Familial Hypercholesterolemia Variant and Cardiovascular Risk in Individuals With Elevated Cholesterol

Importance

Familial hypercholesterolemia (FH) is a genetic disorder that often results in severely high low-density lipoprotein cholesterol (LDL-C) and high risk of premature coronary heart disease (CHD). However, the impact of FH variants on CHD risk among individuals with moderately elevated LDL-C is not well quantified.

Objective

To assess CHD risk associated with FH variants among individuals with moderately (130-189 mg/dL) and severely (≥190 mg/dL) elevated LDL-C and to quantify excess CHD deaths attributable to FH variants in US adults.

Design, Setting, and Participants

A total of 21 426 individuals without preexisting CHD from 6 US cohort studies (Atherosclerosis Risk in Communities study, Coronary Artery Risk Development in Young Adults study, Cardiovascular Health Study, Framingham Heart Study Offspring cohort, Jackson Heart Study, and Multi-Ethnic Study of Atherosclerosis) were included, 63 of whom had an FH variant. Data were collected from 1971 to 2018, and the median (IQR) follow-up was 18 (13-28) years. Data were analyzed from March to May 2023.

Exposures

LDL-C, cumulative past LDL-C, FH variant status.

Main Outcomes and Measures

Cox proportional hazards models estimated associations between FH variants and incident CHD. The Cardiovascular Disease Policy Model projected excess CHD deaths associated with FH variants in US adults.

Results

Of the 21 426 individuals without preexisting CHD (mean [SD] age 52.1 [15.5] years; 12 041 [56.2%] female), an FH variant was found in 22 individuals with moderately elevated LDL-C (0.3%) and in 33 individuals with severely elevated LDL-C (2.5%). The adjusted hazard ratios for incident CHD comparing those with and without FH variants were 2.9 (95% CI, 1.4-6.0) and 2.6 (95% CI, 1.4-4.9) among individuals with moderately and severely elevated LDL-C, respectively. The association between FH variants and CHD was slightly attenuated when further adjusting for baseline LDL-C level, whereas the association was no longer statistically significant after adjusting for cumulative past LDL-C exposure. Among US adults 20 years and older with no history of CHD and LDL-C 130 mg/dL or higher, more than 417 000 carry an FH variant and were projected to experience more than 12 000 excess CHD deaths in those with moderately elevated LDL-C and 15 000 in those with severely elevated LDL-C compared with individuals without an FH variant.

Conclusions and Relevance

In this pooled cohort study, the presence of FH variants was associated with a 2-fold higher CHD risk, even when LDL-C was only moderately elevated. The increased CHD risk appeared to be largely explained by the higher cumulative LDL-C exposure in individuals with an FH variant compared to those without. Further research is needed to assess the value of adding genetic testing to traditional phenotypic FH screening.

Clinical Trial-Ready Patient Cohorts for Multiple System Atrophy: Coupling Biospecimen and iPSC Banking to Longitudinal Deep-Phenotyping

Multiple system atrophy (MSA) is a fatal neurodegenerative disease of unknown etiology characterized by widespread aggregation of the protein alpha-synuclein in neurons and glia. Its orphan status, biological relationship to Parkinson's disease (PD), and rapid progression have sparked interest in drug development. One significant obstacle to therapeutics is disease heterogeneity. Here, we share our process of developing a clinical trial-ready cohort of MSA patients (69 patients in 2 years) within an outpatient clinical setting, and recruiting 20 of these patients into a longitudinal "n-of-few" clinical trial paradigm. First, we deeply phenotype our patients with clinical scales (UMSARS, BARS, MoCA, NMSS, and UPSIT) and tests designed to establish early differential diagnosis (including volumetric MRI, FDG-PET, MIBG scan, polysomnography, genetic testing, autonomic function tests, skin biopsy) or disease activity (PBR06-TSPO). Second, we longitudinally collect biospecimens (blood, CSF, stool) and clinical, biometric, and imaging data to generate antecedent disease-progression scores. Third, in our Mass General Brigham SCiN study (stem cells in neurodegeneration), we generate induced pluripotent stem cell (iPSC) models from our patients, matched to biospecimens, including postmortem brain. We present 38 iPSC lines derived from MSA patients and relevant disease controls (spinocerebellar ataxia and PD, including alpha-synuclein triplication cases), 22 matched to whole-genome sequenced postmortem brain. iPSC models may facilitate matching patients to appropriate therapies, particularly in heterogeneous diseases for which patient-specific biology may elude animal models. We anticipate that deeply phenotyped and genotyped patient cohorts matched to cellular models will increase the likelihood of success in clinical trials for MSA.

