt;0.0001, p for interaction=0.016).

Conclusion

In the current pilot study, we demonstrate that QRS progression is associated with future risk of clinical deterioration of HF. In addition, we show that higher baseline NTproBNP plasma levels combined with higher baseline heart rate indicate a group at markedly increased risk of progression of QRS width, independently of HF therapy. These parameters might therefore identify people potentially benefitting from intensified follow up, optimisation of GDMT and could also help coordinate the application of a more personalised approach to device therapy

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

[Heart and diabetes : Platelet function and antiplatelet therapy in chronic kidney disease]

Patients with chronic kidney disease (CKD) have an increased risk of thrombosis and approximately 50% of patients with advanced CKD die because of a cardiovascular disease. In addition to an increased risk of thrombosis, patients with CKD and particularly with advanced CKD, have an increased risk of hemorrhage, which increases parallel to the decline of kidney function. Due to this parallel existence of the prohemorrhagic and prothrombotic phenotype, antiplatelet treatment is difficult in the daily routine and data show that CKD patients with acute coronary syndrome (ACS) are less likely to receive guideline-conform treatment. The underlying mechanisms are currently insufficiently understood and both platelet-dependent mechanisms and also platelet-independent mechanisms are under discussion. Accordingly, there is currently no specific treatment or treatment strategy for patients with CKD. In addition, CKD patients are underrepresented in registration studies on antiplatelet treatment and there are no data from randomized trials for patients with advanced CKD (CKD ≥ 4). Current guideline recommendations are therefore based on subgroup analyses and observational studies. In addition, questions on the duration of treatment, on risk scores for estimation of the risk of hemorrhage and on potential benefits of escalation and de-escalation strategies remain largely unanswered and should therefore be the focus of future studies.

Long-term effect of anticancer therapy on dentition of Italian children in remission from malignant disease: A cross-sectional study

AIM

To investigate the effects of anticancer therapy on dental development and caries formation in Italian childhood cancer survivors compared to healthy controls.

METHODS

A total of 52 children treated with chemotherapy and/or radiotherapy when younger than 10 years and in remission from at least 2 years, and 52 healthy age- and gender-matched children were consecutively enrolled in this cross-sectional study. All participants were examined for dental caries and enamel defects according to the decayed-missing-filled teeth (dmft/DMFT) index and the Aine rating scale. Panoramic radiographs were taken to estimate dental age and to assess dental abnormalities using the Höltta Defect Index.

CONCLUSION

These children are at high risk for tooth developmental abnormalities and poor dental health and should be closely monitored by a specialist dentist.

Devenir des patients hospitalisés en soins critiques pour infection à SARS-COV2 : évaluation standardisée des séquelles à 6–9 mois

Introduction

Identifié en Chine en décembre 2019, le Severe Acute Respiratory SyndromeCoronavirus 2 (SARS-COV2) s’est rapidement propagé au niveau mondial. Si les études se sont initialement concentrées sur la prise en charge de la phase aiguë de la COrona VIrus Disease (COVID), l’objectif de ce travail est de s’intéresser aux conséquences à distance d’une hospitalisation pour COVID sévère.

Patients et méthodes

Nous avons réalisé une étude prospective, monocentrique, incluant des patients 6 à 9 mois après leur hospitalisation en soins critiques (soins intensifs ou réanimation) pour une infection confirmée à SARS-COV2. Les patients étaient évalués au cours d’une hospitalisation de jour en médecine interne. L’entretien débutait par un recueil des antécédents du patient, des évènements et des symptômes post-COVID. L’examinateur procédait ensuite à un examen clinique détaillé et un test de marche des 6 minutes (TM6). Les patients réalisaient de manière systématique des explorations fonctionnelles respiratoires (EFR), une tomodensitométrie (TDM) thoracique non injectée, une échographie cardiaque trans-thoracique (ETT), et un bilan biologique complet. Une batterie de tests était réalisée, explorant la qualité de vie et les séquelles psychologiques.

