Dental services market in Poland and its impact on the health decisions of patients and doctors

AIM

The aim of the paper is to verify the impact of the current dental services market in Poland on the society decisions regarding dental treatment as well as to assess the differences in the valuation of commercial and public dental services.

METHODS

Study Design: In the first step 1,444 subjects including children, adults and elderly were subjected to a questionnaire survey to characterise them in terms of sex, age, place of residence and level of education, type of dental treatment used including services privately funded and reimbursed by the National Health Fund and the reasons of his/her decisions. In the second step we compared the results of the survey to the average price of commercial and reimbursed procedures to verified a possible correlations between them. The research tool was a questionnaire survey by the author. The questionnaires were distributed among randomly selected kindergartens, schools, workplaces, senior clubs, social care homes and random passers-by in the streets. Average prices of dental procedures were based on price lists of 12 commercial offices and National Health Fund's contract conditions for the reimbursed services.

CONCLUSION

Regardless of the age, Poles are far more likely to use private dental care. The level of education affects the form of financing of the dental treatment of children. There is a large disproportion between the revenues of private and public dental offices providing the same dental services.

Impact of the COVID-19 Pandemic on Pulmonary Hypertension Patients: Insights from the BNP-PL National Database

We aimed to evaluate the clinical course and impact of the SARS-CoV-2 pandemic on the rate of diagnosis and therapy in the complete Polish population of patients (pts) with pulmonary arterial hypertension (PAH-1134) and CTEPH (570 pts) treated within the National Health Fund program and reported in the national BNP-PL database. Updated records of 1704 BNP-PL pts collected between March and December 2020 were analyzed with regard to incidence, clinical course and mortality associated with COVID-19. Clinical characteristics of the infected pts and COVID-19 decedents were analyzed. The rates of new diagnoses and treatment intensification in this period were studied and collated to the proper intervals of the previous year. The incidence of COVID-19 was 3.8% (n = 65) (PAH, 4.1%; CTEPH, 3.2%). COVID-19-related mortality was 28% (18/65 pts). Those who died were substantially older and had a more advanced functional WHO class and more cardiovascular comorbidities (comorbidity score, 4.0 ± 2.1 vs. 2.7 ± 1.8; p = 0.01). During the pandemic, annualized new diagnoses of PH diminished by 25–30% as compared to 2019. A relevant increase in total mortality was also observed among the PH pts (9.7% vs. 5.9% pre-pandemic, p = 0.006), whereas escalation of specific PAH/CTEPH therapies occurred less frequently (14.7% vs. 21.6% pre-pandemic). The COVID-19 pandemic has affected the diagnosis and treatment of PH by decreasing the number of new diagnoses, escalating therapy and enhancing overall mortality. Pulmonary hypertension is a risk factor for worsened course of COVID-19 and elevated mortality.

A256 SURVEILLANCE OF SMALL, NON-FUNCTIONING, ASYMPTOMATIC PANCREATIC NEUROENDOCRINE TUMORS: THE BRITISH COLUMBIA EXPERIENCE

Background

Expert consensus surrounding surveillance for small, non-functioning, asymptomatic pancreatic neuroendocrine tumors (PNETs) remains conflicting. Recent observational studies have shown that surveillance is a safe strategy while large database studies show superior overall survival with surgical resection.

Aims

To describe the growth of small (<2cm), non-functioning, asymptomatic PNETs undergoing surveillance at a tertiary hospital in British Columbia.

Methods

We conducted a retrospective case series of patients with biopsy-proven, non-functioning, asymptomatic PNETs which were <2cm by RECIST criteria at diagnosis, who were followed through active surveillance at Vancouver General Hospital, British Columbia from February 1, 2011-February 1, 2021. Patients were included if serial imaging, whether by endoscopic ultrasound or cross-sectional imaging, was available for a minimum of 24 months.

Results

Of the 57 patients with pathology-proven PNETs that were identified, 14 cases were included after excluding those with resection within 1 year (n=17), lost to follow up (n=13), metastatic disease (n=6), size greater than 2cm at diagnosis (n=4), and with concurrent cancer (n=3). Included patients were predominantly female (n=10, 71%), Caucasian (n=8, 57%), and had a mean Charlson comorbidity index of 3.14. Mean PNET size at diagnosis was 12mm with standard deviation of 4.26mm. Tumors were located in the pancreatic head (n=4, 29%), body (n=6, 42%), and tail (n=4, 29%). Of 8 patients who had Ki67 stains, all were <3%, and of 11 patients with mitotic index, all had <2 mitotic figures. As such, of the 8 patients with available WHO grading, all were grade 1. The average follow-up was 49.6 months with an average tumor growth of 0.82mm per year. When grouping these tumors by growth, 9 (62%) tumors exhibited no growth, 2 tumors grew <1mm per year, 2 tumors grew 1-1.5mm per year, and 1 tumor grew 7.7mm per year. Two cases (14%) of PNETs underwent surgical resection due to size surpassing 2 cm. No patients undergoing surveillance developed metastatic disease.

Conclusions

To our knowledge, we have performed the first Canadian series of small, low-grade PNETS and demonstrated that active surveillance is a safe strategy with most tumors exhibiting no growth of several years. Of the subset of PNETs which demonstrate progression, the preceding surveillance strategy did not disadvantage patients in terms of progression to metastases and allowed for delay of potentially morbid surgery. Further research with prospective studies and larger samples should be conducted.

Funding Agencies

CAG

A126 ONCE IS BY CHANCE, TWO IS A TREND: A RECURRING FINDING WITHIN THE POST-RESECTION DEFECT

Background

A 74-year-old male was referred for the management of a large non-pedunculated colorectal polyp in the transverse colon. On optical evaluation, including high-definition white-light and narrow-band imaging (NBI), a 30mm 0-IIA non-granular large non-pedunculated colorectal polyps (LNPCP) was identified with optical features in keeping with adenomatous histopathology (NBI International Colorectal Endoscopic II, Japan NBI Expert Team IIA, Kudo Pit Pattern III/IV). Endoscopic mucosal resection (EMR) was performed. During sequential tissue transection and evaluation of the expanding submucosal defect a hole with a surrounding white-cautery ring was identified in keeping with significant deep mural injury. However, on careful evaluation a cystic structure was identified with a viscous amorphous substance emanating from it. Endoscopic resection of the lesion was completed with subsequent through-the-scope mechanical clip closure of the area of concern.