Comparison of Follicular Helper T-Cell Markers with the Expression of the Follicular Homing Marker CXCR5 in Peripheral T-Cell Lymphomas-A Reappraisal of Follicular Helper T-Cell Lymphomas

Peripheral T-cell lymphomas (PTCLs) expressing multiple follicular T helper (TFH) cell-related antigens are now classified as TFH lymphomas (TFHL), including angioimmunoblastic, follicular, and not otherwise specified (NOS) types. CXCR5 is the TFH cell-defining chemokine receptor that, together with its ligand CXCL13, plays a critical role in the development of follicles and the positioning of TFH and B cells within follicles. A comprehensive immunomorphologic study was performed to investigate the expression pattern of CXCR5 in a large cohort of nodal PTCLs, particularly those with a TFH cell phenotype, and to compare its expression with six other TFH cell-related antigens. We found that CXCR5 is widely expressed in neoplastic TFH cells, except in TFHL-NOS, and represents a specific marker of this lymphoma entity. Our results suggest that CXCR5 directs the distribution of neoplastic T cells in the affected lymph nodes and may influence the formation of the pathognomic pathological FDC network.

Review on flower-visiting behaviour of orthopterans and setting priorities for further studies

The importance of pollination and pollinators is easy to underestimate and impossible to overstate, since its importance goes far beyond the crop production and even the maintenance of plant populations. Most terrestrial ecosystems ultimately depend on the plant-pollinator interactions formed by million years coevolution. This is essential for both the daily functioning of the ecosystems and the long-term development of biodiversity. At the same time, the loss of biodiversity caused by climate change and human activities will soon lead to an ecological crisis, a catastrophe, which could endanger our life: For example, through the decline and loss of various ecosystem services. Such may be the pollination crisis, resulted from a significant loss of pollinating insects' diversity and abundance. The discovery of a pollinator Orthoptera species has encouraged researchers in the densely populated region of Indo-Malaysia to explore the potential role of orthopterans as pollinators. Although the flower visitation of some species has been already known, the role of orthopterans in pollination is scarcely revealed. Here, we collected and reviewed the available data in order to point out some factors of their importance and set priorities that may serve as a basis for further investigations regarding ecological, evolutionary and practical points of view.

Setting priorities and evaluation of habitats for the conservation of orthopterans: case study in the Aggtelek National Park (N Hungary)

The biodiversity conservation needs recent high-quality data and efficient methods for prioritizing species and sites for conservation. Here we prioritized Orthoptera habitats of the Aggtelek National Park, based on revised and actualized distribution data of 69 Orthoptera species living at 98 sites. The simple ranking and complementary areas methods were used with species richness (S), rarity weighted species richness (SR), and number of rare species (SQ). Additionally, the Grasshopper Conservation Indexes (GCI" and GCIn") combining European and local rarity and dispersal capacity of the species were also tested. Contrary to simple ranking the complementary areas method represented the whole fauna and significant part of the species-site data records. All the used indices performed similar except the standardized GCIn" which is highly affected by the differences in study intensity of sites. High-priority areas of the Aggtelek National Park were designated in the plateau above Jósvafő and Aggtelek villages and in the small, isolated hill near Jósvafő (Szőlő-hegy) covered with remained mosaic of former vineyards, orchards and hayfields. The combined use of the efficient indices provides additional ranking that allows the best selection of hotspots to support efficient use of limited resources in nature conservation.

Multidisciplinary management of acute cholecystitis during the COVID-19 pandemic

The coronavirus disease 2019 pandemic had a major impact on most medical services. Our aim was to assess the outcome of acute cholecystitis during the nationwide lockdown period. All patients admitted to our emergency department for AC were analysed. Patient characteristics, performance status, AC severity, treatment modality and outcome of AC were assessed during the lockdown period (Period II: 1 April 2020-30 November 2021) and compared to a historical control period (Period I: 1 May 2017-31 December 2018). AC admissions increased by 72.8% in Period II. Patients were younger (70 vs. 74 years, p = 0.017) and greater in number in the CCI 1 group (20.4% vs. 11.2%, p = 0.043) in Period II. The unplanned readmission rate (6.3 vs. 0%, p = 0.004) and the gallbladder perforation (GP) rate was higher (18.0 vs. 7.3%, p = 0.006) in Period II. Percutaneous transhepatic gallbladder drainage (PTGBD) was more frequent (24.1 vs. 12.8%, p = 0.012) in Period II. In addition to a drop in patient age and CCI, a significant rise in the prevalence of acute cholecystitis, GP and unplanned readmissions was observed during the nationwide lockdown due to the COVID-19 pandemic. PTGBD was more frequent during this period, whereas successful conservative treatment was less frequent.

