Alleviating the burden of depression: a simulation study on the impact of mental health services

AIMS

Depressive disorders are ranked as the single leading cause of disability worldwide. Despite immense efforts, there is no evidence of a global reduction in the disease burden in recent decades. The aim of the study was to determine the public health impact of the current service system (status quo), to quantify its effects on the depression-related disease burden and to identify the most promising strategies for improving healthcare for depression on the population level.

METHODS

A Markov model was developed to quantify the impact of current services for depression (including prevention, treatment and aftercare interventions) on the total disease burden and to investigate the potential of alternative scenarios (e.g., improved reach or improved treatment effectiveness). Parameter settings were derived from epidemiological information and treatment data from the literature. Based on the model parameters, 10,000,000 individual lives were simulated for each of the models, based on monthly transition rates between dichotomous health states (healthy vs. diseased). Outcome (depression-related disease burden) was operationalized as the proportion of months spent in depression.

RESULTS

The current healthcare system alleviates about 9.5% (95% confidence interval [CI]: 9.2%-9.7%) of the total disease burden related to depression. Chronic cases cause the majority (83.2%) of depression-related burden. From a public health perspective, improving the reach of services holds the largest potential: Maximum dissemination of prevention (26.9%; CI: 26.7%-27.1%) and treatment (26.5%; CI: 26.3%-26.7%) would result in significant improvements on the population level.

CONCLUSIONS

The results confirm an urgent need for action in healthcare for depression. Extending the reach of services is not only more promising but also probably more achievable than increasing their effectiveness. Currently, the system fails to address the prevention and treatment of chronic cases. The large proportion of the disease burden associated with chronic courses highlights the need for improved treatment policies and clinical strategies for this group (e.g., disease management and adaptive or personalized interventions). The model complements the existing literature by providing a new perspective on the depression-related disease burden and the complex interactions between healthcare services and the lifetime course.

Cardiovascular rehabilitation delivery and outcomes in Switzerland: data from a national database over the last decade

Background

Cardiac rehabilitation (CR) is a multidisciplinary, comprehensive, exercise-based intervention strongly recommended by current guidelines to improve symptoms and quality of life and to reduce cardiovascular adverse outcomes, mainly in patients with coronary artery disease and heart failure. CR activities have not been reported on a Swiss national base so far.

Purpose

To report CR outcome variables from a Swiss national base.

Methods

As part of the Swiss working group for cardiovascular prevention, rehabilitation, and sports cardiology (SCPRS) quality standards, all Swiss CR centres provide yearly a quality indicator report on an online questionnaire. Annual data from 2010 to 2019 were transferred as medians or means of all individual patients' data from each centre. We used the t-Student test to compare changes of outcome variables between entry and exit of the programme.

Results

A total of 133,060 CR patients were included (68,690 inpatients and 64,370 outpatients) with a progressive increase reaching its climax with 14'909 patients/year in 2018. Mean age ± standard deviation (SD) in outpatient and inpatient programmes was 60±1 and 68±1 years, and women percentage 21% and 32%, respectively. The most common CR indication was acute coronary syndrome (51%) in outpatient, whereas cardiovascular surgery of various types (60%) was the main indication in inpatient programmes. Mean improvement ± SD of functional capacity was 38% ±3.6 using the six-minute walk test in inpatient (p<0.001) and 21% ±2 using cycle-ergometer maximal exercise testing in outpatient programmes (p<0.001). Quality of life mainly assessed with the 12-item Short Form Survey (SF-12) in outpatient CR improved by 13% ±4.5. MacNew Heart questionnaire systematically performed in inpatient programmes showed significant improvement at emotional level by 12% ±0.4, at physical level by 30% ±0.9, and at social level by 18% ±0.6.

Conclusion

Even if still underutilised in certain groups of patients such as women or heart failure, CR has gained growing importance in Switzerland during the last decade. Functional capacity, as well as quality of life, was significantly improved. Individual CR patient data should be collected in the future to improve assessment of outcome parameters and benchmarking of centres.

Funding Acknowledgement

Type of funding sources: None.

Breathing patterns and ventilatory efficiency in elderly cardiac patients with and without left ventricular dysfunction before and after exercise-based cardiac rehabilitation: the EU-CaRE study

Introduction

Coronary artery disease (CAD) may progress to left ventricular dysfunction (LVD) and chronic heart failure. A reduced ventilatory efficiency in these patients is associated with worse outcome. However, breathing patterns at rest and during exercise and their change during exercise-based cardiac rehabilitation (exCR) have been poorly described in this population. We aimed to analyse respiratory and gas-exchange parameters in elderly patients with CAD included in a multicentre study on effectiveness of exCR across seven European countries (EU-CaRE).

Methods

Patients aged 65 years and older with acute (ACS) and chronic coronary syndromes (CCS) who participated in exCR were included. Cardiopulmonary exercise testing (CPET) was performed before (T0) and at termination of exCR (T1), and 12 months after start of exCR (T2). Ventilation (VE), breathing frequency (BF), and end-expiratory carbon dioxide pressure (PetCO2) were measured at rest, at first ventilatory threshold and peak exercise. Ventilatory efficiency, expressed as VE/VCO2 slope and the nadir of VE/VCO2 ratio were measured during the ramp test. Peak oxygen uptake was averaged over 30 s. Breathing parameters over time were compared between patients without and with left ventricular dysfunction (LVD, defined as LV ejection fraction <45%) by mixed linear models corrected for age, sex and body mass index.

Results

818 out of 1633 patients of the EU-CaRE study fulfilled inclusion criteria, 151 (18%) had LVD, of these, 86% were in New York Heart Association (NYHA) functional class I. Mean age was 72.5±5.4 years, 21.9% were women, and 79.8% had acute ACS. Compared to patients without LVD, in patients with LVD resting VE was increased 9%, VE/VCO2 slope 14%, and nadir VE/VCO2 ratio 9%, while PetCO2 was reduced at rest and peak exercise by 6%. From before to after exCR, resting ventilation and breathing frequency, as well as VE/VCO2 slope and nadir VE/VCO2 during exercise decreased significantly more in patients with LVD compared to patients without, while improvement in peak oxygen uptake was similar (Figure 1).

Conclusions

In contrast to their own perception based on NYHA class, patients with LVD had exaggerated breathing at rest and as response to exercise with consistently reduced PetCO2 and ventilatory efficiency. Abnormal breathing patterns may be an early and clinically relevant sign of LVD and linked to increased chemosensitivity and/or abnormal ergoreflex. Exercise-based CR may contribute to improvements of breathing patterns and ventilator efficiency in this population.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 research and innovation program and Swiss State Secretariat for Education, Research and Innovation for the Swiss consortium partner

Comparison of the 2010 and 2020 World Health Organization guidelines on physical activity in patients with percutaneous coronary interventions early after hospital discharge

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Swiss heart foundation

Background

Physical activity (PA) is inversely associated with mortality and adverse outcome in patients with cardiovascular disease, and can be objectively measured by accelerometry. In 2020, the World Health Organization (WHO) has updated their recommendations on PA for adults including those with chronic conditions, omitting the 10 min bout criterion.[1] The aim of this study was to determine the proportions of cardiac patients immediately after hospital discharge from percutaneous coronary interventions (PCI) who fulfil the old [2] and updated WHO PA criteria, and compare the results with established step-based cut-off values.