Aims

case report showing unique finding of intra-cellular mucin emanating from the post-resection defect has been identified as a potential intra-procedural finding of a mucinous adenocarcinoma

Methods

Endoscopic mucosal resection of a mid transverse colon polyp

Results

Histopathology identified a villous adenoma with high-grade dysplasia with submucosal mucin and an indeterminate focus of carcinoma; highly suspicious for a mucinous adenocarcinoma. No muscularis propria was identified. After multi-disciplinary review, the patient underwent laparoscopic right hemicolectomy with no evidence of invasive disease.

Conclusions

Recently coined as the “fish-eye” polypectomy defect, intra-cellular mucin emanating from the post-resection defect has been identified as a potential intra-procedural finding of a mucinous adenocarcinoma; specifically, in an otherwise benign appearing LNPCP based on real-time optical evaluation. Herein we describe the second case in the literature. This reinforces the importance of meticulous evaluation of the post-resection defect to stratify this finding from deep mural injury. Moreover, further understanding of the clinical ramifications of this unique intra-procedural finding is needed.

Funding Agencies

None

A90 WHEN DO TRAINEES ACHIEVE COMPETENCY IN PERFORMING ENDOSCOPIC SUBMUCOSAL DISSECTION: A SYSTEMATIC REVIEW

Background

Endoscopic submucosal dissection (ESD) is an established organ sparing curative endoscopic resection technique for the management of pre-malignant and superficially invasive malignant lesions of the gastrointestinal tract. However, little is understood of its learning curve with suggested competency measures including en bloc resection, R0 resection, adverse events and resection speed.

Aims

We aimed to perform a systematic review on when competency is achieved in ESD.

Methods

Two authors independently searched MEDLINE and EMBASE (1946 to Aug 2021) for full-text original citations including grey literature assessing the ESD learning curve. A learning curve was defined as an assessment of competency as a function of increasing trainee experience. Thresholds for competency were defined as en bloc resection ≥ 80%, R0 resection ≥ 80%, perforation rate ≤ 5% and resection speed ≤ 6.67min/cm².

Results

Forty-three studies (1 esophageal, 11 gastric, 27 colorectum, 4 multiple sites) with 157 trainees and 8780 ESD procedures were included. Baseline experience in esophagogastroduodenoscopy, colonoscopy, endoscopic mucosal resection and ESD were 800–10,000, 100–10,000, 4–700 and 0–300 procedures, respectively. 16 studies used animal model training prior to assessing the ESD learning curve.

En bloc resection, R0 resection, perforation rate and resection speed were used as markers of competency in 33, 29, 28 and 21 studies, respectively. When pooling evaluations where competency was achieved, it was reached in the esophagus, stomach, colorectum and for multiple sites between <10, <10–150, <10–301, and <20–300 procedures, respectively (Table 1). However, competency in R0 resection, perforation rate, and resection speed was not uniformly achieved within 12 studies.

Conclusions

Competency in ESD can be achieved in <10 - 399 procedures, with variability dependent on organ site and baseline level of training. With the widespread adoption of ESD, standardization of training and the assessment of competency are needed.

Funding Agencies

None

Standard clinical computed tomography fails to precisely visualise presence, course and branching points of deep cerebral perforators

BACKGROUND

Standard computed tomography (CT) images have earned a well-established position in neuroimaging. Despite that, CT is somehow limited by its resolution, which does not enable to distinctively visualise structures smaller than 300 μm in diameter. Perforating arteries, most of which measure 100-400 μm in diameter, supply important subcortical structures (thalamus, basal ganglia, internal capsule). Consequently, pathologies affecting these vessels (e.g. lacunar strokes) can have a devastating clinical outcome. The aim of our study was to assess standard CT's ability to visualise perforators and compare it with microscopic and micro-CT pictures.

MATERIALS AND METHODS

We have obtained 6 brainstem and 17 basal ganglia specimens. We infused them with barium sulphate contrast medium administered into either vertebral or internal cerebral artery. After that, the specimens were fixed in formalin and subsequently a series of CT, micro-CT and microscopic examinations were performed.

RESULTS

The median number of visualised perforators in brainstem and basal ganglia specimens was 8 and 3, respectively for CT and 18 and 7 for micro-CT (p < 0.05). Standard CT failed to clearly visualise branching points and vessels smaller than 0.25-0.5 mm (1-2 voxels) in diameter. Parallel vessels, like lenticulostriate arteries could not be differentiated in standard CT due to their proximity being smaller that the resolution.

CONCLUSIONS

Basing on our results, we infer that CT is a poor modality for imaging of the perforators, presenting both quantitative and qualitative flaws in contrast with micro-CT.

A88 PATIENT AND PHYSICIAN PERSPECTIVE OF TELE-HEALTH IN GASTROENTEROLOGY

Background

Given the social distancing measures employed to reduce the transmission of SARS-CoV-2, tele-health has rapidly expanded and is now routinely used in new patient encounters and in follow up appointments across Canada.

Aims

To determine the patient and physician perspective towards tele-health in a gastroenterology outpatient setting.

Methods

An anonymous voluntary online survey was distributed to patients who had previously undergone at least one tele-health visit in a tertiary care gastroenterology outpatient setting. A separate online survey was distributed to gastroenterologists practising across Canada.

Results

A total of 181 patients from British Columbia (59.8% female) completed the survey. The tele-health appointment was the first visit for 21.8% of patients. Appointments occurred by phone call alone (61.4%) or by video and audio software (38.6%) and started within 5 minutes of the scheduled time in 75% of visits. Patient satisfaction with the tele-health visit was high (8.54 on a scale of 0–10; 0 completely dissatisfied, 10 extremely satisfied; IQR 8–10). Most patients did not perceive a difference in likelihood of compliance compared to a non-tele-health visit (90.6%), were not concerned about the lack of physical exam during a tele-health visit (82.4%) and did not with-hold information they would have revealed in person (88.7%). After the COVID-19 pandemic, some patients would prefer tele-heath visits (39.2%), whereas others would prefer in office visits (28.5%) and the remainder were indifferent (32.3%). Post-pandemic, most patients would prefer tele-health for follow up visits (68.4%), over tele-health for all possible visits (27.9%) or no tele-health visits (3.8%).

A total of 25 Canadian gastroenterologists (28.0% female; 60% academic practice, 40% community practice) completed a separate survey. Regarding the lack of physical exam in tele-health, 44% of physicians believed this did not affect the quality of their assessment, whereas some physicians believed it had either minimally (48%) or greatly (8%) impaired the quality of their assessment. Almost all physicians (96%) perceived that patients either appreciate tele-health as much as or more than in office visits.

Post-pandemic, most physicians (96%) supported a hybrid model of both tele-health and in office visits. Appointments for follow up of benign endoscopic pathology results (96%), follow up visits (92%), consultations prior to endoscopy (76%) were deemed to be most appropriate for tele-health. Follow up of malignant pathology results (24%) and consultations for new patients (32%) were thought to be less appropriate for tele-health visits.

