Effectiveness of hand hygiene campaigns and interventions across the League of Arab States: a region-wide scoping review

Hand hygiene is a standard public health practice for limiting the spread of infectious diseases, yet they are still not routine global health behaviours. This review aimed to examine the effectiveness of various hand hygiene interventions conducted across the League of Arab States, identify gaps in the existing literature, and propose areas for future research and intervention development. A scoping review was conducted across 16 databases for relevant publications published up to and including October 2023. Forty studies met the inclusion criteria; of these, 34 were hospital-based and six community-based. Of the reviewed studies, 24 provided adequate details that would enable replication of their intervention. Eighteen of the studies used some variation of the World Health Organization's Five Moments for intervention content or assessment. More than half (N = 25) reported healthcare worker or student hand hygiene behaviours as an outcome and 15 studies also included some form of patient-centred outcomes. Six studies specified the use of theory or framework for their evaluation design or intervention content, and four studies mentioned use of local government guidelines or recommendations. Future research should focus on bridging the literature gaps by emphasizing community-based studies and integrating cultural nuances into intervention designs. Additionally, applying theoretical frameworks to hand hygiene studies could enhance understanding and effectiveness, ensuring sustainable improvements in hygiene practices across diverse settings in the League of Arab States.

Improved outcomes after hypothermic oxygenated machine perfusion in liver transplantation-Long-term follow-up of a multicenter randomized controlled trial

BACKGROUND

While 4 randomized controlled clinical trials confirmed the early benefits of hypothermic oxygenated machine perfusion (HOPE), high-level evidence regarding long-term clinical outcomes is lacking. The aim of this follow-up study from the HOPE-ECD-DBD trial was to compare long-term outcomes in patients who underwent liver transplantation using extended criteria donor allografts from donation after brain death (ECD-DBD), randomized to either HOPE or static cold storage (SCS).

METHODS

Between September 2017 and September 2020, recipients of liver transplantation from 4 European centers receiving extended criteria donor-donation after brain death allografts were randomly assigned to HOPE or SCS (1:1). Follow-up data were available for all patients. Analyzed endpoints included the incidence of late-onset complications (occurring later than 6 months and graded according to the Clavien-Dindo Classification and the Comprehensive Complication Index) and long-term graft survival and patient survival.

RESULTS

A total of 46 patients were randomized, 23 in both arms. The median follow-up was 48 months (95% CI: 41-55). After excluding early perioperative morbidity, a significant reduction in late-onset morbidity was observed in the HOPE group (median reduction of 23 Comprehensive Complication Index-points [p=0.003] and lower incidence of major complications [Clavien-Dindo ≥3, 43% vs. 85%, p=0.009]). Primary graft loss occurred in 13 patients (HOPE n=3 vs. SCS n=10), resulting in a significantly lower overall graft survival (p=0.029) and adverse 1-, 3-, and 5-year survival probabilities in the SCS group, which did not reach the level of significance (HOPE 0.913, 0.869, 0.869 vs. SCS 0.783, 0.606, 0.519, respectively).

CONCLUSIONS

Our exploratory findings indicate that HOPE reduces late-onset morbidity and improves long-term graft survival providing clinical evidence to further support the broad implementation of HOPE in human liver transplantation.

Multicentric case series of scuba diving fatalities: The role of intracardiac gaseous carbon dioxide in the forensic diagnosis

Scuba diving fatalities post-mortem diagnosis presents a higher level of forensic complexity because of their occurrence in a non-natural human life environment. Scuba divers are equipped with diving gas to breathe underwater. It is essential for them to be fully trained in order to be able to manage their dive safely despite the varying increase of ambient pressure and temperature decrease. Throughout the dive, the inhaled diving gas is dissolved in the diver's tissues during the descent and if the decompression steps are not respected during the ascent, the balance between the dissolved gas and the tissues (including blood) is disrupted, leading to a gaseous release in the organism. Depending on the magnitude of this gaseous release, free gas can occur in blood and tissue. Venous or arterial gas embolism can also occur as a consequence of decompression sickness or barotraumatism. It can also induce drowsiness that consequently leads to drowning. As a result, the occurrence of gas in dead scuba divers is very complex to interpret, as is the difficulty to distinguish it from resuscitation maneuver artifacts or body decomposition. Although the literature is scarce in this domain, significant work has been done to provide a precise intracadaveric gas sampling method to enlighten the cause and circumstances of death during the dive. The aim of this study is to obtain higher statistical significance by collecting a number of cases to confirm the gas sampling protocol and analysis and gain more information about the cause of death and the events surrounding the fatality through the establishment of clear management guidelines.

Cenicriviroc for the treatment of COVID-19: first interim results of a randomised, placebo-controlled, investigator-initiated, double-blind phase II trial

OBJECTIVES

C-C-chemokine receptors (CCRs) are expressed on a variety of immune cells and play an important role in many immune processes, particularly leukocyte migration. Comprehensive preclinical research demonstrated CCR2/CCR5-dependent pathways as pivotal for the pathophysiology of severe COVID-19. Here we report human data on use of a chemokine receptor inhibitor in patients with COVID-19.

METHODS

Interim results of a 2:1 randomised, placebo-controlled, investigator-initiated trial on the CCR2/CCR5-inhibitor Cenicriviroc (CVC) 150 mg BID orally for 28 d in hospitalised patients with moderate to severe COVID-19 are reported. The primary endpoint is the subject's responder status defined by achieving grade 1 or 2 on the 7-point ordinal scale of clinical improvement on day 15.

RESULTS

Of the 30 patients randomised, 18 were assigned to receive CVC and 12 to placebo. Efficient CCR2- and CCR5 inhibition was demonstrated through CCL2 and CCL4 elevation in CVC-treated patients (485% and 80% increase on day 3 compared to the baseline, respectively). In the modified intention-to-treat population, 82.4% of patients (14/17) in the CVC group met the primary endpoint, as did 91.7% (11/12) in the placebo group (OR = 0.5, 95% CI = 0.04-3.41). One patient treated with CVC died of progressive acute respiratory distress syndrome, and the remaining had a favourable outcome. Overall, treatment with CVC was well tolerated, with most adverse events being grade I or II and resolving spontaneously.

CONCLUSIONS

Our interim analysis provides proof-of-concept data on CVC for COVID-19 patients as an intervention to inhibit CCR2/CCR5. Further studies are warranted to assess its clinical efficacy.

Outcomes After Early Postoperative Myocardial Infarction Due to Graft Failure in Patients Undergoing Coronary Artery Bypass Grafting

BACKGROUND

Early graft failure (EGF) after coronary artery bypass grafting (CABG) occurs in up to 12% of grafts, but is often clinically unapparent. EGF may result in perioperative myocardial infarction with consequently increased mortality. The aim of the present study was to analyze the incidence of clinically apparent EGF in patients undergoing CABG and the influence on mortality.

METHODS

We analyzed outcomes of consecutive patients undergoing CABG from January 2015 to December 2018 with respect to postoperative emergency coronary angiography (CAG) due to suspected EGF and 30-day mortality. Patients with CAG-documented EGF were matched to patients without EGF to examine predictors of mortality.

RESULTS

The analysis included 5638 patients undergoing CABG. Eighty-six patients (1.5%) underwent emergency CAG due to suspected EGF. Clinically apparent EGF was observed in 61 of these patients (70.9%), whereas 14 (16.3%) had a culprit lesion in a native coronary artery. The majority of patients (n = 45; 52.3%) were treated with percutaneous coronary intervention and 31 (36%) underwent re-do CABG. The remaining patients were treated conservatively. The 30-day mortality rate of suspected EGF patients undergoing CAG was 22.4% (n = 19), which was higher than the mortality rate of 2.8% overall (P<.001); this remained higher after matching the EGF patients with the control group (11 [20.4%] vs 2 [4.0%]; P=.02).

CONCLUSION

Emergency CAG after CABG is rare and is primarily carried out in patients with EGF. The 30-day mortality rate of these patients is high, and EGF is an independent predictor of mortality. Perioperative CAG with subsequent treatment is mandatory in these patients.

Dietary Patterns in Adolescent Obesity as Predictors of Long-Term Success Following an Intensive Inpatient Lifestyle Programme

(1) Background: Lifestyle interventions for adolescents with obesity show minor long-term effects on anthropometric parameters. The persistence of dietary changes after obesity inpatient rehabilitation has not been sufficiently investigated. (2) Objectives: To analyse dietary patterns in German adolescents with obesity as predictors of long-term success following an intensive inpatient lifestyle programme regarding food choices as well as body weight and comorbidities. (3) Methods: Food consumption data of 137 German adolescents with obesity aged 10-17 years were collected by a nutrition interview. Cluster analysis was used to group the participants according to their food consumption. Dietary patterns, changes in body weight and insulin resistance were compared over a 2-year-period. (4) Results: Three dietary patterns were identified. Big Eaters (n = 32) consume high amounts of total sugar and meat, Moderate Eaters (n = 66) have a diet comparable to the national average, and Snackers (n = 39) have a particularly high consumption of total sugar. Big Eaters and Snackers significantly reduced the consumption of total sugar. Among Moderate Eaters, no persistent changes were observed. (5) Conclusion: Weight reduction interventions can induce long-lasting changes in the diet of adolescents with obesity. Therefore, the success of a weight reduction intervention should not be determined by weight reduction only.

Impact of atrial flow regulator implantation on survival in patients with heart failure with reduced and preserved ejection fraction: a post-hoc analysis of the PRELIEVE study

Purpose

This analysis aims to assess the theoretical impact of atrial flow regulator implantation on mortality by comparing the observed survival rate with the median predicted probability for one-year survival.

Methods

The prospective, multicentre, open-label, non-randomised PRELIEVE study assessed the safety and efficacy of the atrial flow regulator in patients with symptomatic HFrEF (left ventricular ejection fraction (LVEF) ≥15% and &lt;40%) or HFpEF (LVEF ≥40% and &lt;70%) and elevated PCWP (≥15mmHg at rest or ≥25mmHg during exercise). In this analysis, after the first 60 patients completed twelve months of follow-up, the theoretical impact of atrial flow regulator implantation on survival was assessed by comparing the observed mortality rate with the median predicted probability for one-year mortality. Each subject's risk of mortality was predicted from individual baseline data using the Meta-Analysis Global Group in Chronic HF (MAGGIC) prognostic model.

Results

A total of 87 patients had undergone successful device implantation for the treatment of HFrEF (53%) and HFpEF (47%). Sixty patients had a complete twelve-month follow-up. The median follow-up was 351 days (interquartile range [IQR] 202–370). A total of six (7%) patients died during follow-up (8.6 deaths per 100 patient-years; 95% confidence interval [CI] 2.7 to 15.5), all of which had HFrEF. The median predicted mortality rate for the overall study population was 12.2 deaths per 100 patient-years (95% CI 10.2 to 14.7). While the observed mortality rate (0 deaths per 100 patient-years) was significantly lower than the median predicted mortality rate (9.3 deaths per 100 patient-years; 95% CI 8.4 to 11.1) in patients with HFpEF (−9.3 deaths per 100 patient-years; 95% CI −11.1 to −8.4), there was no difference in patients with HFrEF (−3.6 deaths per 100 patient-years; 95% CI −9.5 to 3.0) (Figure 1). Four deaths were HF-related deaths (5.7 HF-related deaths per 100 patient-years; 95% CI 1.4 to 11.9; 10.8 HF-related deaths per 100 patient-years; 95% CI 2.5 to 23.1 in the HFrEF subgroup).

Conclusion

In patients with HFpEF, the mortality rate following atrial flow regulator implantation was lower than the predicted mortality rate. These findings need to be confirmed by larger randomised, controlled trials.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Occlutech International AB

Exercise MR-proANP unmasks latent right heart failure in CTEPH

Background

Chronic right heart failure is the major determinant of outcome in chronic thromboembolic pulmonary hypertension (CTEPH). Thus, its early detection is crucial for optimal patient management. Hemodynamic assessment with invasive right heart catheterization and the measurement of natriuretic peptides at rest are established diagnostic tools in this context. An elevated right atrial pressure (RAP) is a sensitive parameter of right right heart failure. Mid-regional pro-atrial natriuretic peptide (MR-proANP) is a natriuretic peptide that reflects right atrial stress levels.

There is a growing recognition of exercise diagnostics in the assessment of right heart failure, particularly in patients with normal or borderline findings at rest. There are no data on the dynamics of MR-proANP in correlation to RAP during physical exercise.

Purpose

The present study was designed to investigate the dynamics of RAP and MR-proANP during physical exercise in patients with CTEPH and to determine whether these parameters might serve as a tool to measure exercise-dependent atrial stress as an indicator of right heart failure.

Methods

This observational cohort study included 100 CTEPH patients who underwent right heart catheterization during physical exercise (eRHC). Blood samples for MR-proANP measurement were taken prior, during, and after eRHC. MR-proANP levels were correlated to RAP levels at rest, at peak exercise (eRAP), and during recovery. RAP at rest ≤7 mmHg was defined as normal and eRAP &gt;15 mmHg as suggestive of right heart failure.