Résultats

Quatre-vingt-six patients, dont 71 (82,6 %) hommes, d’âge médian 65,8 ans (56,7;72,4), ont été évalués dans un délai moyen de 7 mois (min 3,4; max 14,9). L’hypertension artérielle (46,5 %), le diabète (34,9 %) et la dyslipidémie (39,5 %) étaient les antécédents médicaux les plus représentés. Douze (14,0 %) patients avaient une pathologie pulmonaire sous-jacente, principalement une broncho-pneumopathie chronique obstructive (BPCO). L’indice de comorbidités de Charlson médian était de 1 (0,0; 2,0). La durée médiane du séjour en soins critiques était de 10,0 (6,0;17,0) jours. Cinquante-quatre (62,8 %) patients ont eu une ventilation invasive et 67 (77,9 %) patients ont reçu un traitement par corticothérapie. Cinquante-sept (71,3 %) patients ont présenté une asthénie post-COVID, 39 (48,1 %) une faiblesse musculaire, 30 (36,6 %) des arthralgies. Quinze patients ont développé un déséquilibre du diabète et 9 un déséquilibre de la pression artérielle. Dix-sept (21,3 %) patients avaient une distance au TM6 < 80 % de la théorique. Quarante-six patients53,5 %) avaient un score de dyspnée Medical Reaserch Council (MRC) de 0 et 24 (27,9 %) avaient un score MRC de 1. Treize (15,5 %) patients avaient une auscultation anormale à type de crépitants secs des bases. Cinquante-deux (64,2 %) patients ont présenté un déficit de la diffusion du CO défini par une DLCO < 80 % et 16 (19,8 %) avaient une DLCO < 60 %. Le scanner thoracique montrait chez 35 (40,7 %) patients des lésions de verre dépoli et 18 (21,7 %) de la fibrose. Trente-deux patients (37,6 %) avaient un score PHQ-9 significatif pour une dépression, 20 (23,5 %) un score GAD-7 significatif pour un trouble anxieux et 8 (9,4 %) patients avaient un score PCL5 supérieur au seuil évoquant un état de stress post-traumatique. Le niveau de qualité de vie à distance de l’épisode aigu était satisfaisant avec une médiane de l’EQ-5D-3L à 0,89 (0,64;1,00). En analyse univariée, la fibrose sur le scanner de réévaluation et une DLCO < 60 % étaient associées à la durée du séjour en soins critiques et au niveau maximal de CRP pendant l’épisode aigu. En analyse multivariée, la fibrose et la DLCO étaient associées à la durée de séjour. En analyse uni et multivariée, le PHQ-9 et le GAD-7 étaient associés au sexe féminin.

Discussion

À ce jour, rares sont les études qui ont étudié de manière systématisée les séquelles somatiques et psychologiques à long terme de la COVID chez les patients qui ont été pris en charge en soins critiques. Conformément à la littérature, la diminution de la DLCO est l’anomalie la plus fréquemment retrouvée aux EFR, les plages de verre dépoli persistent sur le scanner et des lésions fibrotiques sont retrouvées chez plus d’un patient sur 5 [1], [2]. Ces anomalies contrastent avec une plainte respiratoire modérée et un examen clinique rassurant. Les symptômes généraux (asthénie, faiblesse musculaire et arthralgies) sont au cœur de la plainte fonctionnelle. Les déséquilibres de la tension artérielle et du diabète observés justifient un suivi accru des pathologies chroniques au décours de l’épisode aigu. Enfin, nous avons noté une prévalence plus importante des troubles psychologiques que celles relevées rétrospectivement (dossier informatisé) dans une autre étude [3], renforçant, selon nous, la nécessité d’un dépistage systématique des troubles psychiatriques.

Conclusion

De nombreux patients présentent des séquelles à distance d’une COVID sévère nous incitant à un dépistage systématique afin de proposer une prise en charge adaptée.

Free water diffusion MRI and executive function with a speed component in healthy aging

Extracellular free water (FW) increases are suggested to better provide pathophysiological information in brain aging than conventional biomarkers such as fractional anisotropy. The aim of the present study was to determine the relationship between conventional biomarkers, FW in white matter hyperintensities (WMH), FW in normal appearing white matter (NAWM) and in white matter tracts and executive functions (EF) with a speed component in elderly persons.