Autoantibodies neutralizing type I IFNs underlie West Nile virus encephalitis in ∼40% of patients

Mosquito-borne West Nile virus (WNV) infection is benign in most individuals but can cause encephalitis in <1% of infected individuals. We show that ∼35% of patients hospitalized for WNV disease (WNVD) in six independent cohorts from the EU and USA carry auto-Abs neutralizing IFN-α and/or -ω. The prevalence of these antibodies is highest in patients with encephalitis (∼40%), and that in individuals with silent WNV infection is as low as that in the general population. The odds ratios for WNVD in individuals with these auto-Abs relative to those without them in the general population range from 19.0 (95% CI 15.0-24.0, P value <10-15) for auto-Abs neutralizing only 100 pg/ml IFN-α and/or IFN-ω to 127.4 (CI 87.1-186.4, P value <10-15) for auto-Abs neutralizing both IFN-α and IFN-ω at a concentration of 10 ng/ml. These antibodies block the protective effect of IFN-α in Vero cells infected with WNV in vitro. Auto-Abs neutralizing IFN-α and/or IFN-ω underlie ∼40% of cases of WNV encephalitis.

West Nile virus infections in Hungary: Epidemiological update and phylogenetic analysis of the Hungarian virus strains between 2015 and 2022

Following the introduction of the West Nile virus (WNV) into Hungary in 2004, it has shortly become one of the most important human arbovirus infections, with a gradually increasing number of cases. The study aimed to summarize the current epidemiological situation in Hungary and sequence the WNV PCR-positive clinical specimens and virus isolates by next-generation whole genome sequencing (NGS) to obtain a detailed phylogenetic analysis of the circulating virus strains. Whole blood and urine samples from confirmed WNV-infected patients and WNV isolates were investigated by reverse transcription PCR assays. Genome sequencing was carried out by Sanger-method, followed by NGS on the Illumina MiSeq platform. Altogether 499 human infections were diagnosed between 2004 and 2022. A particularly remarkable increase in human WNV infections was observed in 2018, while the number of reported cases significantly decreased during the COVID-19 pandemic. Between 2015 and 2022, 15 WNV isolates, and 10 PCR-positive clinical specimens were investigated by NGS. Phylogenetic analysis revealed that the major European WNV lineage 2 clades, namely the Eastern European (or Russian) and the Central European (or Hungarian) clades, are presented in Hungary. Strains of the Balkan and other European clusters within the Central European clade are co-circulating in the country, following a characteristic geographical distribution. In Hungary, the presence and co-circulation of multiple lineage 2 WNV strains could be identified in the last few years. Therefore, in light of the 2018 WNV outbreak, sequence-based typing of the currently circulating strains could highly support outbreak investigations.

SPTSSA variants alter sphingolipid synthesis and cause a complex hereditary spastic paraplegia

Sphingolipids are a diverse family of lipids with critical structural and signalling functions in the mammalian nervous system, where they are abundant in myelin membranes. Serine palmitoyltransferase, the enzyme that catalyses the rate-limiting reaction of sphingolipid synthesis, is composed of multiple subunits including an activating subunit, SPTSSA. Sphingolipids are both essential and cytotoxic and their synthesis must therefore be tightly regulated. Key to the homeostatic regulation are the ORMDL proteins that are bound to serine palmitoyltransferase and mediate feedback inhibition of enzymatic activity when sphingolipid levels become excessive. Exome sequencing identified potential disease-causing variants in SPTSSA in three children presenting with a complex form of hereditary spastic paraplegia. The effect of these variants on the catalytic activity and homeostatic regulation of serine palmitoyltransferase was investigated in human embryonic kidney cells, patient fibroblasts and Drosophila. Our results showed that two different pathogenic variants in SPTSSA caused a hereditary spastic paraplegia resulting in progressive motor disturbance with variable sensorineural hearing loss and language/cognitive dysfunction in three individuals. The variants in SPTSSA impaired the negative regulation of serine palmitoyltransferase by ORMDLs leading to excessive sphingolipid synthesis based on biochemical studies and in vivo studies in Drosophila. These findings support the pathogenicity of the SPTSSA variants and point to excessive sphingolipid synthesis due to impaired homeostatic regulation of serine palmitoyltransferase as responsible for defects in early brain development and function.

Participation in a national diagnostic research study: assessing the patient experience

INTRODUCTION

The Undiagnosed Diseases Network (UDN), a clinical research study funded by the National Institutes of Health, aims to provide answers for patients with undiagnosed conditions and generate knowledge about underlying disease mechanisms. UDN evaluations involve collaboration between clinicians and researchers and go beyond what is possible in clinical settings. While medical and research outcomes of UDN evaluations have been explored, this is the first formal assessment of the patient and caregiver experience.

METHODS

We invited UDN participants and caregivers to participate in focus groups via email, newsletter, and a private participant Facebook group. We developed focus group questions based on research team expertise, literature focused on patients with rare and undiagnosed conditions, and UDN participant and family member feedback. In March 2021, we conducted, recorded, and transcribed four 60-min focus groups via Zoom. Transcripts were evaluated using a thematic analysis approach.