Methods

Patients after PCI for acute or chronic coronary syndrome with a maximal age of 80 and eligible for ambulatory cardiac rehabilitation were recruited for this observational single centre study. They were provided with a wrist-worn tri-axial accelerometer without display that recorded movement data starting from the day following hospital discharge for the subsequent 18 days. Acceleration data was analysed with the widely used free GGIR package. The proportions of patients fulfilling recommendations for moderate to vigorous PA (MVPA) were determined according to the 2010 and 2020 WHO guidelines as well as 7,500 [3] and 10,000 steps.[4]

Results

159 patients (41%) participated in this study. Data from 135 patients (85%), who had at least 7 days of ≥12 h wear-time were included in the analyses. Their median age was 62 (1st quartile 56, 3rd quartile 68), 22 (16%) were women, and 15 and 120 patients had a CCS and ACS, respectively. Their median wear time was 18 (16, 18) days. 102 (75.6%) had at least 30 min of MVPA on an average day and hence fulfilled the 2020 WHO guidelines. When MVPA was determined using the 2010 WHO guidelines, which only counted MVPA of bouts of at least 10 min, only 23 patients (17.8%) achieved at least 30 min of MVPA on an average day (Figure 1). 67.4% of our patients achieved ≥7,500 steps/d and 71 patients (52.6%) performed ≥10,000 steps/d.

Conclusion

In cardiac patients early after PCI most of the MVPA was accumulated in bouts shorter than 10 min. Applying the 2010 and 2020 WHO PA criteria to objectively measured PA led to a fourfold discrepancy. The 7,500 step cut-off corresponded with the 2020 WHO recommendations. Since achievement of intensity- or step-based cut-offs is greatly dependent on device type, wearing location, data sampling and analysis, it is currently poorly defined and not suited for patient classification and counselling. The clinical implication of this observation will be assessed in a cardiovascular outcome analysis.

Facilitators and barriers to centre- and home-based exercise training in breast cancer patients - a swiss tertiary centre experience

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss Cancer Research

Background

Exercise is an effective therapy for cancer patients to reduce fatigue and to improve health-related quality of life and physical function. Yet, cancer patients often do not meet physical activity guidelines.

Purpose

To understand why recommendations are not met, we aimed at identifying facilitators and barriers to supervised, centre-based exercise within a cardio-oncologic rehabilitation (CORE) programme and to unsupervised, home-based exercise as well as strategies used to manage these barriers.

Methods

Breast cancer patients who had completed a CORE programme at a Swiss tertiary centre were recruited. Semi-structured interviews were conducted with subsequent thematic analysis.

Results

Of 37 eligible breast cancer patients, 19 patients (mean age 48.9±9.7 years) participated to our invitation. Facilitators for centre-based exercise were social support, committedness and provision of structured exercise. Barriers towards centre-based exercise included physical and environmental barriers, while psychological barriers were reported predominantly for home-based exercise. Strategies to manage barriers included the adaptation of training circumstances, behaviour change strategies and strategies to deal with side effects.

Conclusions

Our results support the importance of providing CORE programmes and suggest that a special focus should be directed at the transition from supervised to self-organized exercise in order to enhance long-term exercise participation.

Effect of exhaustion on dynamic balance of professional padel players

Padel is an intermittent multidirectional racket sport that uses tennis’ rules and its scoring system. The popularity of padel has seen exponential growth; becoming one of the most practiced sports in the world. Balance constitutes a central component of racquet sports competitive demands. The aim of this study was exploring the effect of an exhaustive exercise on dynamic balance in elite padel players. 34 first division padel players with national rankings (age: 31.6 ± 7.9 years, height: 181.1 cm ± 5.26 cm; body mass: 81.1 kg ± 9.95 kg) volunteered for this study. Subjects were first tested for dynamic balance using the Y balance test. Then, they performed a volitional exhaustion test, followed by a dynamic balance retest. A significant main effect of condition for all balance variables was detected (all p < 0.03) except for the postero-lateral distance. A significant main effect of time was only found for the anterior distance (p < 0.001). Significant condition*time interaction was found for all variables (p < 0.02) except for the posterolateral distance. Posthoc analysis of the condition × time interaction indicated that compared to the control condition, exhaustive exercise deteriorated balance as showed by the significant decrease in the composite score (p = 0.05) and in the anterior direction (p < 0.001). This makes us focus on elaborating novel training systems in padel to improve the anterior direction distance after fatigue, being the reason of the decrease of dynamic balance capacity. This will boost the possibilities of scoring during a competitive situation.

Diagnostic yield and cost analysis of electrocardiographic screening in Swiss paediatric athletes

OBJECTIVES

Athletes performing sports on high level are at increased risk for sudden cardiac death. This includes paediatric athletes, even though data on screening strategies in this age group remain scarce. This study aimed to assess electrocardiogram interpretation criteria in paediatric athletes and to evaluate the cost of screening.

METHODS

National, multicentre, retrospective, observational study on 891 athletes of paediatric age (<18 years) evaluated by history, physical examination and 12-lead electrocardiogram. The primary outcome measure was abnormal electrocardiogram findings according to the International Recommendations for Electrographic Interpretation in Athletes. The secondary outcome measure was cost of screening.

RESULTS

19 athletes (2.1%) presented abnormal electrocardiogram findings requiring further investigations, mainly abnormal T-wave inversion. These 19 athletes were predominantly males, performing endurance sports with a mean volume of 10 weekly hours for a mean duration of 6 years of training. Further investigations did not identify any relevant pathology. All athletes were cleared for competition with regular follow-up. Total costs of the screening were 108,860 USD (122 USD per athlete).

CONCLUSIONS

Our study using the International Recommendations for Electrographic Interpretation in Athletes identified a low count of abnormal findings in paediatric athletes, yet raising substantially the cost of screening. Hence, the utility of electrocardiogram-inclusive screening of paediatric athletes remains to be elucidated by longitudinal data.

Physical activity trajectories are associated with the risk of all-cause and cardiovascular disease mortality in patients with coronary heart disease. A systematic review and meta-analysis

Background

Current guidelines recommend that adults with chronic health conditions should engage in regular physical activity (PA), and avoid inactivity. Yet, the exact role of PA trajectories in the mortality risk of patients with coronary heart disease (CHD) remains unclear.

Purpose

We aimed to perform a systematic review and meta-analysis on the association of longitudinal trajectories of PA with all-cause and cardiovascular disease (CVD) mortality in patients with CHD.

Methods

We performed a systematic review and meta-analysis based on PRISMA statement. Six electronic databases were searched for cohort studies that analysed the association of PA trajectories (inactive over time, active over time, increased activity over time, and decreased activity over time) with the risk of all-cause and CVD mortality in patients with CHD. Study quality was evaluated by the Newcastle Ottawa scale. We used the inverse variance weighted method to combine summary measures using random-effects models to minimize the effect of between-study heterogeneity. The study is registered in PROSPERO.