Conclusions

Patient and physician satisfaction with tele-health in a Canadian outpatient gastroenterology setting is high. Most patients and physicians wish for tele-health to remain available in the post-pandemic setting.

Funding Agencies

Gastrointestinal Research Institute, Vancouver, British Columbia

A83 IMPACT OF TELEHEALTH ON MEDICATION ADHERENCE IN GASTROENTEROLOGY CHRONIC DISEASE MANAGEMENT

Background

With the COVID-19 pandemic, the demand and availability of telehealth in outpatient care has increased. Although use of telehealth has been studied and validated for various medical specialties, relatively few studies have looked at its role in gastroenterology despite burden of chronic diseases such as inflammatory bowel disease (IBD).

Aims

To assess effectiveness of telehealth medicine in gastroenterology by comparing medication adherence rate for patients seen with telehealth and traditional in-person appointment for various GI conditions.

Methods

Retrospective chart analysis of patients seen in outpatient gastroenterology clinic was performed to identify patients who were given prescription to fill either through telehealth or in-person appointment. By using provincial pharmacy database, we determined the prescription fill rate.

Results

A total of 241 patients were identified who were provided prescriptions during visit with their gastroenterologists. 128 patients were seen through in-person visit during pre-pandemic period. 113 patients were seen through telehealth appointment during COVID pandemic.

The mean age of patients in telehealth cohort was 42 years (57% male). On average patients had 10 prior visits with their gastroenterologists before index appointment, used for adherence assessment. 92% of patients were seen in follow-up, while 8% were seen in initial consultation. The majority of the patients in the telehealth cohort had IBD (89%), while the remaining 11% had various diagnoses, including functional GI disorder, gastroesophageal reflux disease, viral hepatitis, or hepatobiliary disorders. Biologic therapy was the most commonly prescribed medication (66.4%). 45 patients were provided either new medication or dose change, and 68 patients had prescription refill to continue their current medications. It took a mean of 18 days (SD = 16.2) for patients to fill their prescriptions.

Prescription fill rate for patients seen through telehealth and in-person visit were 98.2% and 89.1% (P = 0.004) respectively. Patients seen through telehealth were 6.8 times more likely to fill their prescriptions compared to the in-person counterparts (OR 6.82, CI 1.51 – 30.68, P = 0.004). When we compared adherence rate while excluding biologic therapies, the prescription fill rate was 94.7% in telehealth group and 81.4% in in-person group (OR 4.11, CI 0.88 – 19.27, P = 0.056). Due to high level of adherence, statistical analysis comparing adherent and non-adherent groups was performed but yielded insignificant results.

Conclusions

Medication adherence rate for patients seen through telehealth was higher compared to patients seen through in-patient visit in this study. Telehealth is a viable alternative for outpatient care especially for patients with chronic GI conditions such as IBD.

Funding Agencies

None

Targeting of Evolutionarily Acquired Cancer Cell Phenotype by Exploiting pHi-Metabolic Vulnerabilities

Evolutionary dynamics can be used to control cancers when a cure is not clinically considered to be achievable. Understanding Darwinian intratumoral interactions of microenvironmental selection forces can be used to steer tumor progression towards a less invasive trajectory. Here, we approach intratumoral heterogeneity and evolution as a dynamic interaction among subpopulations through the application of small, but selective biological forces such as intracellular pH (pHi) and/or extracellular pH (pHe) vulnerabilities. Increased glycolysis is a prominent phenotype of cancer cells under hypoxia or normoxia (Warburg effect). Glycolysis leads to an important aspect of cancer metabolism: reduced pHe and higher pHi. We recently showed that decreasing pHi and targeting pHi sensitive enzymes can reverse the Warburg effect (WE) phenotype and inhibit tumor progression. Herein, we used diclofenac (DIC) repurposed to control MCT activity, and Koningic acid (KA) that is a GAPDH partial inhibitor, and observed that we can control the subpopulation of cancer cells with WE phenotype within a tumor in favor of a less aggressive phenotype without a WE to control progression and metastasis. In a 3D spheroid co-cultures, we showed that our strategy can control the growth of more aggressive MDA-MB-231 cells, while sparing the less aggressive MCF7 cells. In an animal model, we show that our approach can reduce tumor growth and metastasis. We thus propose that evolutionary dynamics can be used to control tumor cells' clonal or sub-clonal populations in favor of slower growth and less damage to patients. We propose that this can result in cancer control for tumors where cure is not an option.

Unusual formation of the musculocutaneous and median nerves: a case report refined by intraneural dissection and literature review

This report presents a detailed anatomical investigation of an upper limb specimen showing an atypical formation of the musculocutaneous (MCN) and median (MN) nerves. The study was refined by intraneural dissection, which supplements earlier descriptions of similar anatomical variations and allows for revision of the accepted classification. The case described in this report was an incidental finding during routine dissection of a fixed isolated upper limb. Intraneural dissection revealed partial fusion between the MCN and aberrant bundles of the MN. Those aberrant bundles joined the main steam of the MN at the level at which the MCN branched off as an independent nerve. The procedure allowed the aberrant fibers of the MN to be differentiated from the MCN. The presence of separate bundles in a territory corresponding to the MCN was confirmed, although those bundles and the aberrant MN bundles were covered by a common epineurium. The aberrant MN bundles running within the MCN did not contribute to innervation of the forearm muscles. They rejoined the main nerve trunk in the arm. A comprehensive understanding of the diverse anatomical variations of the upper limb nerves could be crucial for the safety and success of surgical procedures, especially procedures for reconstructing the brachial plexus or its branches.

Co-registration of optoacoustic tomography and magnetic resonance imaging data from murine tumour models

As optoacoustic tomography (OT) emerges as a mainstream pre-clinical imaging modality, understanding the relationship between optoacoustic and other imaging biomarkers in the context of the underlying tissue biology becomes vitally important. Complementary insight into tumour vasculature and hypoxia can be gained using OT alongside magnetic resonance imaging (MRI)-based techniques. To evaluate the relationship between these metrics and the relative performance of the two modalities in assessment of tumour physiology, co-registration of their output imaging data is required. Unfortunately, this poses a significant challenge due to differences in animal positioning during imaging. Here, we present an integrated framework for registration of OT and MR image data in mice. Our framework combines a novel MR animal holder, to improve animal positioning during imaging, and a landmark-based software co-registration algorithm. We demonstrate that our protocol significantly improves registration of both body and tumour contours between these modalities, enabling more precise multi-modal tumour characterisation.