RESULTS

The adult undiagnosed focus group described the UDN evaluation as validating and an avenue for access to medical providers. They also noted that the experience impacted professional choices and helped them rely on others for support. The adult diagnosed focus group described the healthcare system as not set up for rare disease. In the pediatric undiagnosed focus group, caregivers discussed a continued desire for information and gratitude for the UDN evaluation. They also described an ability to rule out information and coming to terms with not having answers. The pediatric diagnosed focus group discussed how the experience helped them focus on management and improved communication. Across focus groups, adults (undiagnosed/diagnosed) noted the comprehensiveness of the evaluation. Undiagnosed focus groups (adult/pediatric) discussed a desire for ongoing communication and care with the UDN. Diagnosed focus groups (adult/pediatric) highlighted the importance of the diagnosis they received in the UDN. The majority of the focus groups noted a positive future orientation after participation.

CONCLUSION

Our findings are consistent with prior literature focused on the patient experience of rare and undiagnosed conditions and highlight benefits from comprehensive evaluations, regardless of whether a diagnosis is obtained. Focus group themes also suggest areas for improvement and future research related to the diagnostic odyssey.

Size distribution and relationship of airborne SARS-CoV-2 RNA to indoor aerosol in hospital ward environments

Aerosol particles proved to play a key role in airborne transmission of SARS-CoV-2 viruses. Therefore, their size-fractionated collection and analysis is invaluable. However, aerosol sampling in COVID departments is not straightforward, especially in the sub-500-nm size range. In this study, particle number concentrations were measured with high temporal resolution using an optical particle counter, and several 8 h daytime sample sets were collected simultaneously on gelatin filters with cascade impactors in two different hospital wards during both alpha and delta variants of concern periods. Due to the large number (152) of size-fractionated samples, SARS-CoV-2 RNA copies could be statistically analyzed over a wide range of aerosol particle diameters (70-10 µm). Our results revealed that SARS-CoV-2 RNA is most likely to exist in particles with 0.5-4 µm aerodynamic diameter, but also in ultrafine particles. Correlation analysis of particulate matter (PM) and RNA copies highlighted the importance of indoor medical activity. It was found that the daily maximum increment of PM mass concentration correlated the most with the number concentration of SARS-CoV-2 RNA in the corresponding size fractions. Our results suggest that particle resuspension from surrounding surfaces is an important source of SARS-CoV-2 RNA present in the air of hospital rooms.

Tick-borne encephalitis epidemic in Hungary 1951-2021: The story and lessons learned

The authors analysed epidemiological data of the Hungarian tick-borne encephalitis epidemic from the past seven decades. A total of 911 meningitis serosa cases were described from 1930-1950 s by local hospital physicians, indicating that the virus had been present in the country decades before its official identification in 1952. The virus spread freely in the 1950s-1960s, occupying almost all habitats where ticks occurred in large numbers. The increasing number of cases drove authorities to classify this illness as a notifiable disease in 1977 and to organize the first measures to stop the epidemic. Statistical analysis revealed that the large-scale vaccination launched from the 1990s was responsible for the sharp decrease in the number of human cases from 1997. A significant negative correlation was found between the number of vaccine doses sold and human cases 6 years later. The TBEV endemic area covers 16.57% of the territory and 16.65% of the population of the country. In the last 10 years, 186,000 vaccine doses/year in average were enough to keep the incidence of human TBEV infections between 0.45 and 0.06/100,000 persons. A 20-year-long study found evidence for easing clinical signs in TBEV-infected hospitalized patients. Statistics found a sharp decrease in the number of samples sent for TBEV diagnosis after 1989. Male dominance of patients was characteristic of the epidemics since the 1940s, but now analysis of detailed data from the 1981-2021 period (60.5%-87.5%) proved the statistical significance of this dominance. Obviously, the voluntary vaccination programme was the tool which broke the spread of the epidemic. Widespread public awareness of the disease and the tick vector, probable evolutionary spread of less pathogenic virus strains supplemented with the vaccination campaign led to a negligible level of human TBE cases in Hungary in the last years.

Clinical determinants of non-invasive global myocardial work index before and after transcatheter aortic valve implantation: a prospective study

 

The estimation of non-invasive global myocardial work indices is a novel method of the left ventricular (LV) functional assessment, which may overcome the load-sensitvity of the traditional functional measures. The diagnostic and prognostic role of this approach may gain particular importance in pressure overload states, such as in patients with severe aortic stenosis. However, the longitudinal changes of this recently introduced measure are scarcely investigated, and data are also lacking about the main determinants of these measures.

Accordingly, our aim was to investigate the clinical determinants of preoperative and also postoperative GMWI in patients undergoing transcatheter aortic valve replacement (TAVR).

Fifty patients (62% male, age: 78±5 years) were enrolled. Prior to the procedure, subjects underwent echocardiographic investigation and the detailed medical history was also recorded. Speckle-tracking analysis was performed and global longitudinal strain (GLS) was measured. LV pressure curve was estimated by adding the mean aortic valve gradient to the systolic blood pressure. Using these measures, global myocardial work index (GMWI) and global constructive work index (CMWI) was quantified by commercially available software. A 6 months follow-up examination was also performed and at that time point we determined the aforementioned parameters.