Results

During eRHC mean RAP increased from 6±4 mmHg to 16±7 mmHg (p&lt;0.001). MR-proANP levels and dynamics correlated with RAP at rest (rs=0.61; p&lt;0.001; figure 1a) and at peak exercise (rs=0.66; p&lt;0.001; Figure 1b). Furthermore, the relative percent increase in MR-proANP correlated with the relative percent increase in eRAP (rs=0.52; p&lt;0.001; Figure 1c) Logistic regression analysis revealed the peak MR-proANP level (B=0.058; p=0.004) and the right atrial area (B=0.389; p&lt;0.001) to be associated with eRAP dynamics. A peak MR-proANP level ≥139 pmol/L (AUC=0.81) and recovery level ≥159 pmol/L (AUC=0.82) predicted an eRAP &gt;15 mmHg. Physical exercise unmasked RH failure in 39% of patients with normal RAP at rest; they were also characterized by a more distinct increase in MR-proANP levels (p=0.005) and higher peak (p&lt;0.001) and recovery levels (p&lt;0.001).

Conclusions

RAP and MR-proANP dynamics unmask manifest and latent right heart failure in CTEPH patients, which may be useful in estimating prognosis.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): SFB 1213 area CP-01 projectWilliam G. Kerckhoff-FoundationKerckhoff Heart Research Institute (KHFI)German Center for Cardiovascular Research (DZHK)

Impact of inflammatory phenotype on prognostic discrimination for the novel biomarker cellular communication network factor 1 (CCN1) in patients with dilated cardiomyopathy

Objective

Circulating cellular communication network factor 1 (CCN1) improves risk stratification in ACS patients and, as we have recently shown, predicts all-cause mortality in patients with dilated cardiomyopathy (DCM). It was the aim of this study to evaluate whether the prognostic role of CCN1 is influenced by an inflammatory phenotype.

Methods

Patients with a primary diagnosis of DCM, defined as LVEF &lt;45% and an increased LVEDD (according to HENRY &gt;117%), were included in this single-center study. Exclusion criteria comprised primary valvular diseases (≥second degree), acute myocarditis, active infectious diseases, pulmonary diseases, cancer, chronic alcoholism, and heart failure of other origins. CCN1 levels were determined in serum at study inclusion using an enzyme-linked immunosorbent assay. The primary endpoint was all-cause mortality during follow-up. An adjusted multivariable cox regression model was used to assess the association between CCN1 and all-cause mortality. We further analysed potential effect modifications by adding either an interaction term between CCN1 and DCMi diagnosis (DCMi vs. DCM). The Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score to predict all-cause mortality in HF patients was used as a reference model. The performance of CCN1 in combination with the MAGGIC score and NT-proBNP to predict all-cause mortality was assessed using Cox's proportional-hazards models

Results

A total of 283 predominantly male DCM patients (78.5% males) with a median age of 55.7 (interquartile range [IQR 48.2, 65.7]) years and predominantly recent onset of disease (3.8 [IQR 1.1, 20.5] months) with a severely reduced LVEF (31 [IQR 25, 37] %), increased LVEDD (67.0 [IQR 62.8, 72.0] mm), and normal eGFR (CKD-EPI) (90.9 [IQR73.9, 102.4] ml/min) were analyzed. During a median follow-up of 12.4 [IQR 10.5, 14.0] years, a total of 107 (37.8%) patients died. Patients in the highest CCN1 tertile had a significantly higher mortality risk than those in the lower tertile (HR 1.82; 95% CI 1.06, 3.14; P=0.030) in adjusted multivariable Cox regression models. Adding CCN1 to the MAGGIC risk score improved c-statistics for prognostic accuracy of all-cause mortality at 6 years (0.624 to 0.645, p=0.012), unlike NT-proBNP (0.624 to 0.630, p=0.123). Patients classified as DCMi (n=128) had significantly lower CCN1 levels compared with classical DCM (n=155) (154.9 (115.4–191.7) vs. 174.7 (130.0–241.0) pg/ml, P=0.022). Inflammation status (DCMi vs DCM) had no significant impact (P interaction = 0.28) on the association of CCN1 and all-cause mortality (Fig. 1).

Conclusion

CCN1 independently predicts all-cause mortality in DCM patients and improves risk stratification beyond the MAGGIC score. In this pilot cohort, the inflammatory phenotype had no impact on prognostic discrimination. Data are currently analyzed in a validation cohort.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Kerckhoff Research Foundation

The long non-coding RNA Heat4 is dynamically regulated during cardiogenic shock

Background and purpose

Cardiogenic shock (CS) remains the leading cause of death in acute myocardial infarction (AMI), with high mortality rates of 40–50%. The long non-coding RNA (lncRNA) Heat4 is associated with the inflammatory response of non-classical monocytes. Previous experimental work shows that this mechanism may be important in heart failure (HF) and during regeneration after vascular injury. Here, we investigate the association of Heat4 with survival in patients with chronic HF and assessed its regulation in AMI and CS.

Methods and results

Heat4 was elevated in the blood of HF patients compared to age-matched non-failing controls (+5.2-fold; HF: N=63; Controls: N=38; p&lt;0.05). Heat4 showed a positive correlation with systemic inflammation (hsCRP; r=0.41; p&lt;0.05) and was negatively associated with LVEF (r=−0.45; p&lt;0.001). Heat4 blood levels showed good discriminatory power for prevalence of HF (AUC = 0.734; p&lt;0.05) and mortality prediction after 4-year follow-up (AUC = 0.789; HF: Death N=32; Controls: Death N=0; p&lt;0.05). Furthermore, Heat4 was elevated in the blood of patients with AMI compared to controls (+1.85-fold; AMI: N=42; Controls: N=23; p&lt;0.05). Heat4 showed a very strong induction in patients suffering from CS (+284.5-fold; CS: N=4; Controls: N=5; p&lt;0.05). In agreement with an anti-inflammatory signaling, Heat4 showed a dynamic regulation in patients with CS with a 284.5-fold increase during acute shock and a decrease 24 hours after revascularization (−82.3% compared to day of revascularization). This regulation was validated in an independent second cohort.

Conclusion

The lncRNA Heat4 is upregulated in the blood of patients with chronic heart failure, acute myocardial infarction and cardiogenic shock. In CS, Heat4 is dynamically regulated. These data set the stage to further assess Heat4 blood levels as a strategy for risk stratification and potential treatment target in HF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Projektfoerderung im Bereich der Herzmedizin, Leipzig

The long non-coding RNA Heat4 is elevated in heart failure patients and mediates anti-inflammatory functions thereby promoting vascular regeneration

Background and purpose

Activation of the immune system correlates with the severity and the prognosis of patients with heart failure (HF). Here, we aim to identify and characterize long non-coding RNAs (lncRNAs) as a potential mechanistic link between the activation of the immune system and the pathophysiology of HF.

Methods and results

Using next-generation sequencing we found a yet uncharacterized lncRNA to be significantly upregulated in peripheral blood mononuclear cells of ischemic cardiomyopathy patients compared to controls, which we named Heat4 – Heart-disease associated transcript 4 (N=4; 2.05-fold increase; p&lt;0.05). In the blood, monocytes show the highest expression of Heat4 and here in particular the non-classical monocytes compared to classical monocytes (N=4; 3.37-fold; p&lt;0.05). Matching the known anti-inflammatory properties of this monocyte subpopulation we found that overexpression of Heat4 in monocytes resulted in decreased levels of inflammation (TNFα: −38.6%; p&lt;0.05). Accordingly, a knockdown of Heat4 increased levels of inflammatory cytokine expression (TNFα: +4.14-fold; p&lt;0.05). Non-classical monocytes are known to maintain vascular homeostasis by patrolling the endothelium in search of injury. Indeed, overexpression of Heat4 in human monocytes increased vascular regeneration after injury of the carotid artery in NOD-SCID mice (N=6; +1.85-fold compared to injection of control monocytes; p&lt;0.05). We found Heat4 enriched in the cytoplasm of monocytes compared to the nuclear fraction. Using biotin-labelled RNA probes containing 2$'$O-Me-RNA oligonucleotides we performed RNA antisense affinity selection and subsequent mass spectrometry to identify proteins interacting with Heat4. We found two proteins, namely IP1 and IP2, enriched in the Heat4 fraction (+1.20 and +1.45-fold, respectively compared to the control probe). Knockdown of IP1 resulted in reduced induction of inflammatory gene expression (IL-6: −49.2%; p&lt;0.05) after stimulation of monocytes with TNFα. Mechanistically, overexpression of Heat4 resulted in reduced extracellular levels of the IP1/IP2 heterodimer (IP1/IP2: −23.6%; p&lt;0.05) as determined by ELISA.

Conclusion

The lncRNA Heat4 is elevated in the blood of patients with HF. Heat4 limits the extent of the inflammatory response of non-classical monocytes and leads to a faster regeneration after vascular injury. Heat4 is located in the cytoplasm of monocytes interacting with the pro-inflammatory proteins IP1/IP2 and repealing their extracellular release. Modulating Heat4 levels may represent a novel strategy for treatment of cardiovascular diseases with impaired vascular functions.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Projektfoerderung im Bereich der Herzmedizin, Leipzig

App-Based Relaxation Exercises for Patients With Chronic Neck Pain: Pragmatic Randomized Trial

Background

Chronic neck pain is a highly prevalent condition. Learning a relaxation technique is recommended by numerous guidelines for chronic neck pain. Smartphone apps can provide relaxation exercises; however, their effectiveness, especially in a self-care setting, is unclear.

Objective

The aim of this pragmatic randomized trial is to evaluate whether app-based relaxation exercises, including audio-based autogenic training, mindfulness meditation, or guided imagery, are more effective in reducing chronic neck pain than usual care alone.

Methods

Smartphone owners aged 18 to 65 years with chronic (>12 weeks) neck pain and the previous week’s average neck pain intensity ≥4 on the Numeric Rating Scale (0=no pain to 10=worst possible pain) were randomized into either an intervention group to practice app-based relaxation exercises or a control group (usual care and app for data entry only). For both groups, the follow-up data were collected using app-based diaries and questionnaires. The primary outcome was the mean neck pain intensity during the first 3 months based on daily measurements. Secondary outcomes included neck pain based on weekly measurements, pain acceptance, neck pain–related stress, sick-leave days, pain medication intake, and adherence, which were all measured until the 6-month follow-up. For the primary analysis, analysis of covariance adjusted for baseline neck pain intensity was used.

Results

We screened 748 participants and enrolled 220 participants (mean age 38.9, SD 11.3 years; mean baseline neck pain 5.7, SD 1.3 points). The mean neck pain intensity in both groups decreased over 3 months; however, no statistically significant difference between the groups was found (intervention: 4.1 points, 95% CI 3.8-4.4; control: 3.8 points, 95% CI 3.5-4.1; group difference: 0.3 points, 95% CI −0.2 to 0.7; P=.23). In addition, no statistically significant between-group differences regarding neck pain intensity after 6 months, responder rate, pain acceptance, pain medication intake, or sick-leave days were observed. There were no serious adverse events that were considered related to the trial intervention. In week 12, only 40% (44/110) of the participants in the intervention group continued to practice the exercises with the app.

Conclusions

The study app did not effectively reduce chronic neck pain or keep the participants engaged in exercising in a self-care setting. Future studies on app-based relaxation interventions should take into account the most recent scientific findings for behavior change techniques.

Trial Registration

ClinicalTrials.gov NCT02019134; https://clinicaltrials.gov/ct2/show/NCT02019134

International Registered Report Identifier (IRRID)

RR2-10.1186/1745-6215-15-490

A data-pipeline processing electrocardiogram recordings for use in artificial intelligence algorithms

Introduction

Artificial intelligence (AI) can be used for various tasks in medicine and specifically in cardiology. Medical data such as electrocardiogram recordings (ECGs) are widely used and universally accepted as diagnostic and prognostic tools. It has been shown that deep learning methods using ECGs yield excellent results detecting cardiac pathologies. A significant amount of reliable data is required for supervised learning algorithms such as deep learning models. However, only a small fraction of ECG data generated in daily practice is available in a fully digital and machine-readable format, such as XML. Frequently, used ECG devices produce PDF files or even paper-based print outs, which need to be digitised later for inclusion in clinical information systems. Such ECGs cannot be used without further effort for training or application of deep learning models. Therefore, aim of the present project was to develop a data-pipeline that generates machine-readable ECG data for AI use data irrespective of the initial ECG format.

Methods

We propose an end-to-end pipeline that can not only process data from modern digital ECG devices but is also capable of extracting all necessary information from PDF files (both scanned hard copies and digitally generated PDFs) (see Figure 1). By using different techniques including adaption of open source libraries for vectorisation of image data, and modern computer vision technologies, such as optical character recognition (OCR), our pipeline is able to flexibly process data from different recording devices and read both data in PDF format and data from native digital devices delivered in XML. The processed files from various sources are either saved as a common and easily accessible CSV file format, or are processed directly with deep learning models (see Figure 2).