A137 COLONOSCOPY RELATED ADVERSE EVENTS IN A POPULATION-BASED COLON SCREENING PROGRAM

Background

The British Columbia Colon Screening Program (BCCSP) is a population-based program enrolling 50–74 year old individuals for biennial FIT (OC-Sensor, cut-off 10 mcg/g) with follow-up colonoscopy for positive FIT. The neoplasia detection rate is 50–55% and over 75% of colonoscopies have a specimen taken. Previously reported colonoscopy adverse event rates for FIT based screening programs vary widely: 0.03–6.2% and 0–2.7% for bleeding and perforation, respectively. Mortality as a result of colonoscopy is rare but has been reported in 0.0004%-0.0074% of colonoscopies. The rate of colonoscopy related adverse events in BCCSP participants is unknown.

Aims

To determine the rate of colonoscopy related serious adverse events within the BCCSP.

Methods

This is a retrospective cohort study of all participants undergoing colonoscopy in BCCSP from November 15, 2013 to December 31, 2017. BCCSP contacts screening participants by phone 14 days post colonoscopy to determine unplanned medical visits the day prior (during bowel preparation) or following the colonoscopy. Unplanned events underwent chart review if the event was a perforation, cardiovascular or respiratory event, or resulted in death, hospitalization, or significant intervention including repeat colonoscopy, interventional radiology, surgery, blood transfusion, cardioversion, casting of a fracture or suturing of a laceration. Chart review was conducted by a Colonoscopy Lead and reviewed by BCCSP Quality Committee. Unplanned events were defined as serious adverse events (SAE) if they resulted in death, hospitalization or significant intervention and further classified as probably, possibly, or unlikely related to the colonoscopy.

Results

A total of 108,004 colonoscopies were performed. Unplanned events were reported in 1753 participants, of which 586 met criteria for review. Of these, 578 were confirmed unplanned events and 409 were SAEs of which 367 (89.7%) were probably, 22 (5.4%) possibly and 20 (4.9%) unlikely associated with colonoscopy. 36/10,000 colonoscopies were associated with a SAE that was probably or possibly related: perforation in 5/10,000, bleeding 22/10,000. Three deaths occurred in the 14 days following colonoscopy that were probably (2 perforations) or possibly related to the colonoscopy (0.3/10,000).

Conclusions

The BCCSP has a colonoscopy SAE rate in keeping with previous publications, particularly in the context of a very high proportion of procedures associated with polypectomy, a known risk factor for perforation and bleeding. This study will help inform screening participants about the risks of colonoscopy in the BC program. Future studies are required to confirm these rates using hospital admission data.

Funding Agencies

None

A276 TOTAL PANCREATIC LIPOMATOSIS AND EXOCRINE PANCREATIC INSUFFICIENCY IN A PATIENT WITH CELIAC DISEASE: AN UNUSUAL ENTITY

Background

Exocrine pancreatic insufficiency (EPI) is characterized by maldigestion and malabsorption of nutrients and is most commonly caused by diseases of the pancreatic parenchyma including chronic pancreatitis and cystic fibrosis (CF). However, EPI is also observed in other conditions including celiac disease (CD).

Aims

We report a case of EPI in a patient with CD found to have total fatty replacement of the pancreas.

Methods

A case report and review of the literature were performed.

Results

Case Report:

A 42-year-old man with CD on gluten-free diet (GFD) presented with a two-year history of increasing bowel frequency (4–6 times daily) and steatorrhea. Quantitative fecal fat over 72 hours confirmed fecal fat excretion of 101g/day; N &lt; 7g) and total stool weight of 3761g. Nadir weight was 67.6 kg. There was a dramatic response to pancreatic enzyme replacement therapy (PERT) with marked improvement in bowel habits and weight gain to 74.8 kg over half a year. There is no history of pancreatitis, abdominal pain or alcohol abuse. He does not smoke but drinks 1–2 units of alcohol per week at most. Family history is negative for pancreatitis and pancreatic malignancy. On examination, following PERT, the patient appeared well-developed and nourished. He did not have clinical features or biochemical evidence of fat-soluble vitamin deficiency following PERT.

Anti-tTG was equivocal (7.6 U/mL; N &lt; 7 U/mL). IgG subclasses were normal. Chromogranin was mildly elevated (100mcg/L; N &lt; 94mcg/L), but gastrin (15ng/L) and 24-hour urine for 5-hydroxyindoleacetate [5-HIAA] (23umol/d) were normal. Endoscopic evaluations including upper endoscopy, colonoscopy, and capsule endoscopy demonstrated intact duodenal villous architecture without inflammation, no microscopic colitis, and no small bowel mucosal disease, respectively.

CT of the abdomen revealed total fatty replacement of the pancreas with no pancreatic parenchyma (Figure 1). Sweat sodium test was positive (67 mmol/L, N &lt; 60 mmol/L) but CFTR gene sequencing was negative. There was no evidence of diabetes, hyperlipidemia, hyperferritinemia, Cushing’s syndrome, or hepatic disease on biochemical investigations.

Literature Review:

Total pancreatic lipomatosis (TPL), or fatty replacement of the pancreas, is a rare cause of EPI which leads to maldigestion, malabsorption, and malnutrition. The pathogenesis of TPL is poorly understood but predisposing factors include obesity, diabetes mellitus, hyperlipidemia, malnutrition, Cushing’s syndrome, hemochromatosis, chronic pancreatitis and CF. EPI can also manifest in patients with CD due to active small bowel inflammation or chronic pancreatitis. Last but not least, there appears to be higher prevalence of CD in CF patients.

Conclusions

Persistent steatorrhea with weight loss despite GFD in patients with CD should prompt other considerations of EPI and trial of PERT.

Funding Agencies

None

A174 RARE BUT DEADLY: AN APPROACH TO MANAGEMENT OF DUODENAL VARICEAL HEMORRHAGE

Background

Common etiologies of upper gastrointestinal bleeding (UGIB) in cirrhotic patients with portal hypertension include gastroesophageal varices (GOV), portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE). Less commonly, patients with portal hypertension develop varices in ectopic sites, including the rectum, biliary tree and duodenum. Ectopic varices are rare, contributing to 1–5% of all variceal bleeding, of which 17% is from duodenal varices.

Aims

To describe the management of duodenal variceal hemorrhage.

Methods

A case report and literature review was performed.