At follow-up, GLS has significantly increased (−13.0±4.1 vs. −14.8±3.8%; p&lt;0.001), while GMWI was significantly lower compared to baseline (1789±748 vs. 1506±561 mmHg%, p&lt;0.01). CMWI did not differ between the two time points (2309±782 vs. 2086±609 mmHg%, p=0.11). Using multivariable analysis, age (β=0.30; p&lt;0.05) preoperative New York Heart Association (NYHA) class (β=−0.48; p&lt;0.001) and having a pacemaker (β=−0.44; p&lt;0.01) were found to be independent predictors of the preoperative GMWI (R2=0.39; overall p&lt;0.001). On the other hand, postoperative GMWI was determined (R2=0.48; overall p&lt;0.001) by gender (β=−0.25; p&lt;0.05), the presence of diabetes mellitus (β=−0.37; p&lt;0.01) and also by having a pacemaker (β=−0.38; p&lt;0.01).

TAVR significantly alters LV functional measures. Different clinical factors influence GMWI before and after the procedure: age, NYHA class-based symptom severity and having a pacemaker were found to be independently associated with preoperative GMWI, while gender, the presence of diabetes mellitus and pacemaker device are the most important clinical determinants of the postoperative GMWI value.

Funding Acknowledgement

Type of funding sources: None.

Internet Use Related to Suicidal Thoughts and Help-Seeking – Preliminary Results of a Study with Depressive Patients

Introduction

Suicide-related Internet use is becoming more common, and many research study its potential risks and benefits.

Objectives

Data on suicidal thoughts and Internet use of patients with depressive disorders were collected to assess their suicide-related Internet use and its relation to help-seeking preferences.

Methods

Semi-structured interviews were completed to assess Internet use patterns and suicidal thoughts among patients treated with depressive disorders, and preferred forms of help-seeking were also examined.

Results

113 patients completed the interviews, most of them spend more hours a day using the Internet. More than 80% came across suicide-related contents while browsing, a quarter reported specific search for suicidal contents. In case of suicidal thoughts, three-quarters of depressed patients would seek help from a mental health professional, two-thirds from their partners, half from friends, and nearly one-third from parents, other relatives or from GPs. Most patients would prefer offline (personal) help for their psychological problems and suicidal thoughts, online methods were less preferred, with only one-fifth choosing these options. However, a third of them also considered it probable that they would not ask anyone for help.

Conclusions

Despite of the frequent use of the Internet, online help-seeking is less common in depressive patients. However, in the times of pandemic, online help facilities may provide an opportunity to prevent suicidal behavior for those, who have suicidal thoughts and use the Internet regularly, especially searching for suicide-related contents. In the future, further research is needed to develop more effective online suicide prevention programs and applications.

Disclosure

No significant relationships.

Changes of the non-invasive myocardial work in patient undergoing transcatheter aortic valve replacement: the influence of left bundle branch block

Funding Acknowledgements

Type of funding sources: None.

Patients with left bundle branch block (LBBB) are known to have substantially increased afterload sensitivity. It gains particular importance in subjects with aortic stenosis: patients with pre-existing LBBB may benefit more from interventions such as transcatheter aortic valve replacement (TAVR) by an effective and rapid reduction of the left ventricular (LV) pressures.

Accordingly, our aim was to investigate the changes of LV myocardial work indices in patients undergoing TAVR by the presence of preoperative LBBB. Non-invasive myocardial work indices are novel echocardiographic parameters which adjust LV deformation to the instantaneous LV pressure, overcoming the the load-sensitivity of the traditional LV functional measures.

Thirty patients undergoing TAVR were enrolled (37% female; age: 78±6 years; aortic valve area [AVA]: 0.7±0.3 cm2). Fourteen patients (47%; LBBB group) showed LBBB pattern on ECG, by demonstrating native LBBB (n=6; 20%) or having ventricular pacing dependency (n=8; 27%), while 16 patients had narrow QRS (53%; non-LBBB group). Prior to the procedure, subjects underwent a detailed echocardiographic investigation. Speckle-tracking analysis was performed and global longitudinal strain (GLS) was measured. LV pressure curve was estimated by adding the mean aortic valve gradient to the aortic systolic pressure. Using these measures, LV global constructive work index (CMWI) and global work efficiency (GWE). were quantified by commercially available software. A 6 months follow-up examination was also performed and at that time point we determined the aforementioned parameters.

As expected, AVA significantly improved after the procedure in the pooled study group (1.8±0.4 cm2; p&lt;0.001). GLS also significantly increased (-13.2±4.2 vs. -15.2±3.9 %; p&lt;0.01), while CMWI only showed a tendential decrease (2422±788 vs. 2166±640 mmHg%; p=NS) at the follow-up. GLS (-10.6±3.7 vs. -15.5±3.4%; p&lt;0.001), CMWI (1877±679 vs. 2898±529 mmHg%; p&lt;0.001), and also GWE (82±9 vs. 91±4%; p&lt;0.01) was significantly lower in the LBBB-group compared to the non-LBBB patients. At the follow-up, GLS was still significantly lower in the LBBB patients (-13.2±4.6 vs. -16.9±2.1%; p&lt;0.01), however, CMWI was comparable between the two groups (1956±776 vs. 2350±439 mmHg%, p=NS).