Results

The developed data-pipeline was validated using data from a set of 113 12-lead ECGs for which data was available in multiple formats. Each format dataset was separately processed by our pipeline and then used for training and validation of a deep learning architecture for myocardial scar detection based on raw ECG signals. The quality of the extraction process by our pipeline was assessed by the respective deep learning models with their prediction capability depicted by receiver operator characteristic analyses (ROC). Comparing the benchmark model that was generated from XML data against a model that was purely trained on PDF data processed by the pipeline shows that both models produced comparable results, reaching area under the curve (AUC) values of 0:79±0:10 (XML) and 0:83±0:07 (PDF).

Conclusion

The data pipeline facilitates acceleration of ECG-based AI research and application of AI algorithms by providing access to ECG data irrespective of the format of the stored ECG. Future work will focus on independent validation as well as expanding this pipeline to include additional ECG types.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Flexi Funds by Forschungscampus Mittelhessen

Effect of transcatheter aortic valve implantation on left ventricular pressure overload indicated by inflammatory biomarkers in high-risk patients

Background

Severe aortic stenosis (AS) is associated with left ventricular (LV) pressure overload that leads to myocardial remodelling and inflammatory processes. Interleukin 6 (IL6) is secreted by leukocytes as an early response to infection and tissue damage as well as high senisitve C-reactive Protein (hsCRP), which is subsequent in the same pathway. Several studies have suggested an association of elevated serum levels with a higher risk of cardiovascular events. GDF-15 and MR-proADM are also associated with inflammatory processes in cardiovascular diseases and are predictors for adverse events and mortality in patients with AS. The aim of the present study was to evaluate their potential prognostic value regarding the patients all-cause mortality.

Methods

A total of 92 consecutive patients (mean age: 80,8 [±5,3] years) undergoing TAVI were included in this study. TAVI was performed according to standard clinical practice. Venous blood samples for biomarker analysis were collected prior to and 6 months after TAVI, these were processed immediately and frozen at −80°C until the assay was performed. Safety events, physiological- and echocardiographical parameters, were assessed at the baseline and the 6-month follow-up. Furthermore, we compiled the all-cause mortality of our patients after two years.

Results

TAVI was performed successfully in all patients. During the two-year follow-up period 24 patients met the endpoint of all-cause mortality. At baseline, serum levels of the inflammatory biomarkers were significantly higher in patients who died within the follow-up period, when compared to survivors (IL6:14,450pg/ml [IQR:7,550; 42,150] vs. 4,200pg/ml [IQR:2,515; 13,875],p=0,0004; hsCRP:5,360 mg/l [IQR:2,248; 26,790] vs. 2,900mg/l [IQR:1,208; 8,210],p=0,022); MR-proADM:1,347nmol/l [IQR:1,038–1,678] vs. 0,922nmol/l [IQR:0,706; 1,202],p=0,0003 and GDF-15:2770,0pg/ml [IQR:2401,0; 3701,0] vs. 1675,2pg/ml [IQR:1141,6; 2524,4],p=0,001). The area under the curve was 0,767 for IL-6, 0,665 for hsCRP, 0,735 for MR-proADM and 0,735 for GDF-15. In addition, there was a significant decrease of IL-6 (baseline: 4,200pg/ml [IQR:2,525; 13,875] vs. 6FU:2,600pg/ml [IQR:1,500; 7,000],p&lt;0,0001), hsCRP (baseline:2,900mg/l [IQR:1,208; 8,210] vs. FU: 2,101 mg/l [IQR: 0,980; 4,540],p=0,002) and MR-proADM (baseline:0,922nmol/l [IQR:0,706–1,202] vs. FU: 0,828nmol/l [IQR:0,642–1,132],p=0,01) serum levels in survivors after a follow-up of 6 months after TAVI, when compared to baseline values. While the median serum levels of GDF-15 (baseline:1675,2pg/ml [IQR:1141,6; 2524,4] vs. FU: 1663,8pg/ml [IQR:1176,5; 2538,1],p=0,563) remained stable.

Conclusions

In the present study there was a significant decrease of inflammatory biomarkers after TAVI in high risk patients with severe aortic stenosis and good clinical outcome. In this regard, IL-6, hsCRP, MR-proADM and GDF-15 were predictors of all-cause mortality in patients, who underwent TAVI.

Funding Acknowledgement

Type of funding sources: None.

On the importance of representative datasets in ECG-based artificial intelligence

Background/Introduction

ECG-based artificial intelligence (AI) is an emerging field in digital cardiology. Training on diseased records vs. healthy controls is common practice. We aimed to evaluate if such an approach can lead to unwanted behaviour in real-world settings and thus unnecessarily reduce diagnostic precision of the developed AI model.

Purpose

Several studies have shown that deep neural networks are able to exceed performance of medical experts. However, when these models are applied to different cohorts, results vary strongly. We hypothesise that this is because the datasets used for training were not representative for the target population.

Methods

Based on the public ECG database PTB-XL we sampled three distinct subsets of n=150 records representing ECG groups labelled for diagnoses 'old myocardial infarction' (M), 'normal ECG' (N), or 'other cardiac abnormality' (O). These groups were combined to three datasets ([M, N] (n=300), [M, O] (n=300), [M, N, O] (n=450)), representing different approaches to data sampling. On each dataset, we trained a separate but equally structured deep neural network using 100-fold bootstrapping. The diagnostic performance of each model was validated on unseen data from all datasets with sensitivity, specificity and area under the receiver operator characteristic curve.

Results

Evaluation of the three differently trained models shows best diagnostic performance on the M vs. N records and worst on the M vs. O records. However, in the out-of-dataset setting, the best-performing model (trained on [M, N]) shows weaker performance on the [M, N, O] and [M, O] datasets. Sensitivity for the same model remained equal, as identical M records were used throughout corresponding bootstrapping folds. Detailed results are presented in Table 1.

Conclusions

Our results suggest that the model trained on a dataset including only diseased records vs. healthy controls [M, N] learned to recognise healthy (N) instead of diseased (M) records, which explains why it performed poorly on datasets including records showing other cardiac abnormalities (O). Such behaviour is a common problem in AI and requires special attention in dataset sampling. For small cohorts, it is tempting to increase the amount of training data by using healthy controls. However, we have shown that this can be a poor option, since classifiers can more easily rely on features that are not actually related to the target disease. Training and validation of classifiers should therefore be performed on representative datasets that are as close as possible to the target population.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Forschungscampus Mittelhessen, Flexi Funds Table 1

Predicting mortality in cardiovascular patients using electrocardiogram data and artificial intelligence

Background/Introduction

The electrocardiogram (ECG) is an ubiquitously used non-invasive tool for diagnosis and risk prediction in cardiology, granting deep extensive insights into the heart. Artificial intelligence (AI) is a modern resource allowing the processing of vast complex datasets in a way that is comparable to humans. Risk stratification in cardiovascular patients is mainly based on scoring systems, such as the ESC-SCORE, relying on traditional risk variables like cholesterol levels or arterial hypertension, rather than actual cardiac structure and function. Goal of this project was to predict mortality using AI in patients with cardiovascular risk based on the current cardiac situation represented by a standard 12-lead ECG recording.

Methods

The study population is based on an ongoing registry that started in 2010 and enrolled patients scheduled for an invasive coronary angiography due to suspected chronic coronary syndrome. Data of the following study patients were analysed: enrolment within the first two study years with available long-term follow-up data on the outcome measure overall mortality, availability of an ECG at admission without pacemaker stimulation and availability of all variables needed to calculate the ESC-SCORE (in the version weighed for a German population) as comparison. This led to a cohort of 720 patients, of whom 70 died within the follow-up period. Information on presence of a relevant coronary artery disease (CAD) was available for all patients, to differentiate between primary and secondary prevention. A deep learning architecture that was previously developed to detect myocardial scar in raw ECG time-series data was used. This model was trained with 1400 ECG recordings, from the publicly available PTB-XL dataset with 700 of those ECGs labelled for acute, recent or old myocardial infarction while 700 were labelled as healthy. This pre-trained model was then applied to our study cohort to predict long-term mortality based on a single 12-lead ECG obtained at admission.

Results

For mortality prediction in patients without CAD (primary prevention) the AI model compares to the ESC-SCORE with an AUROC of 0.606 vs 0.584. For CAD patients (secondary prevention) the AI model compares with an AUROC of 0.612 vs 0.658. Detailed results are presented in Table 1.

Conclusion(s)

Our data underlines the potential of an AI based approach, predicting mortality in cardiovascular patients using only single 12-lead ECG recordings. Additionally, our model achieved similar predictive information to established risk classification systems, such as the ESC-SCORE. Since data acquisition is still ongoing, we will continue to improve our model. In future work training AI to specifically predict mortality while also exploring explainable AI could lead to breakthrough findings in ECG interpretation.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): FlexiFunds by Forschungscampus Mittelhessen

The long non-coding RNA Heat4 is upregulated in heart failure and decreases the immune response of non-classical monocytes

Background and purpose

Activation of the immune system correlates with the severity and the prognosis of patients with heart failure (HF). This study aims to identify and characterize long non-coding RNAs (lncRNAs) as a potential mechanistic link between the pathophysiology of HF and the activation of the immune system.

Methods and results

Next-generation sequencing (NGS) studies identified a 2.05-fold increase of the lncRNA Heat4 in the blood of patients with HF compared to controls, which was validated in a larger cohort (HF: N=63; Controls: N=38; p&lt;0.05). Interestingly, the lncRNA Heat4 is encoded in the well-known immune receptor locus CD300, together with 8 CD300-receptors which are associated with activation of the immune system. To determine the cellular origin of Heat4 in blood, we performed MACS and identified Heat4 to be enriched in non-classical monocytes compared to classical monocytes (3.37-fold, p&lt;0.05). The expression of Heat4 in non-classical monocytes was further validated by single-cell RNA sequencing. Overexpression of Heat4 in monocytes decreased levels of pro-inflammatory cytokines such as TNFα (38.6% reduction, p&lt;0.05). Conversely, the knockdown of Heat4 resulted in elevated levels of pro-inflammatory cytokines, including IL6 (10.83-fold, p&lt;0.05) and TNFα (4.14-fold, p&lt;0.05). In a larger cohort including patients with HF, Heat4 was able to determine the prevalence of heart failure by AUC=0.734 (p&lt;0.05). Moreover, in a 4-year follow-up of the same cohort, Heat4 predicted mortality by AUC=0.789 (HF: N=63, Dead=32; Controls: N=38, Dead=0; p&lt;0.05).

Conclusion

The long non-coding RNA Heat4 is elevated in the blood of HF patients. Mechanistically, Heat4 limits the extent of the inflammatory response of non-classical monocytes. Therefore, Heat4 may provide a regulatory link between inflammation and HF.

Funding Acknowledgement

Type of funding sources: None.

C0-C1f region of cardiac myosin binding protein-C induces pro-inflammatory responses in fibroblasts

Background

Cardiac myosin binding protein-C is a protein expressed in the myosin thick filament backbone that was recently described as a novel cardiac biomarker. Its N-terminal region, C0-C1f, is released within the first minutes of ischemia and plays a crucial role in the initiation of inflammation in bone marrow-derived macrophages. Long-term C0-C1f exposure induces cardiac fibrosis in transgenic mice; however, the mechanism by which C0-C1f causes fibrosis is unclear. The aim of the study was to investigate the effects of C0-C1f on fibroblasts, which are the main contributor to cardiac fibrosis, in vitro. We determined whether C0-C1f directly activates fibroblasts and causes a transdifferentiation to myofibroblasts or induces inflammatory responses. Moreover, we clarify whether other cell types could be involved in inducing fibrosis, i.e. by the release of pro-inflammatory cytokines upon C0-C1f interaction.

Methods

A novel human fibroblast cell line (huFib) was treated with C0-C1f, C0-Linker, TGF-β, or LPS for different time periods. Inflammatory and fibrotic responses were evaluated at the RNA and protein level using different techniques including microarray, qRT-PCR, and immunofluorescence imaging. For signalling pathway analysis, TLR4 and NFκB were inhibited using chemical compounds TAK-242 or Bay11–0785 respectively.

Results

C0-C1f treatment induced an increase in mRNA corresponding to pro-inflammatory genes in huFib cells (i.a. CXL1 upon 24 hours treatment: 29 fold, p&lt;0.001 and CCL2 4-fold, p&lt;0.001). The mRNA expression levels of pro-fibrotic genes such as ACTA2 or COL1A1, which were upregulated by TGF-β, were not reduced by C0-C1f (ACTA2 induced by TGF-β: 3,8 fold, p&lt;0.001, co-stimulation with C0-C1f: 1,8 fold, p=0.11 compared to control; COL1A1 induced by TGF-β: 2,94 fold, p&lt;0.001, co-stimulation with C0-C1f: 2.09 fold (p&lt;0.01) compared to control. Interestingly, co-stimulation of fibroblasts with C0-C1f and TGF-β led also to markedly lower inflammatory response compared to C0-C1f treatment alone (CXCL1 induction upon co-stimulation: 2,0 fold, p&lt;0.001, CCL2: 1,9 fold, p=0.001, which is a reduction by 27 fold, p&lt;0.001 or 2 fold, p=0.002, respectively). Inhibition of TLR4 or NFκB signaling diminished C0-C1f-mediated inflammatory responses.