We examined 226 healthy elderly participants (median age 69.83 years, IQR: 56.99–74.42) who underwent brain MRI and neuropsychological examination. FW in WMH and in NAWM as well as FW corrected diffusion metrics and measures derived from conventional MRI (white matter hyperintensities, brain volume, lacunes) were used in partial correlation (adjusted for age) to assess their correlation with EF with a speed component. Random forest analysis was used to assess the relative importance of these variables as determinants. Lastly, linear regression analyses of FW in white matter tracts corrected for risk factors of cognitive and white matter deterioration, were used to examine the role of specific tracts on EF with a speed component, which were then ranked with random forest regression.

Partial correlation analyses revealed that almost all imaging metrics showed a significant association with EF with a speed component (r = −0.213 – 0.266). Random forest regression highlighted FW in WMH and in NAWM as most important among all diffusion and structural MRI metrics. The fornix (R²=0.421, p = 0.018) and the corpus callosum (genu (R² = 0.418, p = 0.021), prefrontal (R² = 0.416, p = 0.026), premotor (R² = 0.418, p = 0.021)) were associated with EF with a speed component in tract based regression analyses and had highest variables importance.

In a normal aging population FW in WMH and NAWM is more closely related to EF with a speed component than standard DTI and brain structural measures. Higher amounts of FW in the fornix and the frontal part of the corpus callosum leads to deteriorating EF with a speed component.

Analysis of cellular water content in T cells reveals a switch from slow metabolic water gain to rapid water influx prior to cell division

Cell growth is driven by the acquisition and synthesis of both dry biomass and water mass. In this study, we examine the increase of water mass in T cell during cell growth. We found that T-cell growth is characterized by an initial phase of slow increase in cellular water, followed by a second phase of rapid increase in water content. To study the origin of the water gain, we developed a novel methodology we call cold aqua trap-isotope ratio mass spectrometry, which allows analysis of the isotope composition of intracellular water. Applying cold aqua trap-isotope ratio mass spectrometry, we discovered that glycolysis-coupled metabolism of water accounts on average for 11 fl out of the 20 fl of water gained per cell during the initial slow phase. In addition, we show that at the end of the rapid phase before initiation of cell division, a water influx occurs, increasing the cellular water mass by threefold. Thus, we conclude that activated T cells switch from metabolizing water to rapidly taking up water from the extracellular medium prior to cell division. Our work provides a method to analyze cell water content as well as insights into the ways cells regulate their water mass.

Measurements of Strong-Interaction Effects in Kaonic-Helium Isotopes at Sub-eV Precision with X-Ray Microcalorimeters

We have measured the 3d→2p transition x rays of kaonic ^{3}He and ^{4}He atoms using superconducting transition-edge-sensor microcalorimeters with an energy resolution better than 6 eV (FWHM). We determined the energies to be 6224.5±0.4(stat)±0.2(syst)  eV and 6463.7±0.3(stat)±0.1(syst)  eV, and widths to be 2.5±1.0(stat)±0.4(syst)  eV and 1.0±0.6(stat)±0.3(stat)  eV, for kaonic ^{3}He and ^{4}He, respectively. These values are nearly 10 times more precise than in previous measurements. Our results exclude the large strong-interaction shifts and widths that are suggested by a coupled-channel approach and agree with calculations based on optical-potential models.