Results

Case report:

We present a case of recurrent UGIB in a 59-year-old male with decompensated cirrhosis due to non-alcoholic steatohepatitis (CP-C; Meld 14). Initial endoscopy was negative for GOV, peptic ulcer, PHG, and GAVE, but an erosion over a mucosal bulge in the third segment of the duodenum was identified, raising possibility of vascular malformation versus ectopic varix. There was active bleeding after water provocation, so clips were deployed for hemostasis. CT imaging showed mesenteric venous collaterals abutting the duodenum, again raising possibility of duodenal varix, which was ultimately confirmed by endoscopic ultrasound (EUS). Patient had recurrent overt bleeding despite beta-blockage for prophylaxis, endoscopic clipping on four separate occasions, attempted angioembolization by interventional radiology, and cyanoacrylate glue. Transjugular intrahepatic porto-systemic shunt (TIPS) was not possible due to portal vein occlusion, so he underwent EUS-guided cyanoacrylate glue a second time.

Literature review:

Ectopic varices are rare, contributing to 1–5% of all variceal bleeding, of which 17% is from duodenal varices. Duodenal variceal hemorrhage can lead to hemorrhagic shock, and is potentially life threatening, with quoted mortality rates of 40%. Unfortunately, duodenal varices can be difficult to identify. Diagnosis is often delayed due to a combination of lower awareness and endoscopic challenges given the unusual serosal and submucosal location.

Evidence-based guidelines for the management of ectopic varices are limited. For this reason, our current management strategies rely heavily on local expertise. Splanchnic vasoconstrictor medication, endoscopic ligation, EUS guided gluing, interventional radiology guided embolization, TIPS, balloon retrograde transvenous obliteration and surgical shunts are potential therapeutic options to manage the acutely bleeding varix. Following a variceal bleed, liver transplantation should be considered in eligible patients with no other contraindications.

Conclusions

Duodenal varices are a rare, potentially fatal, and underrecognized cause of gastrointestinal bleeding in patients with portal hypertension. Definitive therapy currently relies upon local expertise in the absence of clear guideline-based therapy.

Funding Agencies

None

A186 HEPATIC STEATOSIS PREDICTS FIBROSIS IN LONG-TERM METHOTREXATE USE

Background

Methotrexate (MTX) is effective for dermatologic and rheumatologic conditions such as psoriasis (Ps), psoriatic arthritis (PsO) and rheumatoid arthritis (RA). Long-term MTX use may be complicated by hepatic fibrosis, although patient, disease factors and the mechanism remain unclear. Transient elastography (TE) is a non-invasive measure of hepatic fibrosis that is often used as surveillance in this patient population.

Patients with Ps and PsO have higher rates of non-alcoholic fatty liver disease. The controlled attenuation parameter (CAP) measurement is a non-invasive test that correlates with histologic degree of steatosis. To our knowledge, no studies have evaluated hepatic steatosis via CAP scores in MTX use.

Aims

To determine the prevalence of steatosis and significant fibrosis (F≥stage 2) in persons on MTX therapy and to determine the predictive factors for these events.

Methods

A single centred retrospective cohort study was performed. Patients on &gt;6 months of MTX for a dermatologic or rheumatologic disease who had undergone TE from January 2015 to September 2019 were included. Demographic variables, laboratory investigations, TE and CAP scores were collected. Multivariate analysis was performed to determine predictors of steatosis and fibrosis.

Results

A total of 177 patients on methotrexate were included. Ps was the most frequent diagnosis (n=52) followed by RA (n=50) and PsO (n=38). Steatosis (CAP≥245 dB/m) was present in 73.9% of patients. Patients with steatosis had significantly more fibrosis and a higher BMI than those without steatosis (CAP&lt;245 dB/m). Higher CAP score was correlated with increased lifetime dose of methotrexate by Pearson correlation analysis (r=0.48, p=0.001) (n=85 patients). Multivariate regression analysis revealed that diabetes mellitus (OR 10.5, 95% CI 1.38–80.60), hypertension (OR 4.97, 95% CI 1.66–14.84), and BMI&gt; 30 (OR 10.1, 95% CI 1.88–37.14) were predictors of steatosis (CAP≥245 dB/m). Predictors of METAVIR≥F2 (TE≥8.0 kPa) by multivariate regression analysis included CAP score of ≥270 (OR 8.36, 95% CI 1.88–37.14), diabetes mellitus (OR 2.85, 95% CI 1.09–7.48), hypertension (OR 5.4, 95% CI 2.23–13.0), dyslipidemia (OR 3.71, 95% CI 1.50–9.18) and alcohol use (OR 3.06, 95% CI 1.2–7.49).

Conclusions

In patients on MTX for rheumatologic and dermatologic diseases, hepatic steatosis was common and predicted significant fibrosis. Additionally, increasing MTX exposure is correlated with steatosis. Features of the metabolic syndrome including diabetes, hypertension or obesity were predictors of both steatosis and fibrosis (F≥2). Further study is needed to evaluate if steatosis is a mechanism by which fibrosis occurs in patients on MTX, or if it due to other patient factors.

Funding Agencies

None

P855 Extensive right heart endocarditis in the past

Physical examination

significantly enlarged liver, pulsation of jugular veins and numerous scars in the pits elbow.

ECG

sinus rhythm 85 / min. Right axis deviation. LPH. Hypertrophy of the right atrium. QS in V1-V4.

Transthoracic and Transesophageal Echocardiography (TTE,TEE) EF 64%, a significant increase in a right heart chambers (RVDD 4.1 cm, severe tricuspid regurgitation with completely disappearing of tricuspid valve ( only part of septal leaflet was present, which was a consequence of pressure equalization between the right atrium and the right ventricle). In addition, it revealed the structure connected with the pulmonary valve leaflet and moving between the right ventricular outflow tract and pulmonary trunk (most probably healed vegetation, 1.2 x 0.5 cm ).

Computed tomography (CT) confirmed the significant enlargement of right heart chambers (EDV 335 ml, ESV 143 ml, SV 192 ml, EF ∼ 58%) with displacement of interatrial septum to the left and the flattening of the interventricular septum . Complete destruction of the tricuspid valve leaflets, with the remaining residual part of septal leaflet was observed. The pulmonary valve was connected mobile irregular structure 2,5 cm x 0,5 cm.

Laboratory tests revealed a history of cytomegalovirus infection (p / body IgG&gt; 500,000U / ml). Other tests (HIV, hepatitis B, reaction W-R) - were negative. There was no laboratory and clinical signs of active infection at present.

Patient demanded to be discharged from the hospital and refused operation.

DISCUSSION

Echocardiography did not confirm diagnosis of pulmonary hypertension. D-dimer values of 396 ng / ml (normal &lt;500 ng / ml) excluded suspicion of pulmonary embolism. Left ventricular ejection fraction was normal (EF ∼ 64%), BNP reached the value of 153 pg / ml (normal 0-100pg / ml).