Conclusion

C0-C1f induces inflammation in fibroblasts via TLR4/NFκB signalling pathway. Downregulation of C0-C1f mediated inflammatory responses upon co-stimulation with TGF-β suggests crosstalk between the two signaling pathways. Contrary, C0-C1f reduced TGF-β mediated pro-fibrotic responses reflected by conversion of fibroblasts into myofibroblasts was not observed. Taken together, these data are consistent with the idea that C0-C1f might play a key role in the early initiation of inflammation upon myocardial infarction, also in fibroblasts, and that TGF-β acts as a counterpart at later stages of cardiac remodeling.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): William G. Kerckhoff Stiftung für wissenschaftliche Forschung und Fortbildung

Detecting a broader spectrum of cardiac pathologies in electrocardiogram data by applying a deep neural network designed to detect a specific cardiac disease

Background/Introduction

The electrocardiogram (ECG) is a widely used and inexpensive tool that provides extensive insights into the cardiac structure and function. Artificial intelligence (AI) algorithms, especially deep learning (DL) models, are efficient computer based instruments with which large and complex datasets can be processed for identification of e.g. specific diseases. PhysioNet is a NIH research resource for complex signals including a large amount of labelled ECG time-series data. Our aim was to evaluate the diagnostic performance of an AI architecture developed to detect a specific cardiac pathology in a large ECG data set including a broad range of cardiac abnormalities.

Methods

The PhysioNet ECG dataset provided as part of the PhysioNet Challenge 2020 consists of five distinct databases with a total of 43100 12-Lead ECG recordings of varying length stemming from patients from China, Russia, Europe and the United States. Each ECG recording is annotated with diagnoses based on a set of 111 possible labels, which express either a cardiac pathology, e.g. atrial flutter or anterior wall ischemia, or unspecific changes in the ECG, e.g. a prolonged qt interval or low qrs voltages. Based on these labels we defined 10 groups merging PhysioNet labels describing related cardiac abnormalities (see Table 1). We adapted a recently published DL model which used raw ECG time-series data of all 12-leads rather than extracted features as model input. This DL model was adapted to the larger number of output variables and then trained on 80% (n=34480 ECGs) of the PhysioNet dataset. The remaining 20% (n=8620 ECGs) of the PhysioNet dataset were used to evaluate the diagnostic performance of the AI model. Sensitivities, specificities and the areas under the receiver operator characteristic curves (AUROC) were used as performance metrices.

Results

The AI model, that was initially designed to detect a specific cardiac pathology, performed well in the large PhysioNet dataset providing AUROCs ranging from 0.78 to 0.95 to detect the defined 10 cardiac abnormality groups. Interestingly, the AI model was able to detect disease groups with changes in the chronological sequence of the ECG, e.g. arrhythmia, with comparable precision as disease groups associated primarily with changes in the ECG amplitude like e.g. ischemia. Detailed results are presented in Table 2.

Conclusion(s)

Our evaluation shows that an AI model that uses raw ECG time-series data rather than extracted features as model input can be easily transferred to other large datasets with different prediction variables. This might also serve as a proof of concept that raw data instead of pre-selected features should be used as model input if developing AI applications for medical use cases.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): FlexiFunds by Forschungscampus Mittelhessen

Treatment of intraoperative hypotension with cafedrine/theodrenaline versus ephedrine : A prospective, national, multicenter, non-interventional study-the HYPOTENS trial

BACKGROUND

Sympathomimetic drugs are a therapeutic cornerstone for the management of hypotensive states like intraoperative hypotension (IOH). While cafedrine/theodrenaline (C/T) is widely used in Germany to restore blood pressure in patients with IOH, more research is required to compare its effectiveness with alternatives such as ephedrine (E) that are more commonly available internationally.

METHODS

HYPOTENS (NCT02893241, DRKS00010740) was a prospective, national, multicenter, open-label, two-armed, non-interventional study that compared C/T with E for treatment of IOH. We describe a prospectively defined cohort of patients ≥50 years old with comorbidities undergoing general anesthesia induced with propofol and fentanyl. Primary objectives were to examine treatment precision, rapidity of onset and the ability to restore blood pressure without relevant increases in heart rate. Secondary endpoints were treatment satisfaction and the number of required additional boluses or other accompanying measures.

RESULTS

A total of 1496 patients were included in the per protocol analysis. Overall, effective stabilization of blood pressure was achieved with both C/T and E. Post-hoc analysis showed that blood pressure increase from baseline was more pronounced with C/T. Fewer additional boluses or other accompanying measures were required in the C/T arm. The incidence of tachycardia was comparable between groups. Post-hoc analysis showed that E produced dose-dependent elevated heart rate values. By contrast, heart rate remained stable in patients treated with C/T. Physicians reported a higher level of treatment satisfaction with C/T, with a higher proportion of anesthetists rating treatment precision and rapidity of onset as good or very good when compared with E.

CONCLUSION

Neither drug was superior in restoring blood pressure levels; however, post-hoc analyses suggested that treatment is more goal-orientated and easier to control with C/T. Heart rate was shown to be more stable with C/T and fewer additional interventions were required to restore blood pressure, which could have contributed to the increased treatment satisfaction reported by anesthetists using C/T.

Safe procedures despite ultra low radiation doses during catheter ablations of atrial and ventricular arrhythmias-A multicenter experience

INTRODUCTION

Despite the development of non-fluoroscopic catheter visualization options, fluoroscopy is still used in most ablation procedures. The aim of this multicenter study was to evaluate the safety and efficacy of a new ultra-low dose radiation protocol for EP procedures in a large number of patients.

METHODS AND RESULTS

A total of 3462 consecutive patients (male 1926 (55.6%), age 64.4 ± 14.0 years, BMI 26.65 ± 4.70) undergoing radiofrequency ablation (left atrial (n = 2316 [66.9%], right atrial (n = 675 [19.5%], or ventricular (n = 471 [13.6%]) in three German centers were included in the analysis. Procedures were performed using a new ultra-low dose protocol operating at 8nGy for fluoroscopy and 36nGy for cine-loops. Additionally a very low framerate (2-3FPS) was used. Using the new protocol very low Air kerma-area product (KAP) values were achieved for left atrial ablations (104.25 ± 84.22 μGym² ), right atrial ablations (70.98 ± 94.79 μGym² ) and ablations for ventricular tachycardias or PVCs (78.62 ± 66.59 μGym² ). Acute procedural success was achieved in 3289/3388 (97.1%) while the rate of major complications was very low compared to previously published studies not using low dose settings (n = 20, 0.6%).

CONCLUSION

The ultra-low dose, low framerate protocol leads to very low radiation doses for all EP procedures while neither procedural time, fluoroscopy time nor success or complication rates were compromised. When compared to current real-world Air KAP data the new ultra-low dose fluoroscopy protocol reduces radiation exposure by more than 90%.

Prolonged multimodal fasting modulates periodontal inflammation in female patients with metabolic syndrome: A prospective cohort study

AIM

To determine the potential anti-inflammatory effect of a multimodal periodic fasting programme on surrogate parameters of periodontal inflammation in hospitalized patients diagnosed for metabolic syndrome (MetS).

MATERIAL AND METHODS

A total of 47 patients were recruited and hospitalized in an integrative ward for an intensified two-week multimodal fasting, diet and lifestyle programme. Patients were periodontally examined at baseline (t1), after the 2-week fasting protocol (t2) and, subsequently, 4 months after fasting (t3). The following parameters were determined: periodontal screening index (PSI), bleeding on probing (BOP), gingival crevicular fluid volume (GCF), plaque index (PI), C-reactive protein (CRP), blood pressure (BP), waist circumference (WC), fasting glucose (FGLU), triglycerides (TRG), high-density lipoprotein (HDL) and HbA1c.

RESULTS

A total of 28 female and 8 male patients fulfilled the defined criteria for MetS and were analysed separately by gender. At t2, BOP and GCF were reduced when compared to t1 (median: t2 = 39; t1 = 33.1%; p < .001 and t2 = 73.9; t1 = 59.3 Periotron units p = .02, respectively). BOP reduction correlated to FGLU (R = .37, p = .049) and weight reduction (R = .4, p = .04).

CONCLUSION

This study showed for the first time that clinically supervised periodic fasting in female patients with MetS may facilitate the reduction of periodontal inflammation.

Cardiac arrhythmias in patients with COVID-19: Lessons from 2300 telemetric monitoring days on the intensive care unit

BACKGROUND

Patients with COVID-19 seem to be prone to the development of arrhythmias. The objective of this trial was to determine the characteristics, clinical significance and therapeutic consequences of these arrhythmias in COVID-19 patients requiring intensive care unit (ICU) treatment.

METHODS AND RESULTS

A total of 113 consecutive patients (mean age 64.1 ± 14.3 years, 30 (26.5%) female) with positive PCR testing for SARS-CoV2 as well as radiographically confirmed pulmonary involvement admitted to the ICU from March to May 2020 were included and observed for a cumulative time of 2321 days. Fifty episodes of sustained atrial tachycardias, five episodes of sustained ventricular arrhythmias and thirty bradycardic events were documented. Sustained new onset atrial arrhythmias were associated with hemodynamic deterioration in 13 cases (35.1%). Patients with new onset atrial arrhythmias were older, showed higher levels of Hs-Troponin and NT-proBNP, and a more severe course of disease. The 5 ventricular arrhythmias (two ventricular tachycardias, two episodes of ventricular fibrillation, and one torsade de pointes tachycardia) were observed in 4 patients. All episodes could be terminated by immediate defibrillation/cardioversion. Five bradycardic events were associated with hemodynamic deterioration. Precipitating factors could be identified in 19 of 30 episodes (63.3%), no patient required cardiac pacing. Baseline characteristics were not significantly different between patients with or without bradycardic events.

CONCLUSION

Relevant arrhythmias are common in severely ill ICU patients with COVID-19. They are associated with worse courses of disease and require specific treatment. This makes daily close monitoring of telemetric data mandatory in this patient group.

The effect of osteopathic medicine on pain in musicians with nonspecific chronic neck pain: a randomized controlled trial

Background:

Nonspecific chronic neck pain (cNP) is common in adult violinists and violists and is often treated with osteopathic medicine (OM), although the effectiveness of this treatment has not been determined to date. This study aimed to evaluate the effectiveness and safety of OM in adult violinists and violists with cNP.

Methods:

In a two-armed randomized controlled single-center open trial, adult violinists and violists, including music students, with cNP (⩾12 weeks) were randomized to either five individualized OM sessions (OM group) or to no intervention (control group, CG) in the outpatient clinic for integrative medicine, Charité - Universitätsmedizin Berlin, Germany. All patients received a musicians’ medicine consultation and paracetamol on demand. The primary outcome parameter was the neck pain intensity on a visual analog scale (VAS, 0–100 mm, 0 = no pain, 100 = worst imaginable pain) after 12 weeks. Secondary outcomes included neck pain disability (Neck Disability Index, NDI, 0–100%) after 12 weeks. The last follow-up visit was after 52 weeks. Statistical analysis included analysis of covariance adjusted for respective baseline value.

Results:

Altogether, 62 outpatients were included [OM group (n = 28), CG (n = 34); 81% female; mean age, 41.6 ± 11.1 years; mean baseline neck pain, 55.9 ± 11.6 mm]. After 12 weeks, OM was associated with an improvement in the OM group versus the CG in neck pain on the VAS [14.6 mm (95% confidence interval 8.0; 21.2) versus 40.8 mm (34.7; 46.9), p < 0.001, Cohen’s d = 1.4], and neck pain disability as determined by the NDI [8.8% (6.7; 10.8) versus 17.2% (15.3; 19.1), p < 0.001]. Some improvements were maintained until 52 weeks of follow-up. No serious adverse events were observed.

Conclusions:

The results of this study suggest that OM might be effective in reducing pain intensity in adult violinists and violists with nonspecific cNP. Further studies should investigate the efficacy of OM in comparison with a sham procedure and with other effective therapy methods in high-quality multicenter trials.

Trial registration:

WHO Trial Registration https://apps.who.int/trialsearch/NoAccess.aspx?aspxerrorpath=/trialsearch/Trial2.aspx by German Clinical Trials Register DRKS00009258, Universal Trial Number (UTN): U1111-1173-5943.

Shift in transcriptional landscape of human right ventricle in chronic thromboembolic pulmonary arterial hypertension

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) is a sub group of pulmonary hypertension (PH). CTEPH is characterized by the existence of thromboemboli and vascular remodeling in pulmonary vessels. The effect of increase in pulmonary artery pressures causes right ventricle (RV) hypertrophy and dilatation and finally leads to right heart failure and death. Surgical intervention in operable patients makes the CTEPH as an only curable and unique form of ph. Pulmonary endarterectomy (PEA) is the surgical procedure to remove the thromboembolic clots from the pulmonary vasculature, which restores RV function back to normal with significant improvements in cardiovascular magnetic resonance.

Purpose

The aim of this study is to use transcriptomic profiling to identify signaling pathways, master regulators, and potentially new biomarkers that specifically indicate the effect of PEA on the RV of patients with chronic thromboembolic pulmonary hypertension.