Results

We meta-analyzed nine longitudinal cohorts involving 33,576 patients (25010 acute CHD, 8566 chronic CHD, mean age 62.5 years, 34% women, median follow-up duration 7.2 years), according to four PA trajectories. All studies assessed PA through validated questionnaires. The definitions of activity and inactivity at baseline and follow-ups were in agreement with current PA guidelines. Trajectories were calculated based on comparison of activity status at baseline and follow-up. All the studies defined increased activity over time as moving from the inactive to the active category, and decreased activity over time as moving from the active to the inactive category. Compared to patients remaining inactive over time, the lowest risk of all-cause and CVD mortality was observed in patients remaining active over time (HR [95% CI]: 0.50 [0.39–0.63] and 0.48 [0.35–0.68], respectively), followed by patients who increased their PA over time (HR [95% CI]:0.55 [0.44–0.7] and 0.63 [0.51–0.78], respectively), and patients who decreased activity over time (HR [95% CI]: 0.80 [0.64–0.99] and 0.91 [0.67–1.24], respectively). These results were consistent both in the acute and chronic CHD settings. The overall risk of bias was low, and no evidence of publication bias was observed. Multiple sensitivity analyses provided consistent results.

Conclusions

In patients with CHD, the risk of all-cause and CVD mortality is progressively reduced from being inactive over time, to decreased activity over time, to increased activity over time, to being active over time. These findings highlight the benefits of adopting a more physically active lifestyle in patients with chronic and acute CHD, independent of previous PA levels. Future studies should clarify the complex interactions between motivations and disease severity as potential drivers for PA trajectories

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): University of Bern

EU-CaRE study: Could exercise-based cardiac telerehabilitation also be cost-effective in elderly?

BACKGROUND

The role of cardiac rehabilitation (CR) is well established in the secondary prevention of ischemic heart disease. Unfortunately, the participation rates across Europe remain low, especially in elderly. The EU-CaRE RCT investigated the effectiveness of a home-based mobile CR programme in elderly patients that were not willing to participate in centre-based CR. The initial study concluded that a 6-month home-based mobile CR programme was safe and beneficial in improving VO₂peak when compared with no CR.

OBJECTIVE

To assess whether a 6-month guided mobile CR programme is a cost-effective therapy for elderly patients who decline participation in CR.

METHODS

Patients were enrolled in a multicentre randomised clinical trial from November 11, 2015, to January 3, 2018, and follow-up was completed on January 17, 2019, in a secondary care system with 6 cardiac institutions across 5 European countries. A total of 179 patients who declined participation in centre-based CR and met the inclusion criteria consented to participate in the European Study on Effectiveness and Sustainability of Current Cardiac Rehabilitation Programs in the Elderly trial. The data of patients (n = 17) that were lost in follow-up were excluded from this analysis. The intervention (n = 79) consisted of 6 months of mobile CR programme with telemonitoring, and coaching based on motivational interviewing to stimulate patients to reach exercise goals. Control patients did not receive any form of CR throughout the study period. The costs considered for the cost-effectiveness analysis of the RCT are direct costs 1) of the mobile CR programme, and 2) of the care utilisation recorded during the observation time from randomisation to the end of the study. Costs and outcomes (utilities) were compared by calculation of the incremental cost-effectiveness ratio.

RESULTS

The healthcare utilisation costs (P = 0.802) were not significantly different between the two groups. However, the total costs were significantly higher in the intervention group (P = 0.040). The incremental cost-effectiveness ratio for the primary endpoint VO₂peak at 6 months was €1085 per 1-unit [ml/kg/min] improvement in change VO₂peak and at 12 months it was €1103 per 1 unit [ml/kg/min] improvement in change VO2peak. Big differences in the incremental cost-effectiveness ratios for the primary endpoint VO₂peak at 6 months and 12 months were present between the adherent participants and the non-adherent participants.

CONCLUSION

From a health-economic point of view the home-based mobile CR programme is an effective and cost-effective alternative for elderly cardiac patients who are not willing to participate in a regular rehabilitation programme to improve cardiorespiratory fitness. The change of QoL between the mobile CR was similar for both groups. Adherence to the mobile CR programme plays a significant role in the cost-effectiveness of the intervention. Future research should focus on the determinants of adherence, on increasing the adherence of patients and the implementation of comprehensive home-based mobile CR programmes in standard care.

Solvent suppression techniques for coupling of size exclusion chromatography and 1H NMR using benchtop spectrometers at 43 and 62 MHz

The characterisation of polymeric materials in their full complexity of chain length, monomeric composition, branching and functionalization is a tremendous challenge and is best tackled by tailored multi-dimensional coupled analytical and detection techniques. Herein, we focus on the improvement of an affordable but information rich 2D-method for polymer analysis: the online hyphenation of benchtop ¹H NMR spectroscopy with size exclusion chromatography (SEC). The main benefit of this approach is correlated information of chain length (SEC) to chemical composition (¹H NMR). Our setup combines SEC onflow with a benchtop NMR spectrometer at 43 or 62 MHz with chemical shift resolution as a robust detector. A detailed comparison of the two instruments is included considering, that only the 43 MHz instrument is equipped with a dedicated z-gradient enabling pulse sequences such as WET. The main challenge of this method is the very low concentration of species of interest after chromatographic separation. At typical SEC conditions, the analyte dilution is typically more than a factor of 1000:1 in a protonated solvent. Therefore, an efficient solvent signal suppression is needed. In this article, several suppression pulse sequences are explored like WET, WEFT, JNR and a simple one-pulse approach - some for the first time on this hardware. By choosing an optimal method, signal strength ratios of solvent to analyte of 1:1 or better are achievable on flow. To illustrate the broad range of possible applications, three typical cases of analyte to solvent signal proximity (no overlap, partial and full overlap) are discussed using typical polymers (PS, PMMA, PEMA) and solvents (chloroform and THF). For each case, several suppression methods are compared and evaluated using a set of numerical criteria (analyte signal suppression and broadening, solvent signal suppression, remaining solvent signal width).

Transfer mechanisms in semiconductor hybrids with colloidal core/shell quantum dots on ZnSe substrates

Hybrid systems consisting of colloidal CdS/ZnS core/shell quantum dots on ZnSe semiconductor substrates have been studied by continuous-wave and nanosecond time-resolved photoluminescence. On the basis of kinetic calculations, we studied the interplay between the possible transfer processes in these hybrids. The considered transfer mechanisms were resonance energy transfer, photon reabsorption, electron and hole tunneling. Depending on the size of the CdS cores the dominating transfer mechanism is changing. Carrier tunneling was found only for quantum dots in direct contact to the substrate. For large quantum dots a hole tunneling was found, whereas in case of small dots the fast electron tunneling is decisive. Eventually, we were able to determine the conduction band offset between CdS and ZnSe to 0.56 eV at 10 K.

Effect of mobile guided cardiac rehabilitation on quality of life – the EU-CaRE randomised clinical trial

Background and purpose

Although participation in cardiac rehabilitation (CR) improves quality of life (QoL), participation in CR, especially among elderly, is limited.

We conducted this study to assess whether mobile home-based CR (mCR) increases QoL in elderly (≥65 years old) patients with coronary artery disease (CAD) or a valvular intervention who decline participation in conventional CR.