Performance of nanoparticles for biomedical applications: The in vitro/in vivo discrepancy

Nanomedicine has a great potential to revolutionize the therapeutic landscape. However, up-to-date results obtained from in vitro experiments predict the in vivo performance of nanoparticles weakly or not at all. There is a need for in vitro experiments that better resemble the in vivo reality. As a result, animal experiments can be reduced, and potent in vivo candidates will not be missed. It is important to gain a deeper knowledge about nanoparticle characteristics in physiological environment. In this context, the protein corona plays a crucial role. Its formation process including driving forces, kinetics, and influencing factors has to be explored in more detail. There exist different methods for the investigation of the protein corona and its impact on physico-chemical and biological properties of nanoparticles, which are compiled and critically reflected in this review article. The obtained information about the protein corona can be exploited to optimize nanoparticles for in vivo application. Still the translation from in vitro to in vivo remains challenging. Functional in vitro screening under physiological conditions such as in full serum, in 3D multicellular spheroids/organoids, or under flow conditions is recommended. Innovative in vivo screening using barcoded nanoparticles can simultaneously test more than hundred samples regarding biodistribution and functional delivery within a single mouse.

The Tangential Extraperitoneal Retrorenal Approach in Kidney Transplant Biopsy: An Observational Study to Assess Complication and Adequacy Rates

Introduction: Ultrasound-guided percutaneous kidney allograft biopsy is the gold-standard for pathology work-up. Recent studies postulate better safety and efficacy for tangential approaches, however, there is no recommendation regarding biopsy needle path. In this context, we previously described the unified tangential extraperitoneal retrorenal (TER) approach for standard allograft biopsy.

Methods: A single-center retrospective observational study evaluated safety and efficacy of the TER biopsy approach among 250 patients that underwent 330 ultrasound-guided kidney transplant biopsies between January 2011 and May 2020.

Results: The overall major complication rate was 0.56% per biopsy attempt (1.21% per biopsy) including blood transfusion, arterial embolization and bladder catheterization for gross hematuria in 0.28, 0.14 and 0.14% of biopsy attempts, respectively (0.61, 0.30 and 0.30% of biopsies, respectively). Minor complications included subcapsular and/or perinephric hematoma, superficial bleeding, arteriovenous fistula and gross hematuria in 12.6, 3.0, 2.5 and 1.4% of biopsy attempts, respectively (27.0, 6.4, 5.5 and 3.0% of biopsies, respectively). Sample adequacy rate was 86.7%, ranging from 82.2 to 94.1% if one or ≥two cores were analyzed, respectively. Residents and consultants yielded similar complication and adequacy rates.

Conclusion: According to current literature, ultrasound-guided TER kidney transplant biopsy is a safe and efficient approach eligible for nephrology training.

Platelet Abnormalities in CKD and Their Implications for Antiplatelet Therapy

Patients with CKD display a significantly higher risk of cardiovascular and thromboembolic complications, with around half of patients with advanced CKD ultimately dying of cardiovascular disease. Paradoxically, these patients also have a higher risk of hemorrhages, greatly complicating patient therapy. Platelets are central to hemostasis, and altered platelet function resulting in either platelet hyper- or hyporeactivity may contribute to thrombotic or hemorrhagic complications. Different molecular changes have been identified that may underlie altered platelet activity and hemostasis in CKD. In this study, we summarize the knowledge on CKD-induced aberrations in hemostasis, with a special focus on platelet abnormalities. We also discuss how prominent alterations in vascular integrity, coagulation, and red blood cell count in CKD may contribute to altered hemostasis in these patients who are high risk. Furthermore, with patients with CKD commonly receiving antiplatelet therapy to prevent secondary atherothrombotic complications, we discuss antiplatelet treatment strategies and their risk versus benefit in terms of thrombosis prevention, bleeding, and clinical outcome depending on CKD stage. This reveals a careful consideration of benefits versus risks of antiplatelet therapy in patients with CKD, balancing thrombotic versus bleeding risk. Nonetheless, despite antiplatelet therapy, patients with CKD remain at high cardiovascular risk. Thus, deep insights into altered platelet activity in CKD and underlying mechanisms are important for the optimization and development of current and novel antiplatelet treatment strategies, specifically tailored to these patients who are high risk. Ultimately, this review underlines the importance of a closer investigation of altered platelet function, hemostasis, and antiplatelet therapy in patients with CKD.

Does Moderate Altitude Affect VO2max in Acclimatized Mountain Guides?