Results

RNA -sequencing (RNA-seq) was performed on RV biopsies obtained from CTEPH patients at PEA baseline (before PEA surgery) and the results were compared with those from RV biopsies obtained during follow-up evaluation. Bioinformatic analysis of RNA-seq data identified 2799 genes (n=14, −0.585 ≤ Log2 fold change ≥0.585, FDR ≤0.05) differentially regulated between the PEA baseline and follow-up sample groups. The great number of genes (2799) differentially expressed after PEA surgery in CTEPH patients confirms a major shift in the transcriptional landscape of RV in these patients. To further identify potential biomarker candidates from the large pool of 2799 differentially expressed genes (DEGs), extensive bioinformatic analysis of different data sets shortlisted 250 DEGs that were functionally associated with cardiovascular development or disease. The findings of this study reveal prominent transcriptional changes that occur in response to PEA. Gene ontology enrichment and pathway analysis confirmed altered regulation of hypoxia-inducible factor 1 (HIF-1) signaling, advanced glycation end products and their receptors (AGE-RAGE), mitogen-activated protein kinase (MAPK) signaling, hippo signaling, the Janus kinase/ signal transducers and activators of transcription (Jak-STAT) signaling pathway, and proteoglycans after PEA compared with before PEA.

Conclusion

Comparison of the results of RNA-seq analysis of RV biopsies of CTEPH patients, pre and post PEA, revealed a major shift in the transcriptional landscape of these patients after reducing the pressure overload of the RV by PEA.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German Research Foundation (DFG)

Novel potential diagnostic targets revealed by plasma proteomic analysis in chronic thromboembolic pulmonary hypertension

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) is associated with poor outcome if untreated, although it is a curable form of pulmonary hypertension (PH). Successful treatment requires an optimized diagnostic work-up.

Purpose

The aim of this study was to identify non-invasive biomarkers that might serve as new diagnostic parameters in the multifaceted pathophysiology of CTEPH.

Methods

The biomarker profile of 64 CTEPH patients who underwent balloon pulmonary angioplasty (BPA) was analyzed prior to and after therapy and compared with that of a healthy control group (CG1, n=25) at baseline. Proteomes were analyzed by semiquantitative screening based on a proximity extension assay of three high-throughput, multiplex immunoassay panels. Serum levels of a subset of biomarkers identified in the screening were additionally measured by immunochemical methods.

Results

Fifty protein biomarkers were found to differ between CTEPH patients and CG1. Eight biomarkers changed significantly after therapy. The overlap of these two groups revealed six targets that were all upregulated in CTEPH at baseline and modifiable by treatment. In this group of biomarkers, the levels of DCN (decorin), HGF (hepatocyte growth factor), BNP (B-type natriuretic peptide), and PAPP-A (papalysin-1) decreased after therapy, whereas SPON-1 (spondin-1) and MEPE (matrix extracellular phosphoglycoprotein) further increased at follow-up. The differences in these biomarkers in CTEPH as well as the dynamics after therapy were confirmed and quantified in enzyme-linked immunosorbent assays.

Conclusions

This study identified 6 biomarkers that might serve as new diagnostic parameters or constitute new therapeutic targets in CTEPH. Further prospective studies will be necessary to determine the specific pathophysiological role of each marker.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): SFB 1213 area CP01

Chronic coronary syndromes lead to reduced strain parameters compared to patients without myocardial ischemia in a propensity score-matched cohort assessed by cardiac magnetic resonance imaging

Background

Vasodilator perfusion cardiac magnetic resonance (CMR) has evolved as gold standard in detecting myocardial perfusion deficits (MPD). Even reversible chronic MPD in chronic coronary syndromes can lead to impaired myocardial contractility similar to hibernating myocardium. Feature tracking strain analysis (FTS) provides the opportunity to detect these subclinical alterations of myocardial function before ejection fraction (EF) is impaired. It was therefore the aim of this study to investigate, if subtle changes in myocardial mechanics can be detected by FT strain analysis in patients with MPD.

Methods

Between April 2017 and October 2019 we identified 226 patients with MPD by vasodilator stress CMR out of 1500 patients included in our tertiary care center registry. Propensity score matching was used to identify patients without MPD with similar myocardial characteristics defined by EF, enddiastolic volume indexed by body surface area (EDVi) and native T1-mapping. Steady state free precession cine CMR sequences were analyzed by FTS retrospectively generating three global strain parameters: global longitudinal, circumferential and radial strain (GLS, GCS, GRS).

Results

Propensity score matching yielded 104 patients in each group (MPD mean age 63.6±12.8 years, 25 females; no MPD mean age 67.7±10.6 years, 26 females; LV-EF 51.3±16.0% vs. 52.6±15.2%, p=0.2307; EDVi 88.3±32.7 ml/m2 vs. 82.6±29.3 ml/m2, p=0.1533; native T1 values 1139±60 ms vs. 1125±63 ms, p=0.118). All global strain parameters were significantly reduced in MPD patients compared to patients with no MPD (global longitudinal strain −15.5±4.9 vs. −17.1±4.9, p=0.0046, global circumferential strain −18.0±5.4 vs. −19.4±5.6, p=0.0298; global radial strain 35.4±14.8 vs. 39.4±15.6, p=0.0127).

Conclusion

Chronic Coronary Syndromes cause subtle changes of myocardial mechanics, which are not reflected by EF but can be detected with FTS.

Funding Acknowledgement

Type of funding source: None

Copeptin as a non-invasive biomarker in chronic thromboembolic pulmonary hypertension

Introduction

Copeptin is the C-terminal fragment of the precursor protein of vasopressin. In acute pulmonary embolism, copeptin has been suggested to be a strong predictor of outcome and to provide additional predictive value to the established cardiac biomarkers high-sensitivity cardiac troponin and N-terminal pro-brain natriuretic peptide (NT-proBNP). Chronic thromboembolic pulmonary hypertension (CTEPH) is diagnosed in about 5% of patients who survive acute pulmonary embolism. Individualized risk stratification remains a challenge in the work-up of CTEPH patients.

Purpose

The current study investigated whether copeptin has the potential to aid the stratification of patients who have experienced pulmonary embolism and CTEPH patients. We examined the baseline (BL) levels and dynamics of copeptin during therapy in CTEPH patients who underwent balloon pulmonary angioplasty (BPA) or pulmonary endarterectomy (PEA). Moreover, the study compared copeptin levels between patients with or without therapy response.

Methods

The study included a total of 125 CTEPH patients scheduled for treatment. A total of 78 underwent staged BPA and 64 underwent PEA. In accordance with recent studies from our group, therapy success was defined as a decrease in meanPAP ≥25% and PVR ≥35% or a normalization below the thresholds defining pulmonary hypertension. Blood samples were collected at BL, prior to each BPA session in the BPA cohort, and at follow-up (FU) 6 months after BPA or 12 months after PEA. Copeptin was measured in thawed serum aliquots by an immunochemical method.

Results

The 78 patients in the BPA cohort underwent a mean of 6 BPA procedures each; there were a total of 413 interventions. The hemodynamic clinical and functional status the CTEPH patients improved after BPA and PEA therapy: meanPAP (BL: 43±9 mmHg vs. FU: 27±9 mmHg; p&lt;0.001); PVR (BL: 7.6±3.4 WU vs. FU: 3.8±2.0 WU; p&lt;0.001); RAP (BL: 7.9±5.8 mmHg vs. FU: 5.4±2.7 mmHg; p&lt;0.001); WHO functional class [BL: I:0 / II:25 / III:80 / IV:20 vs. FU: I:56 / II:57 / III:10 / IV:2]; 6-minute-walk distance (BL: 405±99 m vs. FU: 456±112 m; p&lt;0.001).

The median serum levels of copeptin [BL 7.7 (4.6–14.2) pmol/L vs. FU 6.3 (3.9–12.5); p=0.009] and NT-proBNP [BL: 811 (157–1857) ng/L vs. FU: 142 (72–335) ng/L p&lt;0.001] decreased significantly after therapy. The copeptin levels did not correlate with hemodynamics at BL: PVR (rrs=0.02; p=0.79) and meanPAP (rrs=0.03; p=0.75). The copeptin levels at BL (AUC=0.61) and the relative change (AUC=0.53) did not predict the endpoint of therapy response.

Conclusions

Copeptin levels are elevated in CTEPH patients compared with normal values in the literature. Although copeptin is known to provide additional value in the context of risk stratification in acute pulmonary embolism, it failed to provide additional diagnostic benefit in CTEPH in the current study.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): SFB 1213 area CP01

Characteristics and outcomes of patients with suspected acute myocardial infarction according to rising and falling patterns of high-sensitive cardiac troponin

Introduction

Current guidelines and Universal Definition of Myocardial Infarction (UDMI) recommend using rising and falling patterns (RP and FP, respectively) of high-sensitive cardiac troponins (hs-cTn) equally to distinguish acute from chronic myocardial injury.

Purpose

To compare patients with RP and FP and assess the diagnostic performance of the ESC 0/1 and 0/3 hour (h) algorithms using a RP or FP.

Methods

Prospectively enrolled patients with suspected MI (excluding those with ST-elevation) were stratified according to their troponin deltas. A RP was defined by an elevation and a FP as a decline in hs-cTnI of ≥2 or &gt;6 ng/L between baseline and 1 or 3h later, respectively. All other patients were classified stable. Three independent cardiologists adjudicated the final diagnoses according to the 3rd UDMI. Our primary endpoints were efficacy measures (positive predictive value [PPV] and specificity in % [95% confidence intervals]) of both algorithms. Patients were followed for up to 4 years for a combined endpoint of all-cause death, incident MI, revascularization or cardiac rehospitalization.

Results

In total, 3,528 patients (age 64.0 (52.0, 74.0), males 64.0%) were included, of those 418 (11.8%) had a FP and 829 (23.5%) a RP. Compared to patients with a RP, those with a FP had similar age (67.0 [55.0, 76.0] vs. 67.0 [56.0, 75.0]), had generally less cardiovascular risk factors and the number of angiographies was lower (39.5% vs. 58.0%), while the number of late-presenters (&gt;6h after symptom onset) was higher (66.4% vs. 48.8%). The prevalence of MI was higher in the RP (22.6% vs 29.1%). The risk of experiencing the combined endpoint was significantly higher for both, FP and RP, with a greater risk for a RP (age-/sex adjusted (adj) HR 1.6 [9%%CI 1.4, 1.9]) than a FP (adjHR 1.3 [95% CI1.2, 1.5]) compared to stable patients (p&lt;0.001, respectively). Overall, patients with AMI and a FP had the highest event rate (Figure). The PPV and the specificity to rule-in MI using both algorithms was significantly higher for patients with RP (0/1h: PPV 75.8 [70.3, 80.7], specificity; 72.3 [66.2, 77.9]; 0/3h: PPV 73.8 [69.9, 77.4], specificity 63.1 [58.1, 67.9]) compared to those with FP (0/1h: PPV 51.0 [42.7, 59.3], specificity 70.1 [63.9, 75.8]; 0/3h: PPV 57.0 [49.4, 64.3], specificity 74.0 [68.6, 78.9]).

Conclusion

Despite the known elevated risk of dynamic hs-cTnI changes (defining myocardial injury), patients with FP are at even greater risk for future events despite having fewer cardiovascular risk factors. The rule-in of MI using established and recommended stratification algorithms is worse in these patients, wherefore the equal treatment of a FP and RP should be questioned.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): German Center of Cardiovascular Research (DZHK), Abbott Diagnostics, Prevencio, Singulex, University Medical Center of the Johannes Gutenberg University of Mainz, BRAHMS Aktiengesellschaft

Copeptin as a novel biomarker for detecting early renal dysfunction after TAVI

Background

Acute kidney injury (AKI) is one of the most prevalent (10–30%) complications after transcatheter aortic valve implantation (TAVI). Furthermore, AKI is accompanied by increased mortality, a higher incidence of dialysis and blood transfusion, and a prolonged hospital stay. Although measurement of serum creatinine is the gold standard in diagnosing AKI, changes in serum creatinine may lag behind compromised renal function. Arginine vasopressin (AVP), or antidiuretic hormone, is a nine-amino acid peptide member of the hypothalamo-neurohypophysial axis. Copeptin is the C-terminal moiety of the AVP precursor pre-proAVP that is secreted into the circulation. Recently, copeptin has been suggested to play a role in chronic kidney injury. We evaluated the value of copeptin in the prediction of AKI in patients undergoing TAVI.

Methods

All patients with severe aortic valve stenosis undergoing TAVI between May 2011 and May 2016 were included in our study. AKI was defined by the VARC-2 definition. Patients with no AKI and stage 1 AKI were compared with patients with stage 2 or 3 AKI. Routine laboratory parameters, including creatinine, were measured immediately after blood draw. Additionally, venous blood samples were collected on admission and after 24, 48, and 72 hours, processed immediately, and stored at −80°C until assay. The copeptin concentration in serum was measured by a sandwich immunoluminometric assay.

Results

Copeptin levels were available in 642 patients who were treated by TAVI in our centre from 2012–2016. AKI was detected in 113 patients (17.6%), including 61 patients with stage 1 (9.5%), 29 with stage 2 (4.5%), and 23 with stage 3 (3.6%).