Pressure overload of the LV may affect patients with LBBB substantially more than subjects without it. TAVR causes an immediate and significant decrease in the LV afterload, which results in a more pronounced improvement in the LBBB group compared to those with no LBBB.

West Nile and Usutu virus seroprevalence in Hungary: A nationwide serosurvey among blood donors in 2019

In Hungary, West Nile virus (WNV) has been responsible for 459 laboratory confirmed human cases between 2004 and 2019, while the first human Usutu virus (USUV) infection was confirmed only in 2018. A comprehensive serosurvey was conducted among blood donors to assess the WNV and USUV seroprevalence in 2019, one year after the largest European WNV epidemic. Altogether, 3005 plasma samples were collected and screened for WNV and USUV specific Immunoglobulin G (IgG) antibodies by Enzyme-Linked Immunosorbent Assay (ELISA). All reactive samples were further tested for tick-borne encephalitis virus IgG antibodies by ELISA. Indirect immunofluorescence test and microneutralization assay were used as confirmatory methods. Overall, the WNV seroprevalence was 4.32%, and in five blood donors USUV seropositivity was confirmed. The highest seroprevalence was measured in Central, Eastern and Southern Hungary, while the Western part of the country proved to be less affected. There was a statistically strong association between the WNV seroprevalence of 2019 and the cumulative incidence in the period of 2004 and 2019 calculated for every NUTS 3 region. The last WNV serological screening was performed in 2016 and the prevalence of anti-WNV IgG proved to be 2.19%. One year after the 2018 WNV outbreak, a significant increase in seroprevalence was observed in the Hungarian population and evidence for USUV seropositivity was also obtained. The spatial pattern of seroprevalence can support the identification of high-risk areas raising awareness of the need for increased surveillance, such as screening vector, equine, and avian populations. The communication with general practitioners and other professionals in primary health care services can support the early identification of acute human cases. Education and awareness-raising on the importance of protection against mosquito vectors amongst residents are also important parts of preventive measures.

Imported tropical arbovirus infections in Hungary between 2016 and 2020

Összefoglaló. Bevezetés: A Dengue-, Zika- és Chikungunya-vírus-fertőzések a trópusokról importált leggyakoribb arbovírusfertőzések. Földrajzi elterjedésük átfedő, közös vektoraik és hasonló tüneteik miatt szerológiai és molekuláris módszerek együttes alkalmazásán alapuló mikrobiológiai vizsgálatokkal különíthetők el megbízhatóan. Célkitűzés: Munkánk célja a 2016 és 2020 között endémiás területen járt, tünetes és tünetmentes utazók vizsgálata volt, minden esetben mindhárom vírusfertőzés irányában. A diagnosztikus tesztek során az alvadásgátolt teljes vér és vizelet bevonásával vizsgáltuk a vírus-RNS kimutathatóságának esélyét a különböző mintatípusokból. Módszer: Savópárminták szerológiai analízise során a Dengue-, Zika- és Chikungunya-vírus-specifikus ellenanyagválasz alakulását vizsgáltuk ELISA-módszerrel. Reaktív eredmények esetében a szerológiai keresztreakciók kizárására immunfluoreszcens és ELISA-technikán alapuló további vizsgálatokat végeztünk a hazai és az utazás során érintett területeken előforduló flavi- és alphavirusok irányában. Vérsavó-, alvadásgátolt teljes vér és vizeletmintákból reverztranszkripciót követő valós idejű polimeráz-láncreakcióval vírus-RNS-kimutatást végeztünk. Eredmények: Az 1037 vizsgált utazó közül 133 esetben kaptunk reaktív szerológiai és/vagy molekuláris eredményt. Az alvadásgátolt teljes vér mintából sikerült a legnagyobb arányban vírusnukleinsavat kimutatni mind a Dengue- és Zika-, mind a Chikungunya-vírus esetében. Megbeszélés: Endémiás területről hazatért utazók vizsgálatát a tünetek hasonlósága miatt mindhárom vírusfertőzés irányában együttesen indokolt elvégezni. A flavi- és alphavirusokra jellemző nagyfokú szerológiai keresztreaktivitás miatt a nukleinsav-kimutatás javíthatja a mikrobiológiai diagnosztika pontosságát. Következtetés: A három vírus mikrobiológiai diagnosztikáját segíti a korai mintavétel és a molekuláris vizsgálatok kiterjesztése további mintatípusokra: alvadásgátolt teljes vér és vizelet. A behurcolt vírusfertőzések azonosítása fokozott jelentőségű, mert az Európában is jelen lévő vektorszúnyogfajok felvetik az autochton átvitel lehetőségét. Orv Hetil. 2021; 162(50): 2000-2009.