Pühringer, Reinhard, Hannes Gatterer, Martin Berger, Michael Said, Martin Faulhaber, and Martin Burtscher. Does moderate altitude affect VO₂max in acclimatized mountain guides? High Alt Med Biol 00:000-000, 2021. Background: Altitude exposure reduces maximal oxygen uptake (VO₂max). Usually, the reduction is not restored with acclimatization (at least at altitudes above 2,500 m) and is more pronounced in highly trained athletes compared to nonathletes. It still remains to be elucidated whether these also apply for well-acclimatized individuals (i.e., mountain guides) acutely exposed to moderate altitude (i.e., 2,000 m). Methods: A total of 128 acclimatized male mountain guides of the Austrian armed forces (42.2 ± 7.0 years, 177.8 ± 5.6 cm, 77.2 ± 7.0 kg) of different fitness levels performed 2 incremental cycle ergometer tests 1 week apart, one at low (600 m) and one at moderate altitude (2,000 m). Oxygen uptake, heart rate (HR), and lactate concentration were measured during the tests. Results: In acclimatized mountain guides, lower baseline VO₂max levels were associated with better preservation of VO₂max at moderate altitude compared to higher levels. At moderate altitude, physiological responses (HR and blood lactate at 100 W) at a submaximal exercise intensity of 100 W remained unchanged or were even slightly reduced in both groups. Conclusions: Long-term acclimatization to moderate altitude may prevent the VO₂max decline at a moderate altitude of 2,000 m particularly in subjects with lower VO₂max levels, that is, below the 80th percentile (for age and sex). In people with higher fitness levels, VO₂max may still be negatively affected. These results are of practical relevance, for example, for workers, athletes, ski and mountain guides, military staff, or rescue staff who regularly or continuously have to perform at moderate altitude.

Photochemical Organocatalytic Regio- and Enantioselective Conjugate Addition of Allyl Groups to Enals

We report the first catalytic enantioselective conjugate addition of allyl groups to α,β‐unsaturated aldehydes. The chemistry exploits the visible‐light‐excitation of chiral iminium ions to activate allyl silanes towards the formation of allylic radicals, which are then intercepted stereoselectively. The underlying radical mechanism of this process overcomes the poor regio‐ and chemoselectivity that traditionally affects the conjugate allylation of enals proceeding via polar pathways. We also demonstrate how this organocatalytic strategy could selectively install a valuable prenyl fragment at the β‐carbon of enals.

Use of local anesthesia for inguinal hernia repair has decreased over time in the VA system

PURPOSE

In 2003, randomized trials demonstrated potentially improved outcomes when local instead of general anesthesia is used for inguinal hernia repair. Our study aimed to evaluate how the use of local anesthesia for this procedure changed over time following the publication of the trials' level 1 evidence.

METHODS

We used the 1998-2018 Veterans Affairs Surgical Quality Improvement Program database to identify adults who underwent open, unilateral inguinal hernia repair under local or general anesthesia. Our primary outcome was the percentage of cases performed under local anesthesia. We used a time-series design to examine the trend and rate of change of the use of local anesthesia.

RESULTS

We included 97,437 veterans, of which 22,333 (22.9%) had hernia surgery under local anesthesia. The median age of veterans receiving local anesthesia remained stable at 64-67 years over time. The use of local anesthesia decreased steadily, from 38.2% at the beginning year to 15.1% in the final year (P < 0.0001). The publication of results from randomized trials (in 2003) did not appear to increase the overall use or change the rate of decline in the use of local anesthesia. Overall, we found that the use of local anesthesia decreased by about 1.5% per year.

CONCLUSION

The utilization of local anesthesia for inguinal hernia repair in the VA has steadily declined over the last 20 + years, despite data showing equivalence or superiority to general anesthesia. Future studies should explore barriers to the use of local anesthesia for hernia repair.