There were no differences among these patients in baseline measurements, but serum copeptin increased in all patients with AKI 24 h post-procedure according to the AKI stage: no AKI 34.5 (18.0–59.3 pmol/L), AKI stage 1: 68.7 (34.6–130.1 pmol/L); AKI stage 2: 96.0 (48.1–185.1 pmol/L); AKI stage 3: 154.9 (79.5–280.7 pmol/L); ANOVA p&lt;0.001 (Fig. 1). Copeptin showed an earlier and sharper increase than creatinine (Fig. 1), with a negative predictive value of 0.97 to rule out AKI after 24 h.

Conclusion

AKI subsequent to TAVI is a common and harmful complication that occurred in almost every 5th patient (17.6%) in our cohort. AVP is secreted in response to hypotension, which commonly occurs during TAVI. In our cohort of TAVI patients, those who developed AKI after TAVI showed a rapid increase in copeptin that was earlier than that of creatinine. In light of these observations, copeptin could be a new parameter for detecting early renal dysfunction.

Figure 1

Funding Acknowledgement

Type of funding source: None

Orally applied bacterial lysate in infants at risk for atopy does not prevent atopic dermatitis, allergic rhinitis, asthma or allergic sensitization at school age: Follow-up of a randomized trial

BACKGROUND

The allergy preventive effects of gut immune modulation by bacterial compounds are still not fully understood.

OBJECTIVE

We sought to evaluate the effect of bacterial lysate applied orally from the second until seventh months of life on the prevalence of allergic diseases at school age.

METHODS

In a randomized, placebo-controlled trial, 606 newborns with at least one allergic parent received orally a bacterial lysate consisting of heat-killed Gram-negative Escherichia coli Symbio and Gram-positive Enterococcus faecalis Symbio or placebo from week 5 until the end of month 7. A total of 402 children were followed until school age (6-11 years) for the assessment of current atopic dermatitis (AD), allergic rhinitis (AR), asthma and sensitization against aeroallergens.

RESULTS

AD was diagnosed in 11.0% (22/200) of children in the active and in 10.4% (21/202) of children in the placebo group. AR was diagnosed in 35% (70/200) of children in the active and in 38.1% (77/202) children in the placebo group. Asthma was diagnosed in 9% (18/199) of children in the active and in 6.6% (13/197) of children in the placebo group. Sensitization occurred in 46.5% (66/142) of participants in the active and 51.7% (76/147) in the placebo group.

CONCLUSION

An oral bacterial lysate of heat-killed Gram-negative Escherichia coli and Gram-positive Enterococcus faecalis applied during the first 7 months of life did not influence the development of AD, asthma and AR at school age.

CytoResc - "CytoSorb" Rescue for critically ill patients undergoing the COVID-19 Cytokine Storm: A structured summary of a study protocol for a randomized controlled trial

OBJECTIVES

Approximately 8 - 10 % of COVID-19 patients present with a serious clinical course and need for hospitalization, 8% of hospitalized patients need ICU-treatment. Currently, no causal therapy is available and treatment is purely supportive. The main reason for death in critically ill patients is acute respiratory failure. However, in a number of patients a severe hyperinflammatory response with excessively elevated proinflammatory cytokines causes vasoplegic shock resistant to vasopressor therapy. A new polystyrene-based hemoadsorber (CytoSorb®, Cytosorbents Inc., New Jersey, USA) has been shown to adsorb effectively cytokines and other middle molecular weight toxins this way reducing their blood concentrations. This has been routinely used in clinical practice in the EU for other conditions where a cytokine storm occurs and an observational study has just been completed on COVID-19 patients. We hypothesized that the extracorporeal elimination of cytokines in critically ill COVID-19 patients with suspected hyperinflammation and shock may stabilize hemodynamics and improve outcome. The primary endpoint is time until resolution of vasoplegic shock, which is a well implemented, clinically relevant endpoint in critical care studies.

TRIAL DESIGN

Phase IIb, multicenter, prospective, open-label, randomized, 1:1 parallel group pilot study comparing the additional use of "CytoSorb" to standard of care without "CytoSorb".

PARTICIPANTS

Patients are recruited from the Intensive Care Units (ICUs) of 7 participating centers in Germany (approximately 10 ICUs). All patients aged 18- 80 with positive polymerase chain reaction (PCR) test for SARS-CoV-2, a C-reactive protein (CRP) ≥ 100 mg/l, a Procalcitonin (PCT) < 2 ng/l, and suspected cytokine storm defined via a vasoplegic shock (Norepinephrine > 0.2 μg/min/kg to achieve a Mean Arterial Pressure ≥ 65mmHg). Patients are included irrespective of indication for renal replacement therapy. Suspected or proven bacterial cause for vasoplegic shock is a contraindication.

INTERVENTION AND COMPARATOR

Within 24 hours after meeting the inclusion criteria patients will be randomized to receive either standard of care or standard of care and additional "CytoSorb" therapy via a shaldon catheter for 3-7 days. Filter exchange is done every 24 hours. If patients receive antibiotics, an additional dose of antibiotics is administered after each change of "CytoSorb" filter in order to prevent underdosing due to "CytoSorb" treatment.

MAIN OUTCOMES

Primary outcome is time to resolution of vasoplegic shock (defined as no need for vasopressors for at least 8 hours in order to sustain a MAP ≥ 65mmHg) in days. Secondary outcomes are 7 day mortality after fulfilling the inclusion criteria, mortality until hospital discharge, Interleukin-6 (IL-6) measurement on day 1 and 3, need for mechanical ventilation, duration of mechanical ventilation, duration of ICU-stay, catecholamine dose on day 1/2/3 after start of "CytoSorb" and acute kidney injury.

RANDOMIZATION

An electronic randomization will be performed using the study software secuTrial® administered by the Clinical Study Center (CSC) of the Charité - Universitätsmedizin Berlin, Germany. Randomization is done in blocks by 4 stratified by including center.

BLINDING (MASKING)

The trial will be non-blinded for the clinicians and patients. The statistician will receive a blinded data set, so that all analyses will be conducted blinded.

NUMBERS TO BE RANDOMIZED (SAMPLE SIZE)

As this is a pilot study with the goal to examine the feasibility of the study design as well as the intervention effect, no formal sample size calculation was conducted. A total number of approximately 80-100 patients is planned (40-50 patients per group). Safety assessment is done after the inclusion of each 10 patients per randomization group.

TRIAL STATUS

Please see the study protocol version from April 24 2020. Recruitment of patients is still pending.

TRIAL REGISTRATION

The study was registered on April 27 2020 in the German Registry of Clinical Trials (DRKS) under the number DRKS00021447.

FULL PROTOCOL

The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

0596 Providers Rarely Assess Obstructive Sleep Apnea Symptoms Among Patients with Chronic Obstructive Pulmonary Disease

Introduction

Professional societies recommend providers assess sleep symptoms in COPD, but it is unclear if this occurs. We aimed to evaluate OSA symptom assessment and documentation among patients with COPD, and the patient and provider characteristics associated with this assessment.

Methods

We conducted a cross-sectional study of adults aged ≥40 years with clinically diagnosed COPD and no prior diagnosis of OSA. We selected patients receiving care at two academic general internal medicine clinics between 6/1/2011 - 6/1/2013. We abstracted charts to assess how often OSA symptoms such as snoring, somnolence, witnessed apneas, or gasping/choking arousals were documented as present or absent. We performed multivariable mixed-effects logistic regression to assess associations of patient and primary care provider (PCP) factors with assessment of OSA symptoms. Patient factors included demographics, body mass index, comorbidities, healthcare utilization, and severity of COPD, and PCP factors including demographics, degree, and years of experience.

Results

Of 523 patients with COPD, only 26 (5.0%) had documentation of OSA symptom assessment within a one-year period. In mixed effects models, only referral to general pulmonary clinic was associated with the assessment of OSA symptoms (OR: 4.56, 95% CI 1.28-15.52). Among the 26 individuals who had OSA symptoms assessed, 9 (34.6%) reported snoring, 15 (57.7%) reported daytime somnolence, 2 (7.7%) reported gasping/choking arousals, and 5 (19.2%) reported witnessed apneas. Among those assessed for OSA symptoms, providers referred 11 (42.3%) for formal sleep consultation.

Conclusion

Providers rarely document OSA symptoms for patients with COPD in primary care clinic, but assessment is greater among those with pulmonary specialty consultation. Given time constraints in primary care, external facilitation of sleep symptom assessment may improve symptom recognition and receipt of appropriate services.

Support

NIH 5K23HL111116-05, VA Center of Innovation for Veteran-Centered and Value-Driven Care.

Prevalence of chronic urticaria in children and adults across the globe: Systematic review with meta-analysis

BACKGROUND AND OBJECTIVES

Urticaria is a frequent skin condition, but reliable prevalence estimates from population studies particularly of the chronic form are scarce. The objective of this study was to systematically evaluate and summarize the prevalence of chronic urticaria by evaluating population-based studies worldwide.

METHODS

We performed a systematic search in PUBMED and EMBASE for population-based studies of cross-sectional or cohort design and studies based on health insurance/system databases. Risk of bias was assessed using a specific tool for prevalence studies. For meta-analysis, we used a random effects model.

RESULTS

Eighteen studies were included in the systematic evaluation and 11 in the meta-analysis including data from over 86 000 000 participants. Risk of bias was mainly moderate, whereas the statistical heterogeneity (I² ) between the studies was high. Asian studies combined showed a higher point prevalence of chronic urticaria (1.4%, 95%-CI 0.5-2.9) than those from Europe (0.5%, 0.2-1.0) and Northern American (0.1%, 0.1-0.1). Women were slightly more affected than men, whereas in children < 15 years we did not find a sex-specific difference in the prevalence. The four studies that examined time trends indicated an increasing prevalence of chronic urticaria over time.

CONCLUSIONS

On a global level, the prevalence of chronic urticaria showed considerable regional differences. There is a need to obtain more sex-specific population-based and standardized international data particularly for children and adolescents, different chronic urticaria subtypes and potential risk and protective factors.

Antagonistic Autoantibodies to Insulin-Like Growth Factor-1 Receptor Associate with Poor Physical Strength

Natural autoantibodies to the IGF1 receptor (IGF1R-aAb) have been described in relation to Graves' ophthalmopathy. Other physiological roles of natural IGF1R-aAb are not known. We hypothesized that IGF1R-aAb may be related to muscle development. Serum samples (n = 408) from young overweight subjects (n = 143) were collected during a lifestyle intervention study. Anthropometric parameters, along with leptin, IGF1 and IGF1R-aAb concentrations, were analyzed, and the subjects were categorized into positive or negative for IGF1R-aAb. Eleven out of 143 subjects (7.7%) were positive for IGF1R-aAb. Identified IGF1R-aAb were molecularly characterized and showed antagonistic activity in vitro impairing IGF1-mediated IGF1R activation. Mean body weight, height or age were similar between IGF1R-aAb-positive and -negative subjects, but IGF1 concentrations differed. Jumping ability, as well as right and left handgrip strengths, were lower in the IGF1R-aAb-positive as compared to the IGF1R-aAb-negative subjects. We conclude that natural IGF1R-aAb are detectable in apparently healthy subjects and are capable of antagonizing IGF1-dependent IGF1R activation. Moreover, the presence of IGF1R-aAb is associated with poor physical strength. Although the causality of this association is unclear, the data imply a potential influence of IGF1R autoimmunity on muscle development.

P5264There is no significant effect of ischemic time and elapse time since cardiac allograft transplant on myocardial T1 relaxation time

Background

Graft failure caused by allograft rejection and vasculopathy is the most common cause of mortality after heart transplantation. To detect an early allograft rejection, endomyocardial biopsy is still needed. Tissue characterization by T1-mapping and Late gadolinium enhancement is well established in acute and chronic myocardial tissue alterations. Therefore several studies investigated T1-mapping as a potential noninvasive parameter to monitor cardiac allograft vasculopathy and allograft rejection. However it is unclear if T1 is also influenced by pretransplant ischemic time and elapsed time since transplantation.

Purpose

It was the aim of our study to examine the influence of ischemic and elapsed time since transplantation to the cardiac allograft tissue characteristics measured by CMR T1 relaxation times.

Methods

Allograft transplant patients underwent stress CMR on a yearly routine. T1-maps were acquired using a modified look locker sequence (MOLLI 3(2)3(2)5) in the midventricular septum. Uni- and multi linear regression analysis was used to predict T1 by ischemic time, time since transplantation, troponin and NT-Pro-BNP.

Results

49 cardiac allograft transplanted patients underwent stress CMR (mean age 58.6±11.7 years, left ventricular ejection fraction 62.1±6.8%; indexed enddiastolic volume 68.4±14.7 ml/m2; native T1 1120±51 ms, extracellular volume 0.27±0.04). A significant correlation was found between T1 and NT-Pro-BNP (1519±3639 pg/ml, p=0.003) and a trend for troponin (17.0±12.8 ng/dl, p=0.051). We saw no correlation between T1 and the ischemic time (198.4±44.9 minutes, p=0.1172) and elapse time since transplantation (47±7 month, p=0.9868). In the multivariate regression analysis none of the four parameters were independently associated with the T1 time (p=0.1017).