Methods

It is designed as a randomised multi-centre study with two parallel arms. Randomisation assigned patients either to mCR or a control group. mCR Consisted of six months of home-based CR with telemonitoring and coaching. Control-group patients did not receive any form of CR throughout the study period. Quality of life was measured with the SF-36v2 questionnaire at 0, 6 and 12 months.

Results

A total of 179 patients were included in this study (90 control, 89 mCR). A flowchart of the trial is presented in Figure 1. Patients were predominantly male (81.1%). Baseline characteristics can be found in Table 1.

Patients using mCR improved on physical QoL after 6 (p=0.026) and 12 (p=0.008) months. There was no difference on mental QoL for both groups (mCR 6 months p=0.563, 12 months p=0.945; control 6 months p=0.589, 12 months p=0.542). No difference existed in QoL between the mCR and control group (physical: 6 months p=0.070, 12 months p=0.150; mental: 6 months p=0.355, 12 months p=0.625).

Conclusion

Although there is no significant difference in QoL between the control and mCR group, mCR increases physical QoL after 6 and 12 months in elderly patients who decline participation in conventional CR. Therefore E-Health tools should be considered as an alternative for conventional CR when (elderly) patients decline to participate in conventional CR.

Figure 1. Flow chart of all eligible patients

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 research and innovation programme

P311Hypertrophic cardiomyopathy and other forms of left ventricular hypertrophy. The P wave can make the difference

Background

Structural disarray of hypertrophied myocytes and interstitial fibrosis characterize hypertrophic cardiomyopathy (HCM). These morphological changes also affect atrial myocytes and, together with hemodynamic alterations because of HCM, may lead to atrial cardiomyopathy. 

Purpose

To investigate the incremental value of P-wave parameters to differentiate left ventricular hypertrophy (LVH) because of HCM from LVH in hypertensive heart disease (HHD) and athletes heart. 

Methods

In a prospective study, we compared electrocardiographic (including signal-averaged ECG of the P wave) and echocardiographic data of patients with HCM, HHD and athletes heart. We developed a predictive model with a simple scoring system to identify HCM.

Results

We compared data of 27 patients with HCM (70% males, 49.8 ± 14.5 years), 324 patients with HHD (52% males, 74.8 ± 5.5 years), and 215 subjects with athletes heart (72% males, 42.3 ± 7.5). The table shows the significant differences among the 3 groups. We included the following parameters into a predictive score to differentiate HCM from other forms of LVH: QRS width (&gt;88ms = 1 point), P-wave integral (&gt;688µVs = 1 point) and septum thickness (&gt;12mm = 2 points). A score &gt;2 (Youden index 0.626) correctly classified HCM in 81% of the cases with a sensitivity and specificity of 82% an 81%, respectively. 

Conclusion Differentiation of HCM from other forms of LVH is improved by including atrial parameters. A simple scoring system including septum thickness, QRS width and P wave integral allowed identification of patients with HCM with a sensitivity and specificity of &gt;80%. This score needs to be validated prospectively.

Table 1 HCM HHD Athletes P-value HCM vs HHD* HCM vs Athletes* 95%-CI P-value 95%-CI P-value P-wave duration [ms] 152.7 ± 25.8 143.9 ± 16.5 133.5 ± 14.2 &lt;0.001 -16.9 -24.6 to -9.1 &lt;0.001 -16.3 -22.7 to -9.9 &lt;0.001 P-wave integral [µVs] 850.4 ± 272.4 672.0 ± 235.4 773.1 ± 260.1 &lt;0.001 -198.6 -320.8 to -76.3 0.002 -68.2 -169.7 to 33.2 0.187 QRS [ms] 110.3 ± 27.3 96.9 ± 20.3 95.1 ± 9.8 &lt;0.001 -16.4 -24.7 to -8.1 &lt;0.001 -13.8 -20.8 to -6.9 &lt;0.001 QTc [ms] 447.9 ± 27.2 438.6 ± 24.5 414.0 ± 22.9 &lt;0.001 -21.1 -32.7 to -9.5 &lt;0.001 -30.8 -40.5 to -21.2 &lt;0.001 LVMMI [g/m2] 153.6 ± 55.5 133.5 ± 30.3 98.6 ± 19.7 &lt;0.001 -15.3 -29.7 to -0.9 0.038 -56.1 -67.7 to -44.6 &lt;0.001 IVS [ms] 16.8 ± 4.2 11.8 ± 2.2 10.3 ± 1.5 &lt;0.001 -5.2 -6.3 to -4.1 &lt;0.001 -6.4 -7.3 to -5.6 &lt;0.001 LAVI [ml/m2] 43.2 ± 13.9 30.5 ± 9.7 30.8 ± 9.5 &lt;0.001 -14.6 -20.0 to -9.3 &lt;0.001 -12.2 -16.6 to -7.9 &lt;0.001 The table shows the study result after univariate and multivariate (*; adjusting for age and sex) analysis.

Abstract Figure 1

Applicability and reproducibility of acute myeloid leukaemia stem cell assessment in a multi-centre setting

Leukaemic stem cells (LSC) have been experimentally defined as the leukaemia‐propagating population and are thought to be the cellular reservoir of relapse in acute myeloid leukaemia (AML). Therefore, LSC measurements are warranted to facilitate accurate risk stratification. Previously, we published the composition of a one‐tube flow cytometric assay, characterised by the presence of 13 important membrane markers for LSC detection. Here we present the validation experiments of the assay in several large AML research centres, both in Europe and the United States. Variability within instruments and sample processing showed high correlations between different instruments (R_pearson > 0·91, P < 0·001). Multi‐centre testing introduced variation in reported LSC percentages but was found to be below the clinical relevant threshold. Clear gating protocols resulted in all laboratories being able to perform LSC assessment of the validation set. Participating centres were nearly unanimously able to distinguish LSC^high (>0·03% LSC) from LSC^low (<0·03% LSC) despite inter‐laboratory variation in reported LSC percentages. This study proves that the LSC assay is highly reproducible. These results together with the high prognostic impact of LSC load at diagnosis in AML patients render the one‐tube LSC assessment a good marker for future risk classification.

P6218Greater burden of risk factors and need of cardiac rehabilitation in elderly patients with lower educational attainment

Background

A socioeconomic gap in cardiac rehabilitation (CR) has been described in younger populations but whether this is also true in the ageing population is unknown.

Purpose

To describe if poorer education is a predictor for exercise capacity, comorbidity, lifestyle- and risk factors and medical treatment at baseline in CR in an elderly population.

Methods

The observational EU-CaRE study is a European prospective study with eight participating CR centers in seven countries (Denmark, France, Germany, the Netherlands, Italy, Spain and Switzerland). Patients aged 65 or older with CHD or valve surgery participating in CR were consecutively included. Educational attainment was divided into basic, intermediate and high

Results

A total of 1626 patients were included. Educational attainment differed across centers (p<0.001). The groups differed little regarding index event, comorbidity and medical treatment. However, patients with only basic education had more diabetes, higher BMI, less physical activity, lower exercise capacity and higher scores for depression (PHQ 9) and anxiety (GAD). Differences were not affected by adjustment for age, gender and country.