This case deserves attention because it documents severe right heart endocarditis by the person using drugs intravenously with an extremely rare takeover of both right heart valves and septic pulmonary embolism. Despite such a large morphological change in the heart of a patient remains in a relatively good clinical condition (NYHA class II/ III). The observed structure of the pulmonary trunk should be considered as healed vegetation. In the absence of consent to the surgery the patient is still treated pharmacologically.

Abstract P855 Figure. Pic.1

113 Echocardiographic assessment of right ventricular outflow tract obstruction in hypertrophic cardiomyopathy - efficacy of dual chamber pacing in reducing of gradient

Hypertrophy of the right ventricle (RV) in the course of hypertrophic cardiomyopathy (HCM) is found in 30-60% of cases, with the possibility of a right ventricular outflow tract obstruction (RVOTO), obstruction in the apex or the middle part of the right ventricle.

A patient, aged 41, admitted due to limitation of exercise tolerance, effort dyspnea, presyncope. In an echocardiogram, interventricular septum (IVS) hypertrophy was observed up to 2.0 cm; normal size of the heart cavities; normal left ventricular systolic function (EF-70%). A color doppler mapping detected the zone of flow acceleraction and turbulent flow in right ventricular outflow tract (RVOT), next a spectral doppler examination showed the RVOT obstruction with a maximal gradient of 64 mmHg. Because of the suboptimal echocardiographic imaging, a heart CT scan was performed, revealing the features of left ventricular hypertrophy, most severe at the base and the medium part of IVS (up to 25 mm). Asymmetric hypertrophy of the middle portion of the right ventricle and right ventricular outflow tract obstruction was also observed. A hemodynamic study confirmed the presence of gradient in RVOT, up to 40 mmHg. Holter electrocardiogram recorded an episode of non-sustained ventricular tachycardia. Taking into account the clinical picture, the family history of the disease, and calculated HCM Risk SCD (7.55%), the decision was made to implant a dual chamber cardioverter defibrillator. The defibrillator electrode was fixed at the apex of the right ventricle. A short AV delay was programmed for prevalent right ventricular stimulation (AV delay 100 ms), resulting in 99.6% ventricular stimulation. The control echocardiogram showed a reduction in the maximum gradient in RVOT to 24 mmHg. In addition, the patient was treated with a beta-blocker.

To sum up, in the case of HCM we should always examine the RV with color and spectral doppler to exclude potential narrowing in RV.

Constant AV sequential stimulation with a short AV delay is a recognized method that can be considered in symptomatic adult HCM patients with a left ventricular outflow tract obstruction. In the case described here, the above mentioned method proved effective in the significant reduction of the gradient in the right ventricular outflow tract.

Abstract 113 Figure. gradient in RVOT

1424The diagnosis of non-adherence in hypertension using a urine biochemical screen is unaffected by drug pharmacokinetics

Introduction

Suboptimal drug adherence in hypertension is pandemic and traditional diagnostic tools to detect non-adherence have lacked accuracy and robustness. The inability to identify non-adherence has therefore driven the development of biochemical drug screening by liquid chromatography tandem mass spectrometry (LC- MS/MS) in urine and blood, which are the most accurate metrics presently available. Urinary antihypertensive testing is evidenced to improve non-adherence rates, significantly decrease blood pressure after physician intervention, and be cost effective. The European Society of Cardiology (ESC) and European Society of Hypertension (ESH) 2018 guidelines have recommended the use of biochemical testing for non-adherence diagnosis. However, it has been argued that the variable pharmacokinetic parameters of the medication (such as their half-lives and clearance rates) may affect the detection of medications in urine and hence the determination of adherence. We hypothesized that pharmacokinetic parameters do not affect the detection of antihypertensive medications in urine.

Aim

This study compared the pharmacokinetic parameters of the most commonly prescribed antihypertensive medications against their detection in urine by LC-MS/MS.

Methods

Results of urinary drug screens from 463 hypertensive patients (total prescribed medications N=1709) were collated. An adherence score termed as the C score (number of detected vs. prescribed medication) was generated for each of the 27 common antihypertensive medications. Pharmacokinetic parameters such as bioavailability, plasma concentration, volume of distribution, half-life, plasma clearance and urinary excretion values for each drug were obtained from published literature. Partial linear correlation was conducted between the C score of all the medications and each pharmacokinetic parameter studied.

Results

40% of patients were non-adherent. The average number of prescribed medications was high (N=3.7, SD: 1.5), and the average number of drugs detected was lower (N=2.5, SD: 1.6). Amlodipine was the most prescribed (N=224), and clonidine was the least (N=10). The half-lives ranged from 0.87 to 39 hours for bumetanide and amlodipine respectively. The urinary excretion percentage varied from <1% for nifedipine, and 94% for benfroflumethiazide. No significant correlation was found between any drug C score and their respective pharmacokinetic variables such as the medication half-lives (figure1).

Half-life versus adherence score

Conclusion

This study reports no significant correlation between drug pharmacokinetics and adherence. To the best of our knowledge this is the first study of its kind. Urinary biochemical testing by LC-MS/MS for non-adherence remains a valid tool for diagnosis although further detailed pharmacokinetic studies are needed to confirm this finding.

Acknowledgement/Funding

None

Abstract 4121: Differences in optoacoustic signal reflect different characteristics of the vasculature and response to antiangiogenic therapy in breast cancer models