Table 1 Characteristics Mean ± SD p Ischemic time (minutes) 198.4±44.9 0.1172 Time since transplant (month) 47±7 0.9868 NT-Pro-BNP (pg/ml) 1519±3639 0.003 Troponine (ng/dl) 17.0±12.8 0.051

Conclusion

There was no significant effect of pretransplant ischemic time and elapse time since transplantation on native T1 times, whereas native T1 was significantly correlated with troponine and NT-Pro-BNP-Levels. T1 is excellently suited to detect acute changes in allograft transplant patients without being influenced by aging of the transplanted heart and the heart's pretransplant condition.

P5260Differences in myocardial mechanics between dilated cardiomyopathy and ischemic cardiomyopathy by CMR derived feature tracking strain - A propensity score-matched study

Background

Adult heart failure in industrialized nations is primarily due to dilated (DCM) and ischemic cardiomyopathy (ICM). Both diseases are characterized by different pathological pathways. While ICM is predominantly caused by local, subendocardial myocyte necrosis, DCM is characterized by a general myocyte apoptosis involving all myocardial layers. Using feature tracking, longitudinal, circumferential, and radial motion of the left ventricle (LV) can be measured, which allows the function of subendocardial, mostly longitudinal orientated, and subepicardial, mostly circumferential orientated fibers to be assessed independently.

Purpose

It was the aim of our study to detect differences of LV motion between DCM and ICM patients in a propensity score-matched cohort.

Methods

Between April 2017 and December 2018 we included 845 patients with a clinical indication for CMR in our tertiary care center registry. Out of this cohort we identified 273 patients with ICM and 126 with DCM. Propensity score matching was used to pair patients in each group based on their indexed enddiastolic volume (EDVi), ejection fraction (EF), septal T1. Feature tracking technique was used for strain analyses quantified on steady state free precession cine CMR images yielding six strain parameters.

Results

Propensity score matching yielded 59 patients in each group (ICM mean age 59.4±13.0 years, 11 females; DCM mean age 66.5±10.6 years, 15 females; LV-EF 32.6±11.4% vs. 33.0±14.2%, p=0.8178; EDVi 124.2±36 ml/m2 vs. 132.9±42 ml/m2, p=0.0909; native T1 values 1161±66 ms vs. 1164±59 ms, p=0.7049). There was no difference in global longitudinal strain between ICM and DCM patients (−10.9±4.4% vs. −10.6±5.8%, p=0.686), whereas global circumferential strain and radial strain were reduced in DCM patients (−12.0±4.3% vs. −10.31±4.8%, p=0.0190 and 21.1±8.9% vs. 18.0±15.5%, p=0.0386).

Conclusion

Our data confirm the inherently different mechanics of ICM and DCM patients. While myocardial fibres are globally affected in DCM, myocardial damage is predominantly confined to subendocardial layers in ICM despite equally reduced EF.

P5478Information on weather conditions improves the prognostic ability of 25 OH-vitamin D in stable coronary artery disease

Introduction and aim

Vitamin D deficiency is associated with an adverse prognosis in patients with coronary artery disease (CAD). Decreased levels of vitamin D are associated with low sunshine exposure, resulting in seasonal variations of vitamin D. The aims of this study were to investigate the influence of different specific weather conditions on vitamin D levels and to explore a possible improvement of risk stratification by vitamin D levels in stable patients with CAD using meteorological data.

Methods

The study population consists of two independent cohorts of stable patients undergoing coronary angiography with suspected or known CAD: as derivation cohort, the ongoing biomarker registry BioPROSPECTIVE with n=1,766 enrolled patients between 2010 and 2013 (median age 70.1 yrs; 30.8% females); and as validation cohort, the Ludwigshafen Risk and Cardiovascular Health (LURIC) Study with n=3,299 patients (median age 63.5 yrs; 30.3% females). In the derivation cohort 235 (13.3%) patients were known to be deceased by 08/2018. In the validation cohort 760 (23.0%) patients died within a median follow-up time of 7.75 years. 25-OH vitamin D levels were measured by commercial assays. Vitamin D deficiency was defined as 25-OH vitamin D levels ≤20 ng/mL. Daily averaged data on six weather conditions of the 180 days prior to enrolment were collected for each patient from the weather station located closest to the respective study centre. Using air pressure, precipitation height, sunshine duration, temperature, relative humidity, and vapour pressure a weather model was constructed that significantly correlated with vitamin D levels (r=0.37; p<0.001).

Results

In the derivation cohort, median vitamin D levels were lower in non-survivors (13.3 [9.65–19.65] ng/mL) than in survivors (15.70 [10.7–22.65] ng/mL; p<0.001). Vitamin D predicted all-cause mortality with an area under the receiver operator characteristic curve (AUROC) of 0.576 (CI: 0.54–0.62). Adding the weather model to vitamin D significantly improved the AUROC to 0.601 (CI: 0.56–0.64; p=0.031). The vitamin D/weather model combination enhanced the prognostic value of the ESC SCORE to predict mortality (AUROC=0.571 [CI: 0.53–0.61] vs. 0.628 [CI: 0.59–0.67]; p=0.004). Comparable results were observed in the validation cohort. Here, vitamin D deficiency predicted mortality with a hazard ratio (HR) of 1.89 (CI: 1.59–2.26) after adjustment for ESC SCORE. Adding the weather model improved this HR to 1.92 (1.62–2.32). Reclassification analyses support the additive prognostic information of weather conditions with a continuous net reclassification improvement of 0.114 ([0.033–0.194]; p=0.006) if adding the weather model to vitamin D as base model for predicting mortality.

Conclusions

Different weather conditions show a significant impact on vitamin D levels in stable patients. Adding data on weather conditions improve the risk stratification by vitamin D for predicting mortality in stable CAD patients.

Acknowledgement/Funding

The study is financially supported by the Kerckhoff Heart Research Institute (KHFI) and the German Center for Cardiovascular Research (DZHK).

P6433Use of high-sensitivity cardiac troponin I (hs-cTnI) for secondary prevention in high-risk patients suffering from stable coronary artery disease

Background

There are several tools for primary prevention (e.g. Framingham, ESC) that can be used to predict mortality risk in healthy individuals. However, only a few scores have been validated to predict outcome in patients with cardiovascular disease. One of these instruments is the REACH (REduction of Atherothrombosis for Continued Health) score. The ESC guideline for stable coronary artery disease (CAD) places a clear emphasis on carrying out risk stratification before using invasive treatment. Recent studies have revealed a prognostic value of serum hs-cTnI in patients with stable CAD.

Purpose

The aim of this study was to evaluate the prognostic information provided by hs-cTnI in stable high-risk CAD patients.

Methods

Between 2011 and 2014, consecutive stable patients with suspected CAD undergoing coronary angiography were included in the study. Data from a 4-year follow-up was obtained; the study endpoint was defined as all-cause mortality. Serum hs-cTnI was measured before angiography using a high-sensitivity assay.

Results

A total of 3,742 patients were included, of whom 2,274 (60.1%) had confirmed CAD. Patients with an estimated annual mortality rate above 3% using the REACH score were defined as having high risk (n=996 in the low-risk group, n=1,278 in the high-risk cohort). Patients with higher risk were more often male (81.5% vs. 69.2%, p<0.001), were older (mean age 73.2±8.1 y vs. 63±9.4 y), and had more cardiovascular risk factors (diabetes mellitus (DM) 43.5% vs. 13.7%, p<0.001; arterial hypertension 90.8% vs. 86%, p<0.001). Median hs-cTnI was elevated in high-risk patients (6.9 ng/L [IQR 1–3: 3.8–14.8 ng/L] vs. 3 ng/L [IQR 1–3: 1.7–5.9 ng/L]; p<0.001). A total of 298 patients (23.3%) died in the high-risk group compared with 74 patients (7.4%) in the low-risk group. Log(hs-cTnI) was found to be a risk factor based on regression analysis including age, gender, DM, arterial hypertension and the REACH score (OR 2.02 [95% CI 1.61–2.54]). The area under the ROC of hs-cTnI for predicting all-cause mortality was 0.69 (95% CI 0.66–0.72) for hs-cTnI and 0.72 (95% CI 0.69–0.72) for the REACH score. There was a correlation between hs-cTnI and the REACH score (Spearman correlation 0.458; p<0.001). In patients at low risk, the best cut-off for hs-cTnI was 3 ng/L, and for high-risk patients 8.25 ng/L was the best threshold value. Using low REACH score and low hs-cTnI levels, it was possible to identify patients at very low risk with a mortality rate below 3.4% in a follow-up of 48 months. It was also feasible to determine patients at very high risk in the group of patients who were already at high risk using the hs-cTnI cut-off (mortality 15.2% vs. 33.7%).

Conclusion

Hs-cTnI was found to be an independent risk factor in low- as well as high-risk patients. Hs-cTnI levels correlate with the REACH risk score. Moreover, it was possible to separate patients at very high and very low risk by combining REACH score and hs-cTnI.

P1730Serial high-sensitivity troponin I measurements to discriminate type 2 from type 1 myocardial infarction

Background

Acute myocardial infarction (MI) is associated with high morbidity and mortality. A robust differentiation between type 1 and type 2 MI (T1/T2MI) has prognostic and therapeutic implications. We investigated whether serial high-sensitivity cardiac troponin I measurements could reliably discriminate T1MI from T2MI in patients presenting with a non-ST elevation myocardial infarction (NSTEMI).

Methods

We used data from a prospective acute coronary syndrome biomarker registry of patients with suspected MI that presented at or were transferred to one of two study centres. Here, we analysed an unselected group of 265 NSTEMI patients (67.2% males). Blood was drawn on admission and after 3 hours. High-sensitivity troponin I (hs-cTnI) was measured in frozen samples by a technician blinded to patient characteristics. T1MI or T2MI was defined as the gold-standard study diagnosis by two independent cardiologists based on all available data according to the Third Universal Definition of MI.

Results

A diagnosis of T2MI was made in 55 patients (20.8%) in the NSTEMI cohort. T2MI patients did not differ from T1MI patients regarding age, gender, traditional risk factors, or percentage of those with a history of coronary artery disease. Median baseline hs-cTnI levels were higher in T1MI (436.25; IQR 63.7–1918.8 ng/L) than in T2MI patients (48.4; IQR 11.7–305.9 ng/L; p<0.001). Absolute change in hs-cTnI concentration between 0 and 3 h was greater in T1MI than in T2MI patients with Dhs-cTnI 93.6 ng/L (IQR 13.5–815.3 ng/L) vs. 20.4 ng/L (IQR 2.5–106.5 ng/L) (p<0.001). hs-cTnI yielded an area under the receiver operator characteristics (AUROC) curve for identifying T2MI at baseline of 0.71 (IQR 0.64–0.79) and after 3 h of 0.7 (IQR 0.61–0.78).Dhs-cTnI was associated with an AUROC of 0.68 (IQR 0.6–0.76). Regarding a rule-out approach, Youden-optimized cut-offs for hs-cTnI at baseline as well as for the absolute change in hs-cTnI concentration were calculated (186.5 ng/L; 154.4 ng/L). Use of these two criteria yielded a sensitivity of 89% (78–96%) and a negative predictive value of 95% (89–98%) to exclude T2MI. 49 of 55 T2MI patients would have been ruled out using this algorithm.

Conclusion

Our data show that hs-cTnI concentrations differ between patients presenting with T1 and T2MI. The concentration of hs-cTnI and its change over time has the potential to rule out T2MI and therefore to identify patients who might benefit from an early invasive management. The differentiation between T1MI and T2MI by using hs-cTnI is nevertheless challenging, and further research on specific algorithms is needed.

Acknowledgement/Funding

3German Center for Cardiovascular Research (DZHK), Partnersite Rhein Main, Bad Nauheim, Germany

3299Performance of the ESC 0/1h- and 0/3h-algorithm for the early diagnosis of myocardial infarction in patients with diabetes mellitus

Background

Patients with diabetes mellitus (DM) may have elevated levels of high-sensitive cardiac troponin (hs-Tn) despite acute myocardial ischemia being present. However, it is unclear whether this constrains diagnostic strategies in patients with suspected acute myocardial infarction (MI).

Purpose

We aimed to assess the diagnostic performance of the European Society of Cardiology (ESC) 0/1 hour (h) and 0/3h-algorithms comparing patients with and without DM and to derive optimized cut-offs.

Methods

We prospectively enrolled patients with symptoms suggestive of MI in two large clinical cohorts and measured hs-TnI at admission (baseline) and 1 (cohort A) and 3h (cohort A+B) thereafter. Patients with ST-elevation MI were excluded. Patients were stratified based on a diagnosis of DM at baseline. Final diagnoses were adjudicated independently by two cardiologists using all clinically available information, including hs-TnT, but blinded to hs-TnI values. Our primary outcomes of interest were safety of rule-out (defined by sensitivity and negative predictive value [NPV]), accuracy of rule-in (defined by specificity and positive predictive value [PPV]) and the overall performance (% of patients adjudicated to either rule-out or -in). For optimized cut-offs, a NPV >99.0% and a PPV >75.0% were targeted.