SGLT-2 Inhibition – neues Therapiekonzept bei Herzinsuffizienz

SGLT2-Inhibitoren stellen eine neue Substanzklasse in der Therapie der Herzinsuffizienz dar, die initial zur Therapie des Typ-2-Diabetes entwickelt wurde. In großen kardiovaskulären Endpunktstudien konnte zunächst bei Patienten mit Typ-2-Diabetes gezeigt werden, dass SGLT2-Inhibitoren Herzinsuffizienz-assoziierte Endpunkte reduzieren. Daher wurden im Verlauf gezielt Studien bei Patienten mit Herzinsuffizienz mit eingeschränkter LV-Funktion (HFrEF) durchgeführt. In den bislang veröffentlichten Studien konnte gezeigt werden, dass Dapagliflozin oder Empagliflozin zu einer signifikanten Reduktion des Endpunktes Hospitalisierung für Herzinsuffizienz oder kardiovaskulären Tod führt. Damit stellt diese Substanzklasse eine neue Therapieoption für Patienten mit HFrEF dar. Der vorliegende Artikel gibt einen Überblick über die aktuelle Datenlage und stellt SGLT2-Inhibitoren in den Kontext der bisherigen Behandlung bei Herzinsuffizienz.

P–801 Effects of Lonomia obliqua venom components on human endometrial stromal cells: A potential source for new cytoprotective biomolecules against recurrent pregnancy loss

Study question

Could new molecules like Lonomia obliqua lipocalins and hemolins have cytoprotective effects on endometrial stem cells (hESC)?

Summary answer

Lonomia obliqua venom-induced hESC viability, proliferation and migration occurred mainly by protection against oxidative damage and ERK-dependent pathway activation

What is known already

Recurrent pregnancy loss (RPL) is associated with severe physical and psychological morbidity, for which there is no treatment options. The pathophysiology involves deficiency in proliferation and migration capacities of endometrial stromal cells (hESCs) impairing embryo implantation and development. Animal venoms are rich sources of bioactive molecules and despite its known toxic effects, they also have protective components such as pro-proliferative molecules, growth factor-like, anti-apoptotic and anti-oxidant.

Study design, size, duration

This study was an experimental in vitro with endometrial stem cells. Treatment duration was 8–72h. Every assay had control cells exposed to phosphate buffered saline (PBS).

Participants/materials, setting, methods

hESCs were isolated from fresh human endometrial biopsies and characterized according standard protocols. Then the effects of L. obliqua venomous secretions on cell viability, proliferation and migration were determined using MTT, wound-healing assay, sulforhodamine B (SRB) assay and measuring the immunocontent of Ki67. Venom components involved in cell enhancing effects were also identified by classical chromatographic methods and proteomic analysis. Assays were conducted in triplicate.

Main results and the role of chance

The hESCs in culture showed adhesiveness properties, presented a fusiform fibroblastoid morphology and ability to in vitro differentiate into adipocytes, osteocytes and chondrocytes. The expression of cell surface markers was also characterized by flow cytometry. hESCs were positive for mesenchymal markers (CD105, CD90 and CD73) and negative for hematopoietic markers (CD45 and CD11), indicating that isolated cells have potential for multilineage differentiation. L. obliqua bristle extract (LOBE) increased dose-dependently hESCs viability in a concentration range varying from 0.001 to 0.1 µg/mL, independently of the cell isolation bath. For some cell isolates (patient ID 1, 3, 4, 6 and 7) it was observed a slightly reduction in hESC viability at highest LOBE concentrations (10 µg/mL). Treatment increased hESC viability in the presence of low concentrations of fetal bovine serum (1% FBS) and even in its complete absence. This effect was long lasting, being significant up to 72 h of incubation with LOBE in serum deprivation conditions. r to identify the potential molecules involved in the cytoprotective action, a mass spectrometry-based proteomic analysis was performed. It was identified a total number of 430 proteins in LOBE and 312 proteins in L. obliqua hemolymph.

Limitations, reasons for caution

This study was only conducted in vitro.

Wider implications of the findings: In this work we reported the identification of at least six protein classes with cytoprotective properties through proteomic analysis and isolated one fraction enriched in this cytoprotective factors. L. obliqua secretions induced increase in hESCs viability, proliferation and migration mainly by the protection against oxidative damage and ERK-dependent pathway activation.

Trial registration number

Not applicable