Demographics and risk factor control N=1626 High (N=388) Intermediate (N=788) Basic (N=460) p-value* DEMOGRAPHICS Age (yrs), median (IQR) 72 (68, 76) 71 (68, 75) 74 (70, 78) <0.001 Men 330 (86.8%) 603 (79.3%) 291 (67.4%) <0.001 RISK FACTORS p-value** LDL >1.8 mmol/l*** 255 (66.1%) 518 (66.8%) 293 (63.7%) 0.060 Systolic BP >140 mmHg 85 (22.0%) 179 (23.1%) 100 (21.7%) 0.601 Smoker 26 (6.8%) 80 (10.3%) 46 (10.0%) 0.214 Moderate exercise <4days/week 179 (46.4%) 340 (43.9%) 271 (58.9%) 0.024 BMI >27 kg/m2 133 (35.5%) 389 (50.2%) 255 (55.4%) <0.001 VO2 peak <80% of predicted 220 (57.0%) 443 (57.2%) 252 (54.8%) 0.037 HbA1c >48mmol/mol*** 115 (29.8%) 264 (34.1%) 230 (50.0%) <0.001 Diet score, mean (SD) 6.50 (2.28) 5.93 (2.47) 7.32 (2.35) <0.001 GAD score, median (IQR) 2.0 (0.0,4.0) 2.0 (0.0,5.0) 3.5 (0.0,7.0) 0.051 PHQ-9 score, median (IQR) 4.0 (1.0,7.0) 4.0 (1.0,7.0) 6.0 (2.0,10.0) 0.020 Abbreviations: IQR, interquartile range; SD, standard deviation; ACS, acute coronary syndrome; CAD, coronary artery disease. *Adjusted for center. **Adjusted for center, age, gender. ***Only for ischemic heart disease patients.

Conclusions

The results emphasize the need of CR in this patient-group and that a targeted CR approach should be considered to achieve equal health opportunities also in the elderly.

Acknowledgement/Funding

Horizon2020

P1927A European randomised controlled trial for m-health guided cardiac rehabilitation in the elderly; results of the EU-CaRE RCT study

Introduction

Knowledge about effectiveness of cardiac rehabilitation (CR) in the elderly is limited. Participation rates in supervised CR are consistently lower in the elderly and innovative interventions are needed. The EU has granted a CR study project; a randomised controlled trial conducted in 5 European countries, investigating the effectiveness of mobile telemonitoring guided CR (mCR) in elderly cardiac patients who declined regular CR.

Methods

Patients ≥65 years with indication for CR who declined regular CR were eligible for inclusion. Patients were randomised between regular care (without CR) and a 6-month mCR programme: dedicated programmed smartphone, heartrate monitoring (target HR zones) and coaching. The primary endpoint is the difference in VO2peak between 6-months follow-up and baseline.

Results

Between 2015 and 2018 179 patients were included. Baseline characteristics between groups (table 1) did not differ significantly, except for hypertension. The difference in VO2peak was significantly better in the mCR group (table 1). After correction (mixed linear model) for baseline VO2 peak (fixed factor) and centre (random factor) this difference remained significant. Mean number of registered activity sessions was 4.79 (95% CI; 4.07–5.50) per patient per week.

Table 1. Baseline and primary outcome parameters Baseline Control Programme (n=90) mCR Programme (n=89) P-value Gender (m/f) 76/14 69/20 0.238 Age (mean±SD) 73.57±5.46 72.38±5.37 0.121 Diabetes 15 (16.7%) 23 (25.8%) 0.133 Hypertension 60 (66.7%) 73 (82.0%) 0.019* Hypercholesteremia 71 (78.3%) 74 (83.1%) 0.468 Normal LV-function 48/89 (53.9%) 53/89 (59.6%) 0.497 Index event (CABG/Valve/PCI/none) 0.735   Cardiac history prior to index event 48/89 (53.9%) 53/89 (59.6%) 0.702   Non cardiac comorbidity 40 (44.4%) 44 (49.4%) 0.503 Results   Baseline VO2peak (ml/kg/min) (95% CI) 19.83 (18.65–21.01) 18.78 (18.67–19.89) 0.191   Delta VO2peak at 6 months (ml/kg/min) (95% CI) 0.20 4 (−0.34–0.83) 1.62 (0.86–2.39) 0.005*   Corrected delta VO2peak at 6 months (ml/kg/min) 0.50 (−1.04–2.04) 1.65 (0.11–3.2) 0.015* *Significant.

Conclusions

The application of mCR in elderly patients who declined regular CR results in a better physical condition after 6 months. Compliance to mCR was excellent.

Acknowledgement/Funding

European Union's Horizon 2020 research and innovation programme under grant agreement number 634439, and funding from the Swiss Government.

P2509Less effect of cardiac rehabilitation for elderly cardiac patients with lower educational attainment

Background

Previous analyses from EU-CaRE study have shown that elderly cardiac patients with basic education have a greater burden of cardiovascular risk factors and a lower exercise capacity at baseline of cardiac rehabilitation (CR). We hypothesize that participation in CR will diminish this socioeconomic gap.

Purpose

To describe if educational level predicts the benefits of CR in an elderly population in Europe.

Methods

The observational EU-CaRE study is a prospective study with eight participating CR centers in seven countries (Denmark, France, Germany, the Netherlands, Italy, Spain and Switzerland). Consecutive patients age 65 or older with coronary heart disease or valve surgery participating in CR were included. Data were obtained at baseline (T0) and at the end of CR (T1) and include risk factors for cardiovascular disease, clinical and psychological assessment, medical treatment and exercise capacity. Patients were divided into basic, intermediate and higher educational levels. We compared changes from T0-T1 by multiple regression models.

Results

A total of 1621 (99% of included) patients were eligible for follow-up analyses. At baseline patients with basic education had more diabetes, higher BMI, lower exercise capacity (VO2 peak) and higher scores for depression (GAD) and anxiety (PHQ-9). At T1 they had improved significantly less on these parameters. The results were not affected by adjustment for gender, age, country and baseline value of the variable. Use of evidence-based medication did not differ by level of education.

Difference between T0 and T1 Factor High Intermediate Basic p-value* N total 1621 N=386 N=775 N=460 BMI, mean (SD) −0.16 (0.71) −0.08 (0.82) −0.26 (0.95) 0.794 LDL (mmol/L), mean (SD) −0.07 (0.63) −0.11 (0.62) −0.04 (0.58) 0.978 HbA1c (mmol/mol), mean (SD) 0.23 (3.70) 0.52 (4.39) 0.04 (5.79) 0.021 GAD score, mean (SD) −0.92 (2.72) −0.76 (3.07) −0.13 (3.47) 0.003 PHQ-9 score, mean (SD) −1.45 (3.21) −1.16 (3.36) −0.93 (4.49) <0.001 Diet score, mean (SD) 0.57 (1.72) 0.63 (1.90) 0.23 (1.81) 0.003 VO2 peak (ml/kg/min), mean (SD) 2.47 (2.90) 1.95 (2.78) 1.75 (2.56) 0.016 *Adjusted for gender, age, country and baseline value.