Optoacoustic imaging has the potential to monitor tumour neo-vascularization, essential for disease progression and also a target for therapy. While promising in some settings, anti-angiogenic therapy has yet to fulfil its promise and mechanisms of resistance are poorly understood. In breast cancer, for example, resistance has been linked to hormonal status, oxygen consumption and alternative mechanisms of neo-vasculogenesis, including vascular mimicry (VM). Here, we use two mouse xenograft models: estrogen-dependent MCF-7 and estrogen independent MDA-MB-231. We analyse their characteristics in vivo using Multispectral optoacoustic tomography (MSOT) to detect oxy- and deoxy- haemoglobin (Hb) during tumour growth. We also analysed their histological and biochemical characteristics for blood vessel density (CD31) and maturity (aSMA, PAS staining), tumour hypoxia (CAIX), angiogenesis, inflammation and VM. Anti-angiogenic therapy response was also tested using Bevacizumab (BV, 10 mg/Kg) in two cohorts. While MSOT reveals similar blood content in both tumours, estrogen-dependent MCF-7 tumours show higher blood oxygenation than estrogen-independent MDA-MB-231 (55.8±7.5 % vs. 45.6±5.1%, p=0.0008) with values similar to healthy tissue (55.8±7.5 % vs. 57.8±5.3%, p=0.917). Ex vivo histological analysis shows that while MDA-MB-231 tumours are more hypoxic compared to MCF-7, they have a higher blood vessel density, however, the vasculature of MCF-7 tumours is more mature (vessel wall thickness and aSMA coverage). Based on molecular biomarkers, MCF-7 presents a more pro-inflammatory endothelial-like response, marked by an increase of vascular endothelial growth factor (p&lt;0.0001) of host origin (mVEGF), macrophage Nitric Oxide Sinthase (iNOS) and circulating NO, a mediator in inflammation and endothelial homeostasis (p=0.0031). VE-Cadherin of human origin is detectable in MDA-MB-231 tumours, which present CD31-absent blood vessels; together, these findings indicate presence of VM in MDA-MB-231 tumours. Interestingly, these 2 biological profiles respond differently to the anti-angiogenic drug BV: we observed a partial response in MDA-MB-231 tumours (CR=2/22, PR=3/22), but no effect in tumour size or survival was observed in MCF-7 tumours. While no change was observed in mVEGF upon BV treatment in any cohort, changes in optoacoustic signal of total Hb were observed in the MDA-MB-231 tumours after treatment. In conclusion, optoacoustic imaging delineates the vascular function of the blood vessel networks generated by angiogenesis and vascular mimicry respectively in our estrogen-dependent and estrogen-independent breast cancer xenografts. This study highlights the potential application of this technique in monitoring tumour vasculature development and in the future could be used to assess response to therapy.

Citation Format: Isabel Quiros-Gonzalez, Michal Tomaszewski, Laura Ansel-Bollepalli, Sarah J. Aikten, Michael Gill, Sarah E. Bohndiek. Differences in optoacoustic signal reflect different characteristics of the vasculature and response to antiangiogenic therapy in breast cancer models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4121.

The possibility of modification and improvement of dental services in Poland for children and adolescents with special emphasis on orthodontic service

AIM

World Dental Federation reveals that dental caries is one of the most common diseases in the world, and as much as 90% of the population is facing oral cavity problems. About 28% of teenagers aged 10 and 15 absolutely needs orthodontic treatment and about another third of this age group represents very serious cases. The aim of this study is to verify the authorial model which modifies and facilitates the system of dental services in Poland with a special emphasis on orthodontic service.

MATERIAL AND METHODS

The research was carried out with the method of diagnostic survey through a survey questionnaire. For this study, 1159 people were questioned for the research. In order to check the reliance between the variables Pearson chi-square test and the test of the Highest Reliability were used. Average market prices and the "prices expected" by the Greater Poland Voivodship Department of National Healthcare System were used to price dental services.

RESULTS

The research revealed that the highest percentage of people who used only private dental services is between 19 and 64 years of age and the lowest percentage is represented by the elderly, i.e. subjects over 65 years of age. As for the dental services offered by the National Health Fund, the highest percentage of patients are children and adolescents under 18 and the lowest percentage of patients is represented by people in the working age. The tendency towards private healthcare is in direct proportion to parents' increase in the level of education. The main reason why parents take their children to a private dentist is the long waiting time for the visit offered by the National Health Fund as well as better materials and equipment offered by private dentists. The costs connected with extending the basket of guaranteed services for children and youngsters are combined with the increase in National Health Fund expenditure reaching EUR 7,014,151. The lack of refunding dental services for patients aged 19-64 will generate savings reaching about EUR 34,756,765.

CONCLUSION

The reduction of public funds allocated for dental treatment of patients aged 19-64 will generate savings which will satisfy the needs connected with the increase in the range of refunded orthodontic treatment with the use of orthodontic permanent braces for patients under 18 years of age. The solution suggested will only slightly affect people in the working age as they reveal a strong tendency for treatment financed with their private funds.

Abstract 2866: Volumetric optoacoustic imaging of tumor cell death using a targeted imaging agent

Multispectral optoacoustic tomography (MSOT) generates high-resolution cross-sectional images in less than a second. MEDI3039, is a newly described agonist of the TNF-related apoptosis-inducing ligand receptor2 (TRAILR2), which has been shown in preclinical studies to preferentially induce cell death in cancer versus normal cells1. We show here that MSOT, when used with a near infra-red (NIR) fluorophore-labelled protein domain of Synaptotagmin-I (C2Am-750, ~15kDa) that binds to phosphatidylserine (PS) exposed by apoptotic and necrotic cells2, can be used to image MEDI3039-induced cell death within the entire tumor region. Non-specific probe retention was assessed using a site-directed mutant (iC2Am-680 or iC2Am-750).

PS-specific binding of C2Am-750 to MEDI3039-treated TRAIL-sensitive Colo205 and TRAIL-resistant HT-29 human colon adenocarcinoma cells in vitro was evaluated by flow cytometry and confocal microscopy. The capability of C2Am-750 to detect cell death in vivo was assessed in mice bearing Colo205 or HT-29 xenografts, following a single dose (0.4 mg/kg, i.v.) of MEDI3039. All mice then received an i.v. injection of a 1:1 mixture of 0.1 µmole/kg C2Am-750 and iC2Am-680 16 h post treatment, followed by fluorescence imaging (FLI) measurements using an IVIS 200 camera at 0 and 3 h post probe injection. FLI measurements in treated Colo205 xenografts showed significantly increased retention of C2Am-750 uptake versus size-matched untreated tumors (6.0-fold, P value &lt;0.0001), but there was no significant difference between treated and untreated HT-29 xenografts. iC2Am-680 retention was negligible in all groups. Next, volumetric MSOT measurements of C2Am-750 and iC2Am-750 (0.2 µmole/kg) retention in MEDI3039-treated Colo205 tumors were made using an iTheraMedical inVision 256 system at different wavelengths (660-900nm) and time points (3-24 h). C2Am-750 signal was markedly increased in tumors at 3 h post probe injection. Maximal C2Am-750 signal appeared in the center of treated tumors, whereas there was negligible iC2Am-750 retention. Subsequent histological analyses showed that C2Am-750 signal was strongly correlated with both cleaved caspase-3 and TUNEL staining of dead cells.

We have shown that real-time volumetric MSOT measurements with a NIR fluorophore-labelled C2Am, can be used to detect early tumor cell death within the entire tumor region following TRAILR2 agonist treatment. This study shows that this imaging technique can be used to characterize tumor heterogeneity and to determine the most appropriate therapy at an early stage post drug administration.

1.

Swers, J.S. et al. Multivalent scaffold proteins as superagonists of TRAIL receptor 2-induced apoptosis. Molecular cancer therapeutics 12, 1235-1244 (2013).