SUMMARY

INTRODUCTION

Dengue-, Zika- and Chikungunya infections are among the most frequently imported tropical arbovirus infections. Due to their shared endemic regions, vectors and similar clinical symptoms, differential diagnosis is based on serological and molecular analysis.

OBJECTIVE

The aim of our study was to identify the imported arbovirus infections of travellers between 2016 and 2020. Furthermore, to improve the diagnostic sensitivity, anticoagulated whole blood and urine samples were involved in molecular diagnosis.

METHOD

Virus-specific antibody kinetics was tested in paired sera of patients by ELISA method. In case of reactive results, further serological analysis was performed using immunofluorescence assays and/or ELISA tests to exclude serological cross-reactions caused by other members of the flavi- and alphaviruses. Detection of viral RNA was attempted from serum, anticoagulated whole blood and urine specimens using reverse transcription and real-time polymerase chain reaction.

RESULTS

Out of the tested 1037 travellers, reactive serological and/or molecular results were obtained in 133 cases. Anticoagulated whole blood proved to be the most suitable specimen for viral RNA detection of the three viruses.

DISCUSSION

Parallel testing of Dengue-, Zika- and Chikungunya infections is recommended, as symptom-based differential diagnosis is challenging. Due to the characteristic serological cross-reactivity of flavi- and alphaviruses, microbiological diagnosis relies on both serological and molecular tests.

CONCLUSION

Involving anticoagulated whole blood and urine samples into molecular analysis and early sample collection improve the sensitivity of microbiological diagnostics. Identification of imported tropical arbovirus infections is of high importance as the presence of vector mosquitos in Europe raises the possibility of autochthon transmission. Orv Hetil. 2021; 162(50): 2000-2009.

Relationship Between Coronary Atheroma, Epicardial Adipose Tissue Inflammation, and Adipocyte Differentiation Across the Human Myocardial Bridge

Background Inflammation in epicardial adipose tissue (EAT) may contribute to coronary atherosclerosis. Myocardial bridge is a congenital anomaly in which the left anterior descending coronary artery takes a "tunneled" course under a bridge of myocardium: while atherosclerosis develops in the proximal left anterior descending coronary artery, the bridged portion is spared, highlighting the possibility that geographic separation from inflamed EAT is protective. We tested the hypothesis that inflammation in EAT was related to atherosclerosis by comparing EAT from proximal and bridge depots in individuals with myocardial bridge and varying degrees of atherosclerotic plaque. Methods and Results Maximal plaque burden was quantified by intravascular ultrasound, and inflammation was quantified by pericoronary EAT signal attenuation (pericoronary adipose tissue attenuation) from cardiac computed tomography scans. EAT overlying the proximal left anterior descending coronary artery and myocardial bridge was harvested for measurement of mRNA and microRNA (miRNA) using custom chips by Nanostring; inflammatory cytokines were measured in tissue culture supernatants. Pericoronary adipose tissue attenuation was increased, indicating inflammation, in proximal versus bridge EAT, in proportion to atherosclerotic plaque. Individuals with moderate-high versus low plaque burden exhibited greater expression of inflammation and hypoxia genes, and lower expression of adipogenesis genes. Comparison of gene expression in proximal versus bridge depots revealed differences only in participants with moderate-high plaque: inflammation was higher in proximal and adipogenesis lower in bridge EAT. Secreted inflammatory cytokines tended to be higher in proximal EAT. Hypoxia-inducible factor 1a was highly associated with inflammatory gene expression. Seven miRNAs were differentially expressed by depot: 3192-5P, 518D-3P, and 532-5P were upregulated in proximal EAT, whereas miR 630, 575, 16-5P, and 320E were upregulated in bridge EAT. miR 630 correlated directly with plaque burden and inversely with adipogenesis genes. miR 3192-5P, 518D-3P, and 532-5P correlated inversely with hypoxia/oxidative stress, peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PCG1a), adipogenesis, and angiogenesis genes. Conclusions Inflammation is specifically elevated in EAT overlying atherosclerotic plaque, suggesting that EAT inflammation is caused by atherogenic molecular signals, including hypoxia-inducible factor 1a and/or miRNAs in an "inside-to-out" relationship. Adipogenesis was suppressed in the bridge EAT, but only in the presence of atherosclerotic plaque, supporting cross talk between the vasculature and EAT. miR 630 in EAT, expressed differentially according to burden of atherosclerotic plaque, and 3 other miRNAs appear to inhibit key genes related to adipogenesis, angiogenesis, hypoxia/oxidative stress, and thermogenesis in EAT, highlighting a role for miRNA in mediating cross talk between the coronary vasculature and EAT.

Using metabolic markers to identify insulin resistance in premenopausal women with and without polycystic ovary syndrome

BACKGROUND

Insulin resistance (IR) is associated with increased risk for type 2 diabetes mellitus and cardiovascular disease. Quantifying IR is invasive and time-consuming, and thus not routinely used in clinical practice. Simple metabolic markers to predict IR exist, but have not been validated in premenopausal women or women with polycystic ovary syndrome (PCOS).