Difference in VO2peak, GAD and PHQ score

Conclusions

In this large European study with high-quality data from 7 CR centers we found an increased gap disfavoring the lower educated elderly patients participating in CR. These results indicate that “one-size cardiac rehabilitation” does not fit all and indicate that a more personalized CR with attention to the different needs of some patient groups is appropriate.

Acknowledgement/Funding

Horizon2020

P2513Offer and participation in different European cardiac rehabilitation programs in the elderly after ACS or coronary revascularization. The EU-CaRE study

Background

Cardiac rehabilitation programs (CRP) are strongly recommended after acute coronary syndrome (ACS) or coronary revascularization (PCI or CABG), but actual offer and participation among elderly patients (age ≥65) have not been well characterised.

Purpose

To analyse current offer and participation rates in different European CRP in elderly patients.

Methods

Data from elderly patients recruited for CRP, after ACS, PCI or CABG, in centres from seven European countries participating in the EU-CaRE study (NTR5306), were analysed.

Results

3471 patients were screened, of whom 80.9% (n=2806) were offered participation and 68.0% of these (n=1908) agreed to participate in a CRP.

Outpatient CRP were offered to 73–92% of screened patients. Among reasons for not offering the program were contraindications and geographical conditions. Patients who were not offered were mainly older, with worse cardiovascular risk profile and comorbidities. In the multivariable analysis main variables related with offering in Copenhagen were age (OR=0.92, CI95% 0.87–0.98), gender (male, OR=2.42, CI95% 1.10–5.31) and previous CABG (OR=0.12, CI95% 0.04–0.36). In Bern, age (OR=0.89, CI95% 0.85–0.93), ACS (OR=1.85, CI95% 1.01–3.54) and smoking status (OR=0.47, CI95% 0.24–0.93). In Zwolle, age (OR=0.89, CI95% 0.91–0.97), CABG (OR=4.34, CI95% 1.37->10), smoking status (OR=0.23, CI95% 0.06–1.11), diabetes mellitus (OR=0.33, CI95% 0.13–0.91) and comorbidities (i.e. obstructive pulmonary disease). In Santiago, age (OR=0.83, CI95% 0.73–0.91), index event PCI (OR=14.21, CI95% 3.68->10) and rheumatoid arthritis.

The ratio of participation among those who were offered the program varied from 46% to 94% (46% to 67% in outpatients' programs). Main reasons for not participating were patients considered that it was not useful (366, 10.5%), travel distance (205, 5.8%), transport difficulties (134, 3.8%) and exercises on own initiative (70, 2.0%). In a center-specific analysis we performed predictive models of participation. In Copenhagen (AUC=0.69) the main variables predicting participation were age (OR=0.99, CI95% 0.96–1.03), not living alone (OR=1.53, CI95% 0.96–2.42), CABG (OR=2.69, CI95% 1.51–4.80) and comorbidities. In Bern (AUC=0.81), age (OR=0.92, CI95% 0.89–0.95), ACS (OR=3.99, CI95% 2.56–6.20) and peripheral artery disease. In Zwolle (AUC=0.71), age (OR=0.94, CI95% 0.91–0.98), employment status (OR=0.28, CI95% 0.13–0.60), CABG (OR=3.62, CI95% 2.28–5.77) and previous ACS (OR=0.58, CI95% 0.35–0.95). In Santiago (AUC=0.85), age (OR=0.95, CI95% 0.90–0.99), rural habitat (OR=0.58, CI95% 0.32–1.04), valvulopathy (OR=0.33, CI95% 0.14–0.79) and the index intervention PCI.

Conclusions

Knowing reasons (travel distance, usefulness of the program understood by patient) and variables (age, living alone or in rural area) that determine if CRP is offered and whether or not patients participate will help redesign CRP to better adapt to actual needs of an elderly European population.

Acknowledgement/Funding

This project has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement number 634439

P1557Sustainable effectiveness of cardiac rehabilitation in elderly patients in 7 European countries: main results from the EU-CARE study

Background

The EU-CaRE project aims to obtain the evidence base to improve, tailor and optimise cardiac rehabilitation (CR) programmes regarding sustainable effectiveness, cost-effectiveness and participation level in the elderly.

Purpose

To compare the effect of CR programmes in 7 European countries on the main outcome.

Methods

The observational EU-CaRE study is a prospective study with eight participating CR sites in seven countries (Denmark, France, Germany, Italy, the Netherlands, Spain and Switzerland). Consecutive patients age 65 or older with coronary heart disease or valve surgery undergoing CR were included. Data were obtained at baseline (T0), at the end of CR (T1) and at 1 year (T2). VO2peak was assessed by cardiopulmonary exercise test. We compared changes in VO2peak across sites in multilevel regression models for repeated measures, adjusting for age, gender, baseline VO2peak, comorbidities, CVD risk factors and educational attainment. Results are reported separately for patients undergoing surgery (CABG/valve replacement) and other indications (MI/stable CAD/PCI).

Results

1633 patients were included, and VO2peak was available at all three timepoints for 1243 patients (76%), 492 undergoing surgery and 751 for other indications. Lag time from index event to first CPET and baseline VO2peak varied significantly across centres. Mean age was 72.9 (range 65–90), mean VO2peak at T0 was 16.49 (SD 4.94), at T1, 18.55 (5.33) and at T2 19.03 (5.43) ml/kg/min.

For patients not undergoing surgery mean improvement T0-T1 was 1.57 (2.98) and T0-T2 was 1.40 (3.17) ml/kg/min (both p<0.001). In the surgery patients as expected baseline VO2peak was lower but in contrast to non-surgery continued to improve after CR: T0-T1 improvement was 2.77 (2.76) and T0-T2 improvement was 4.29 (3.83) (both p<0.001). At one-year follow-up surgery and non-surgery patients had similar VO2peak (p=0.59). The greatest mean improvement in a site from baseline to one year was 2.04 (3.74) and the smallest 0.59 (2.54) ml/kg/min for non-surgery and, correspondingly 6.13 (4.83) and 1.29 (2.06) ml/kg/min for surgery patients (both multivariable adjusted p for differences between sites p<0.001).

In addition to age and gender, baseline and one-year VO2peak was lower in patients with diabetes, hypertension, smokers, patients with other co-morbidity, lower educational attainment and lower mental component score of the SF36. These factors had no systematic impact on the effect of CR.

VO2peak at baseline, after CR and 1 year

Conclusions

The study provides high-quality data on the effectiveness of current CR programmes in Western Europe. Overall, CR was effective in achieving significant improvements in exercise and maintaining these effects. There were significant differences in effect between sites indicating a potential for improvement by adapting CR programs.