Results

DM was prevalent in 563 (15.29%) of 3683 included patients. MI was more prevalent among patients with DM (137 [24.3%] vs. 498 [16.0%], p<0.001). Using the ESC 0/1h-algorithm (Figure), rule-out was safe in diabetics (p for sensitivity = 1.00) with higher NPV in non-diabetics (p<0.001), while the proportion of patients ruled-out was smaller in diabetics (22.3% vs. 41.8%). Accuracy of rule-in was significantly lower in diabetics (specificity p=0.0035, PPV p=0.48), with a higher rule-in rate of patients with DM (29.5% vs. 21.8%). Using the ESC 0/3h-algorithm, safety of rule-out was lower in both groups compared to the ESC 0/1h-algorithm, with again higher NPV for non-DM (sensitivity p=0.18, NPV p<0.001) and a higher proportion of non-DM ruled-out (65.9% vs. 75.2%). Accuracy of rule-in was significantly lower for patients with DM (specificity p=0.0094, PPV p=0.87). Cut-off adjustment to yield pre-defined accuracy measures resulted in: 4ng/L at baseline or 6ng/L with a delta of 2ng/l for rule–out and 90ng/L or a delta of 10ng/L for rule-in with the ESC 0/1h algorithm; for the ESC 0/3h-algorithm cut-offs were 5ng/L with a delta of 20% for rule-out and 50ng/L with a delta of 20% for rule-in.

Conclusion

Application of the ESC 0/1h- and 0/3h-algorithms in diabetic patients provided reduced safety and accuracy for rule-out and rule-in of MI, respectively. Use of alternative cut-offs resulted in improved diagnostic safety and accuracy.

Acknowledgement/Funding

Abbott Diagnostics, German Center of Cardiovascular Research, German Heart Foundation, Else-Kröhner-Stiftung angegeben

5035Comparative assessment of diagnostic algorithms of myocardial inflammation by endomyocardial biopsy and tissue mapping by CMR against high-sensitive troponin in viral myocarditis

Background

Myocarditis is defined by inflammatory involvement of the myocardium, either histologically by evidence of myocardial necrosis and cellular infiltration on endomyocardial biopsy (EMB), or non-invasively by presence of myocardial oedema using tissue mapping with cardiovascular magnetic resonance (CMR). Objective: to undertake intra-individual comparisons of EMB vs. CMR diagnostic algorithms of myocardial inflammation, as well as against an independent gold-standard of myocardial injury, high-sensitive troponin (hs-TropT).

Methods

Prospective multicentre study of consecutive patients (n=109) with clinical diagnosis of myocarditis. EMBs were analysed by 2 reference centres using the ESC diagnostic and their local algorithms. The CMR criteria used sequence-specific cut-offs for native T1 and T2 (standard deviation, SD); myocardial inflammation T1 ≥2SD, T2 ≥2SD and no inflammation: T1 and T2<2SD, with subcategories for acute/high-grade: T1 ≥5SD, T2 ≥2SD; chronic/low-grade: T1 ≥2SD, T2 ≥2SD; healed: T1 <2SD, T2 <2SD but myocardial impairment and non-inflammatory cardiomyopathy: T1 ≥2SD, T2 <2SD.

Results

The agreement between ESC criteria and CMR criteria (AUC: 0.56, p=0.381) was poor. There was a significant agreement between myocardial injury (hs-TropT ≥13.9 ng/L) and CMR criteria (AUC: 0.84, p<0.001), but not ESC algorithm. hs-TropT levels had significant associations with native T1 and T2 (r=0.37 and 0.35, p<0.001), but not with immunohistochemical inflammatory markers. Viral presence was similarly proportioned between inflammatory/non-inflammatory subjects, irrespective of the algorithm.

AUC of CMR and EMB versus hs-TroponinT

Conclusions

Poor agreement between CMR and EMB-based diagnostic algorithms suggests non-overlapping definitions of myocardial inflammatory involvement. Excellent agreement between CMR algorithm and hs-TropT reiterates its high sensitivity for inflammatory myocardial injury.

Acknowledgement/Funding

1. National Institute for Health Research (NIHR) Biomedical Research Centre 2. German Centre for Cardiovascular Research (DZHK)

P3710Long term follow-up in a real-world study cohort after patent foramen ovale closure

Background

Patent foramen ovale (PFO) closure is the treatment of choice after cryptogenic stroke according recent evidence. The indication is based on results of several randomized controlled trials; however, the results of these trials may not be extrapolated to a real-world clinical setting. Therefore, the aim of the present study was to evaluate long-term outcome regarding recurrent stroke, migraine, and/or peripheral embolism in patients after PFO closure.

Methods

We retrospectively analyzed outcomes of consecutive patients undergoing PFO closure from 2011 to 2018 at two interventional sites with respect to periprocedural events occurring during hospitalization and long-term follow-up. Follow-up data were collected from outpatient visits or telephone interviews.

Results

The analysis included 214 consecutive patients (mean age 52 years; 58% male). The follow-up rate was 96% and the mean follow-up time was 38 (SD 22) months. The index vascular event leading to PFO closure was stroke (n=190; 89%), including patients with repetitive stroke (n=36), embolic myocardial infarction (n=21), and migraine (n=3). One quarter (24.6%) of the population studied had an atrial septal aneurysm (>15 mm). Procedural success was achieved in 98%. There were no procedure-related strokes or deaths. Periprocedural complications occurred in 16 patients (7%): two cases of pericardial tamponade, seven complications at the access site mainly caused by bleeding, two cases of transient atrial fibrillation, and five other complications. The Amplatz Septal Occluder™ was used in two thirds (64.5%) of the cases and the Gore Cardioform™ device in one third (28.6%). Four (2%) patients died during follow-up. None of these patients experienced a recurrent stroke. Ten (5%) other patients experienced a recurrent stroke. Patients with recurrent stroke events were older than patients without recurrent stroke (mean 62.6 [SD 8.8] years vs. mean 52.2 [SD 13.8] years; p=0.015) and had a higher rate of preexisting cerebrovascular occlusive disease (5 [50%] vs. 10 [6%]; p<0.0001). There was no difference in risk for recurrent stroke between patients with one prior stroke and more than one stroke before PFO closure (p=0.71). Atrial fibrillation occurred in 6.6% of the patients during follow-up, but only one of these patients had recurrent stroke. No other anatomic and vascular risk factors or antithrombotic treatments were identified as being predictive of embolic events after closure.

Conclusion

In this real-world PFO closure cohort the recurrent stroke rate is low, although it is higher than reported in the recent randomized controlled trials. Recurrent strokes after PFO closure may reflect additional comorbid risk factors such as age or cerebrovascular occlusive disease that are unrelated to the potential for paradoxical embolism.

P2774Galectin-3, GDF-15, and ST2 in noninvasive assessment of myocardial remodelling in chronic thromboembolic pulmonary hypertension

Background

In chronic thromboembolic pulmonary hypertension (CTEPH), pulmonary artery obstruction leads to impaired pulmonary hemodynamics and secondary right heart failure, which is highly predictive of outcome. Thus, the extent of myocardial -especially right heart- remodelling is an indicator of disease severity.

Purpose

The aim of the present study was to assess growth differentiation factor-15 (GDF-15), galectin-3, and suppression of tumorigenicity 2 (ST2) as non-invasive biomarkers of myocardial remodelling in patients suffering from CTEPH.

Methods

We analysed the serum levels of GDF-15, galectin-3 and ST2 in a cohort of 64 CTEPH patients and in a control group of 25 patients without cardiovascular disease. The biomarker levels were further correlated with clinical, laboratory, and hemodynamic data, including 6-minute walking distance (6-MWD), N-terminal pro-brain natriuretic peptide (NT-proBNP), mean pulmonary artery pressure (meanPAP), pulmonary vascular resistance (PVR), and right atrial pressure (RAP).

Results

The biomarker levels in the control group were: galectin-3: 3.5 ng/l (IQR 2.7–4.0), GDF-15: 92.6 pg/ml (IQR 78.5–129.1), and ST2: 48.65 ng/l (IQR 35.5–57.0). CTEPH patients had higher levels of GDF-15 (196.7 pg/ml; IQR 128.4–302.8; p<0.001) and ST2 (52.6 ng/l; IQR 44.5–71.9; p=0.05) but not galectin-3 (3.4 ng/l; IQR 2.7–4.3; p=0.84). In the CTEPH cohort, patients with a meanPAP >35 mmHg (GDF-15: p=0.01; ST2: p=0.04) and patients with a PVR >500 dyn sec cm–5 (GDF-15: p=0.004; ST2: p=0.002) had significantly increased biomarker levels. For the detection of a meanPAP >35mmHg, ROC analysis revealed an AUC of 0.71 for GDF-15 and 0.67 for ST2. The level of GDF-15 correlated with the level of NT-proBNP (rrs=0.69; p≤0.001) and the RAP (rrs=0.54; p≤0.001) and inversely with the 6-MWD (rrs=−0.47; p≤0.001). The level of ST2 correlated with the level of NT-proBNP (rrs=0.67; p≤0.001) and the RAP (rrs=0.54; p≤0.001) and inversely with the 6-MWD (rrs=-0.31; p=0.02).

Conclusion

Our results demonstrate that GDF-15 and ST2, non-invasive biomarkers of myocardial remodelling, are significantly elevated in patients suffering from CTEPH. The correlation of biomarker levels with established outcome predictors suggests a use as indicators of disease severity.

Sex-specific incidence of asthma, rhinitis and respiratory multimorbidity before and after puberty onset: individual participant meta-analysis of five birth cohorts collaborating in MeDALL

Introduction

To understand the puberty-related sex shift in the prevalence of asthma and rhinitis as single entities and as respiratory multimorbidities, we investigated if there is also a sex-specific and puberty-related pattern of their incidences.

Methods

We used harmonised questionnaire data from 18 451 participants in five prospective observational European birth cohorts within the collaborative MeDALL (Mechanisms of the Development of Allergy) project. Outcome definitions for IgE-associated and non-IgE-associated asthma, rhinitis and respiratory multimorbidity (first occurrence of coexisting asthma and rhinitis) were based on questionnaires and the presence of specific antibodies (IgE) against common allergens in serum. For each outcome, we used proportional hazard models with sex–puberty interaction terms and conducted a one-stage individual participant data meta-analysis.

Results

Girls had a lower risk of incident asthma (adjusted HR 0.67, 95% CI 0.61 to 0.74), rhinitis (0.73, 0.69 to 0.78) and respiratory multimorbidity (0.58, 0.51 to 0.66) before puberty compared with boys. After puberty onset, these incidences became more balanced across the sexes (asthma 0.84, 0.64 to 1.10; rhinitis 0.90, 0.80 to 1.02; respiratory multimorbidity 0.84, 0.63 to 1.13). The incidence sex shift was slightly more distinct for non-IgE-associated respiratory diseases (asthma 0.74, 0.63 to 0.87 before vs 1.23, 0.75 to 2.00 after puberty onset; rhinitis 0.88, 0.79 to 0.98 vs 1.20, 0.98 to 1.47; respiratory multimorbidity 0.66, 0.49 to 0.88 vs 0.96, 0.54 to 1.71) than for IgE-associated respiratory diseases.

Discussion

We found an incidence ‘sex shift’ in chronic respiratory diseases from a male predominance before puberty to a more sex-balanced incidence after puberty onset, which may partly explain the previously reported sex shift in prevalence. These differences need to be considered in public health to enable effective diagnoses and timely treatment in adolescent girls.

How effective is the early support program Babylotse-Plus for psychosocially burdened mothers and their infants? A comparative intervention study

Objectives

Our aim was to examine the effects of an early perinatal prevention program offered to mothers and families suffering from significant psychosocial burden.

Methods

All mothers giving birth in a Berlin university hospital during Jan-Aug 2013 were screened with a standardized 27-item questionnaire by trained staff. Mothers with a screening-score ≥ 3, who were not enrolled in other public support programs, were defined as psychosocially burdened. They received a detailed needs assessment and were followed up with counseling. When necessary, affected mothers were voluntarily guided through to specialized ‘early support’ institutions during the 12-month-intervention period. The historical control group (care-as-usual) consisted of children born at the same hospital the year before.

At 12 months postnatally, we interviewed mothers in both groups to assess their stress burden and coping skills by Parenting Stress Index and assessed the current childcare condition. Differences between the groups were compared by multivariable logistic regression analyses adjusting for potential confounders.

Results

The intervention group and the control group included 225 and 157 families, respectively. After 12-months, mothers in the ‘early support’ intervention group had significantly less often depression (adjusted odds ratio 0.25, 95%-confidence interval 0.07–0.94), less often a disturbed relationship with the parenting partner (0.34, 0.10–1.14) and reported reduced stress due to the child’s demands (0.40, 0.15–1.10) compared to the control group. Childcare indicators did not differ between the 2 groups.

Conclusions

In mothers at high psychosocial risk, the ‘early support’ intervention program Babylotse-Plus seemed to reduce the occurrence of depression and several stress indicators in the first postnatal year.