2.

Alam, I.S. et al. Comparison of the C2A domain of synaptotagmin-I and annexin-V as probes for detecting cell death. Bioconjugate chemistry 21, 884-891 (2010).

Citation Format: Bangwen Xie, Michal Tomaszewski, André A. Neves, Stefanie R. Mullins, David Tice, Richard Sainson, Sarah Bohndiek, Robert W. Wilkinson, Kevin M. Brindle. Volumetric optoacoustic imaging of tumor cell death using a targeted imaging agent [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2866. doi:10.1158/1538-7445.AM2017-2866

Determinants of day-night difference in blood pressure, a comparison with determinants of daytime and night-time blood pressure

Blunted day–night difference in blood pressure (BP) is an independent cardiovascular risk factor, although there is limited information on determinants of diurnal variation in BP. We investigated determinants of day–night difference in systolic (SBP) and diastolic (DBP) BP and how these compared with determinants of daytime and night-time SBP and DBP. We analysed the association of mean daytime, mean night-time and mean day–night difference (defined as (mean daytime−mean night-time)/mean daytime) in SBP and DBP with clinical, lifestyle and biochemical parameters from 1562 adult individuals (mean age 38.6) from 509 nuclear families recruited in the GRAPHIC Study. We estimated the heritability of the various BP phenotypes. In multivariate analysis, there were significant associations of age, sex, markers of adiposity (body mass index and waist–hip ratio), plasma lipids (total and low-density lipoprotein cholesterol and triglycerides), serum uric acid, alcohol intake and current smoking status on daytime or night-time SBP and/or DBP. Of these, only age (P=4.7 × 10⁻⁵), total cholesterol (P=0.002), plasma triglycerides (P=0.006) and current smoking (P=3.8 × 10⁻⁹) associated with day–night difference in SBP, and age (P=0.001), plasma triglyceride (P=2.2 × 10⁻⁵) and current smoking (3.8 × 10⁻⁴) associated with day–night difference in DBP. 24-h, daytime and night-time SBP and DBP showed substantial heritability (ranging from 18–43%). In contrast day–night difference in SBP showed a lower heritability (13%) while heritability of day–night difference in DBP was not significant. These data suggest that specific clinical, lifestyle and biochemical factors contribute to inter-individual variation in daytime, night-time and day–night differences in SBP and DBP. Variation in day–night differences in BP is largely non-genetic.

Fatty foci within the heart and the accompanying changes in the coronary arteries diagnosed in electrocardiogram-gated multislice computed tomography of the heart

BACKGROUND

The purpose of our study was to analyse the relationship between fatty foci within the heart and the accompanying changes in the coronary arteries supplying the relevant heart chambers in a large group of patients referred to multi-slice computed tomography with electrocardiogram-gating examinations (ECG-MSCT) for various clinical reasons.

MATERIALS AND METHODS

The ECG-MSCT examinations of 1,830 consecutive patients were analysed. The examinations were performed using 8-row (1,015 patients) and 64-row (815 patients) MSCT, in pre- and postcontrast scanning. In the group of patients with fatty foci within the heart the concomitant changes in the coronary arteries were assessed. It was analysed: the type of changes in the arteries; the relationship between the locations of the fatty deposits and the occurrence and type of changes in the coronary arteries.

RESULTS

In 200 (10.9%) subjects fatty foci within the heart (112 men; 88 women; mean age 57.8) were detected. The distribution of the fat was as follows: right ventricle (RV) - 32.5%, left ventricle (LV) - 22.0%, biventricular - 45.5%. One hundred and seventy-two patients had concomitant changes in the coronary arteries. In patients with normal coronary arteries, significantly more often fatty deposits were localised within RV. Fat was primarily located subendocardially in the LV in patients with atherosclerosis in the left anterior descending artery (p < 0.001), in the right coronary artery (RCA) (p = 0.003), and in the left circumflex artery (LCX) (p < 0.001). Subpericardial locations of fatty deposits in RV significantly correlated with RCA bridging (p < 0.02); the subpericardial location of fat in LV significantly correlated with LCX bridging (p = 0.001).

CONCLUSIONS

Fatty replacement of the myocardium is common, occurring in up to 10% of diagnosed patients and the majority of this group had concomitant changes in the coronary arteries. However, in the group of patients without changes in the coronary arteries, the fatty deposits locate themselves significantly more frequently within the RV.

Diaphragm fibrillation--an incidental finding detected by transoesophageal echocardiography

We present a case of diaphragmatic fibrillation (with a frequency of 600/min) in a patient at the early post-operative stages. In view of the decreased oxygen saturation and confusion, the patient was sedated and mechanically ventilated. His declining physical condition was partially associated with diaphragmatic fibrillation superimposed on heart failure and lung disease. The transthoracic echocardiography was technically difficult. Consequently, transoesophageal echocardiography was undertaken. This is the first case report presenting diaphragmatic fibrillation as an incidental finding on transoesophageal echocardiography.

Relationship between BDNF expression in major striatal afferents, striatum morphology and motor behavior in the R6/2 mouse model of Huntington's disease

Patients with Huntington's disease (HD) and transgenic mouse models of HD show neuronal loss in the striatum as a major feature, which contributes to cognitive and motor manifestations. Reduced expression of the neurotrophin brain-derived neurotrophic factor (BDNF) in striatal afferents may play a role in neuronal loss. How progressive loss of BDNF expression in different cortical or subcortical afferents contributes to striatal atrophy and behavioral dysfunction in HD is not known, and may best be determined in animal models. We compared age-dependent alterations of BDNF mRNA expression in major striatal afferents from the cerebral cortex, thalamus and midbrain in the R6/2 transgenic mouse model of HD. Corresponding changes in striatal morphology were quantified using unbiased stereology. Changes in motor behavior were measured using an open field, grip strength monitor, limb clasping and a rotarod apparatus. BDNF expression in cortical limbic and midbrain striatal afferents is reduced by age 4 weeks, prior to onset of motor abnormalities. BDNF expression in motor cortex and thalamic afferents is reduced by 6 weeks, coinciding with early motor dysfunction and reduced striatum volume. BDNF loss in afferents progresses until death at 13-15 weeks, correlating with progressive striatal neuronal loss and motor abnormalities. Mutant huntingtin protein expression in R6/2 mice results in progressive loss of BDNF in both cortical and subcortical striatal afferents. BDNF loss in limbic and dopaminergic striatal inputs may contribute to cognitive/psychiatric dysfunction in HD. Subsequent BDNF loss in cortical motor and thalamic afferents may accelerate striatal degeneration, resulting in progressive involuntary movements.