Acknowledgement/Funding

Horizon 2020

The effectiveness of superficial versus deep dry needling or acupuncture for reducing pain and disability in individuals with spine-related painful conditions: a systematic review with meta-analysis

Objective: The purpose of this systematic review was to evaluate the effects of deep versus superficial dry needling or acupuncture on pain and disability for spine-related painful conditions. A secondary purpose was to account for the differences of needling location in relation to the painful area. Methods: This PROSPERO (#CRD42018106237) registered review found 691 titles through a multi-database search. Following a comprehensive search, 12 manuscripts were included in the systematic review and 10 in the meta-analysis. Standardized mean differences (SMD) with 95% confidence intervals were calculated for pain and disability. Results: The included studies demonstrated an unclear to high risk of bias recommending a cautious interpretation of the results. A consistent effect supporting deep needling over superficial with an SMD of 0.585 [0.335, 0.835], p < 0.001 from 10 articles for pain but a non-significant effect of 0.197 [-0.066, 0.461], p = 0.14 from 2 studies for disability. A temporal examination was similar for effects on pain with an SMD of 0.450 [0.104, 0.796] immediately, 0.711 [0.375, 1.048] short-term (1 to 11 weeks), and 0.470 [0.135, 0.805] for time-points ≥12 weeks. Regionally, there was a greater effect needling the area of pain locally (SMD = 0.754) compared to remotely (SMD = 0.501). Discussion: Statistically significant between-group differences were observed favoring deep needling over superficial. Both superficial and deep needling resulted in clinically meaningful changes in pain scores over time. However, differences between groups may not be clinically meaningful. More high-quality trials are needed to better estimate the effect size of deep versus superficial needling while controlling for location and depth of the lesion. Level of evidence: 1a.

Inter-observer agreement in athletes ECG interpretation using the recent international recommendations for ECG interpretation in athletes among observers with different levels of expertise

INTRODUCTION

International criteria for the interpretation of the athlete's electrocardiogram (ECG) have been proposed. We aimed to evaluate the inter-observer agreement among observers with different levels of expertise.

METHODS

Consecutive ECGs of Swiss elite athletes (≥14 years), recorded during routine pre-participation screening between 2013 and 2016 at the Swiss Federal Institute of Sports were analysed. A medical student (A), a cardiology fellow (B) and an electrophysiologist (C) interpreted the ECG's independently according to the most recent criteria. The frequencies and percentages for each observer were calculated. An inter-observer reliability analysis using Cohen Kappa (κ) statistics was used to determine consistency among observers.

RESULTS

A total of 287 ECGs (64.1% males) were analysed. Mean age of the athletes was 20.4±4.9 years. The prevalence of abnormal ECG findings was 1.4%. Both, normal and borderline findings in athletes showed moderate to good agreement between all observers. κ scores for abnormal findings resulted in excellent agreement (κ 0.855 in observer A vs C and B vs C to κ 1.000 in observer A vs B). Overall agreement ranged from moderate (κ 0.539; 0.419-0.685 95% CI) between observer B vs C to good agreement (κ 0.720; 0.681-0.821 95% CI) between observer A vs B.

CONCLUSIONS

Our cohort of elite athletes had a low prevalence of abnormal ECGs. Agreement in abnormal ECG findings with the use of the recently published International recommendations for ECG interpretation in athletes among observers with different levels of expertise was excellent. ECG interpretation resulted in moderate to good overall agreement.

Correction to: JNK-NQO1 axis drives TAp73-mediated tumor suppression upon oxidative and proteasomal stress

Following publication of their Article JNK-NQO1 axis drives TAp73-mediated tumor suppression upon oxidative and proteasomal stress. Cell Death Dis. 2014, 5:e1484, the authors noted a mistake in Figure 2b, in that, the wells of the crystal violet plates showing growth inhibition induced by withaferin A in HCT 116TP53-/- cells were erroneously duplicated for 1 and 2.5 μM WA. The correct wells for 2.5 μM WA are now included in new figure 2b (please see attached file).

Immune cells regulate VEGF signalling via release of VEGF and antagonistic soluble VEGF receptor-1

Vascular endothelial growth factor (VEGF) is an important regulator of physiological and pathological angiogenesis. Besides malignant and stromal cells, local immune cells shape VEGF signalling in the tumour microenvironment. Aminobisphosphonates such as zoledronic acid (Zol) are drugs known to inhibit osteoclast activity and bone resorption, but also have immunomodulatory and anti-tumour effects. These properties have been linked previously to the down-regulation of VEGF and interference with tumour neo-angiogenesis. It was therefore surprising to find that treatment with Zol in combination with low-dose interleukin (IL)-2 increased serum VEGF levels in cancer patients. In this study we aimed to characterize the effect of Zol and IL-2 on VEGF signalling of blood-derived immune cells in vitro. Upon stimulation with IL-2, T cells and natural killer (NK) cells increase production of VEGF consecutively to the release of proinflammatory interferon (IFN)-γ, and Zol accelerates this response specifically in γδ T cells. VEGF can, in turn, be antagonized by soluble VEGF receptor (sVEGFR)-1, which is released depending on stimulatory conditions and the presence of monocytes. Additionally, malignant cells represented by leukaemia and lymphoma cell lines produce VEGF and some release sVEGFR-1 simultaneously. Our findings indicate a mechanism by which the VEGF and the sVEGFR-1 production by immune cells regulates local VEGF signalling. Therefore, immunotherapeutic interventions may enable both pro- as well as anti-tumour effects via immune cell-mediated alterations of VEGF homeostasis.

Esophagopericardial fistula, septic shock and intracranial hemorrhage with hydrocephalus after lung transplantation

A 57-year old woman underwent lung transplantation for non-specific interstitial pneumonia. Primary graft dysfunction was diagnosed requiring continued use of extracorporeal membrane oxygenation (ECMO). Within three days she developed recurring hemothoraces requiring two surgical evacuations. After ECMO removal a series of complications occurred within four months: femoral thrombosis, persisting tachycardic atrial fibrillation, pneumopericardium with an esophagopericardial fistula and purulent pericarditis, septic shock, multiorgan failure and intracerebral hemorrhage with ventricular involvement requiring external ventricular drainage. Interdisciplinary management coordinated by the intensive care specialist, transplant surgeon and pulmonologist with various interventions by the respective specialists followed by intensive physical rehabilitation allowed for discharge home on day 235 post transplant. Subsequently quality of life was considered good by the patient and family.

Ballroom dancing is more intensive for the female partners due to their unique hold technique

In this study, we tested the hypotheses that, relative to the maximum capacities, ballroom dancing is more intensive for females than males, and that the hold technique (female vs. male) regulates dancing intensity. Ten dance couples were tested in a maximal treadmill test, competition simulation, and stationary dance hold position. Peak heart rate and relative oxygen consumption were measured during the tests, except that oxygen consumption was not measured during competition simulation. Regardless of gender, heart rate increased similarly in the treadmill test and in the competition simulation. In the treadmill test, females achieved an oxygen consumption of 78% of the males (p < 0.05). Compared with males, females achieved 14% higher heart rate (p < 0.05) and similar oxygen consumption during the hold position. Heart rate during competition simulation relative to maximum was greater for females than males. Both heart rate and oxygen consumption measured during the hold, relative to maximum, were greater for females than males. It is concluded that lower class ballroom dancers perform at their vita maxima during competition simulation. Using heart rate as an intensity indicator, ballroom dancing is more intensive for females because of their unique hold technique.

Determination of physical emulsion stabilization mechanisms of wood hemicelluloses via rheological and interfacial characterization

Materials manufacturing industries seek efficient, economic, and sustainable compounds for stabilizing dispersed systems such as emulsions. In this study, novel, abundant biobased hydrocolloids spruce galactoglucomannans (GGM) and birch glucuronoxylans (GX) were obtained from a forestry biorefining process and characterized as versatile stabilizers of rapeseed oil-in-water emulsions. For the first time, GGM and GX isolated by pressurized hot water extraction (PHWE) of spruce and birch saw meal, respectively, were studied in emulsions. The PHWE wood hemicelluloses-polysaccharides with relatively low molar mass-facilitated the formation of emulsions with small average droplet size and efficiently prevented droplet coalescence. GGM and GX lowered the surface tension of emulsions' oil-water interface and increased the viscosity of the continuous phase. However, viscosity of the wood hemicellulose-based systems was low compared to that of commercial polymeric stabilizers. GGM-stabilized emulsions with varying oil volume fractions were characterized in terms of their rheological properties, including large amplitude oscillation shear (LAOS) measurements, and compared to emulsions prepared with a classical small-molecular surfactant, Tween20. The physical emulsion stabilization mechanisms of GGM and GX are suggested as steric repulsion assisted by Pickering-type stabilization. Wood hemicelluloses have potential as highly promising future bioproducts for versatile industrial applications involving colloidal systems and soft materials.

Impact of endo- and exogenous estrogens on heart rate variability in women: a review

Measurement of heart rate variability (HRV) is an established method to assess the activity of the autonomic nervous system. The aim of this review was to examine the link between HRV, reproductive life stages and menopausal hormone therapy. A literature review was performed using the Medline database. Based on title and abstract, 45 studies were extracted out of 261 citations screened. Due to different study designs and evaluation methods, HRV indices were not directly comparable. Qualitative comparisons in between the vast majority of studies, however, demonstrated a decrease of the vagal dominance on the heart from the follicular to the luteal cycle phase, although some studies asserted no change. The intake of oral contraceptives appeared not to alter the vagal modulation of the heart. All investigations agreed on a decline of HRV towards higher sympathetic control after menopause. Different menopausal hormone therapy approaches showed a supporting impact of estrogen on HRV in most studies. A combined therapy of estrogen and progestogens revoked this benefit. Further research is needed to demonstrate how this process might be attenuated by different menopausal hormone therapies.

Workshop Report on the European Bone Sarcoma Networking Meeting: Integration of Clinical Trials with Tumor Biology

A key workshop was held in The Netherlands in June 2011, hosted by several European bone sarcoma networks and with a broad range of stakeholders from Europe and Australia. The purpose of the meeting was to identify the strengths and weaknesses in current clinical trials for bone sarcomas and to make recommendations as to how to accelerate progress in this field. Two areas of particular interest were discussed. First, all participants agreed upon the importance of tumor biology to understanding clinical responses for all types of bone sarcoma. Various barriers to biobanking tumor and germline specimens were canvassed and are outlined in this paper. Second, there was consideration of the particular challenges of dealing with adolescent and young adult cancers, exemplified by bone sarcomas. Participants recommended greater engagement of both pediatric and adult sarcoma trial organizations to address this issue. Specific opportunities were identified to develop biological sub-studies within osteosarcoma, focused on understanding germ line risk and pharmacogenomics defining toxicity and biological responses. In Ewing sarcoma, it was harder to define opportunities for biological insights. There was agreement that the results for insulin-like growth factor pathway inhibition in Ewing family tumors were disappointing, but represented a clear indication of the need for companion biologic studies to develop predictive biomarkers. The meeting ended with broad commitment to working together to make progress in this rare but important subgroup of cancers.

Pituitary Adenylate Cyclase Activating Polypeptide, A Potential Therapeutic Agent for Diabetic Retinopathy in Rats: Focus on the Vertical Information Processing Pathway

Pituitary adenylate cyclase activating polypeptide (PACAP) is a neurotrophic and neuroprotective peptide that has been shown to exert protective effects in different neuronal injuries, such as retinal degenerations. Diabetic retinopathy (DR), the most common complication of diabetes, affects the microvasculature and neuronal architecture of the retina. We have proven earlier that PACAP is also protective in a rat model of DR. In this study, streptozotocin-induced DR was treated with intravitreal PACAP administration in order to further analyze the synaptic structure and proteins of PACAP-treated diabetic retinas, primarily in the vertical information processing pathway. Streptozotocin-treated Wistar rats received intravitreal PACAP injection three times into the right eye 2 weeks after the induction of diabetes. Morphological and molecular biological (qRT-PCR; Western blot) methods were used to analyze retinal synapses (ribbons, conventional) and related structures. Electron microscopic analysis revealed that retinal pigment epithelium, the ribbon synapses and other synaptic profiles suffered alterations in diabetes. However, in PACAP-treated diabetic retinas more bipolar ribbon synapses were found intact in the inner plexiform layer than in DR animals. The ribbon synapse was marked with C-terminal binding protein 2/Bassoon and formed horseshoe-shape ribbons, which were more retained in PACAP-treated diabetic retinas than in DR rats. These results are supported by molecular biological data. The selective degeneration of related structures such as bipolar and ganglion cells could be ameliorated by PACAP treatment. In summary, intravitreal administration of PACAP may have therapeutic potential in streptozotocin-induced DR through maintaining synapse integrity in the vertical pathway.

JNK-NQO1 axis drives TAp73-mediated tumor suppression upon oxidative and proteasomal stress

Hyperproliferating cancer cells produce energy mainly from aerobic glycolysis, which results in elevated ROS levels. Thus aggressive tumors often possess enhanced anti-oxidant capacity that impedes many current anti-cancer therapies. Additionally, in ROS-compromised cancer cells ubiquitin proteasome system (UPS) is often deregulated for timely removal of oxidized proteins, thus enabling cell survival. Taken that UPS maintains the turnover of factors controlling cell cycle and apoptosis--such as p53 or p73, it represents a promising target for pharmaceutical intervention. Enhancing oxidative insult in already ROS-compromised cancer cells appears as an attractive anti-tumor scenario. TAp73 is a bona fide tumor suppressor that drives the chemosensitivity of some cancers to cisplatin or γ-radiation. It is an important drug target in tumors where p53 is lost or mutated. Here we discovered a novel synergistic mechanism leading to potent p73 activation and cancer cell death by oxidative stress and inhibition of 20S proteasomes. Using a small-molecule inhibitor of 20S proteasome and ROS-inducer--withaferin A (WA), we found that WA-induced ROS activates JNK kinase and stabilizes phase II anti-oxidant response effector NF-E2-related transcription factor (NRF2). This results in activation of Nrf2 target--NQO1 (NADPH quinone oxidoreductase), and TAp73 protein stabilization. The observed effect was ablated by the ROS scavenger--NAC. Concurrently, stress-activated JNK phosphorylates TAp73 at multiple serine and threonine residues, which is crucial to ablate TAp73/MDM2 complex and to promote TAp73 transcriptional function and induction of robust apoptosis. Taken together our data demonstrate that ROS insult in combination with the inhibition of 20S proteasome and TAp73 activation endows synthetic lethality in cancer cells. Thus, our results may enable the establishment of a novel pharmacological strategy to exploit the enhanced sensitivity of tumors to elevated ROS and proteasomal stress to kill advanced tumors by pharmacological activation of TAp73 using molecules like WA.