OBJECTIVE

To evaluate the ability of metabolic markers to identify premenopausal women with/without PCOS who are insulin resistant.

DESIGN/SETTING

Cross-sectional analysis.

PARTICIPANTS

One hundred and seventy-one non-diabetic premenopausal overweight/obese women without PCOS and 71 women with PCOS.

METHODS

IR was quantified by the steady-state plasma glucose during the modified insulin-suppression test. Metabolic markers (BMI, lipid/lipoprotein concentrations, and fasting glucose) were evaluated for their discriminative ability to identify IR, using area under the receiver-operating-characteristic curve (AUROC) analysis. Optimal cut-points were evaluated for predictive power.

RESULTS

In the non-PCOS group, the triglyceride/HDL cholesterol ratio (TG/HDL-C) was the best marker (AUROC 0.73). Optimal diagnostic cut-point was 1.9. In the PCOS group, the TG/HDL-C ratio, cholesterol/HDL-C ratio (TC/HDL-C), and HDL-C performed well (AUROC > 0.80), with optimal cut-points for TG/HDL-C 1.3, TC/HDL-C 3.4, and HDL-C 52 mg/dL: TG/HDL-C was more sensitive, but HDL-C had a higher PPV for IR.

CONCLUSION

TG/HDL-C can identify IR in premenopausal women with and/without PCOS; diagnostic cut-points differ from those of men and postmenopausal women. HDL-C is an alternative predictor in women with PCOS. These simple metabolic markers, which are standardized between labs, inexpensive, and routinely measured, can be used to tailor lifestyle and medical interventions to improve health outcomes in insulin-resistant premenopausal women.

Real-life measurement of size-fractionated aerosol concentration in a plethysmography box during the COVID-19 pandemic and estimation of the associated viral load

Introduction

There are concerns about pulmonary function tests (PFTs) being associated with aerosol generation and enhanced virus transmission. As a consequence, the number of PFTs was reduced significantly during the coronavirus disease 2019 pandemic. However, there are no robust data supporting this fear.

Objectives

To perform real-life measurement of aerosol concentrations in a PFT laboratory to monitor the concentration of particles near the patient, and to model the associated potential viral load.

Methods

Two optical particle counters were used to sample the background concentration and the concentration of particles near the patient's mouth in a whole-body plethysmography box. Statistical evaluation of the measured particle concentration time series was completed. The particle exhalation rate was assessed based on the measured particle concentration data by applying the near-field/far-field theory. The number of exhaled viruses by an infected patient during the test was compared with the emission of viruses during quiet breathing and speaking.

Results

Twenty-five patients were included in the study. Eighteen patients showed a significant increase in aerosol concentration [mean 1910 (standard deviation 593) particles/L]. Submicron particles dominated the number size distribution of the generated particles, but large particles represented a higher volume fraction in the generated particles compared with background. An average gene exhalation rate of 0.2/min was estimated from this data. This is one order of magnitude higher than the release rate for the same infected person during quiet breathing, and of the same order of magnitude as the release rate during normal speaking.

Conclusions

This study demonstrated that PFTs are aerosol-generating procedures. Based on these results, the moderate increase in viral load does not underpin stopping such examinations.

Mechanically deboned turkey meat with improved digestibility and biological value

Enzymatic hydrolysates of mechanically deboned meat (MDM) for a long time have been used as flavouring and functional food ingredients in the food industry and also as the bases of formula foods for special dietary uses.

The aim of the present study was to produce MDM hypo-antigenic products with improved digestibility and high biological value to be used as a milk protein alternative. turkey MDM was treated with digestive enzymes (trypsin and/or α-chymotrypsin, or pancreatin), followed by freeze drying. The optimised reaction conditions of hydrolysis were at 6% (w/v) of meat protein in 0.1% NaHCO3 buffer, pH 7.5; pancreatin enzyme with 50 TAME units/g meat protein substrate, 37 °C and 60 min). Hydrolysates (MDMH) were assessed for degree of hydrolyses (DH, %) by using trinitrobenzenesulphonic acid method and MW distribution by SDS-PAGE. Modification of immune reactive binding sites in MDMHs was monitored by immunoblot with cow’s milk, chicken egg or meat allergic human patients’ sera. Biological value indices (True Digestibility (TD), Net Protein Utilisation (NPU), Biological Value (BV)) were determined using rat feeding trials. Among the MDMH products, the pancreatic hydrolysate proved to be the most favourable in terms of biological value and digestibility as well as hypoallergenic property.

Rare disease patient matchmaking: development and outcomes of an internet case-finding strategy in the Undiagnosed Diseases Network

Background

Although clinician, researcher, and patient resources for matchmaking exist, finding similar patients remains an obstacle for rare disease diagnosis. The goals of this study were to develop and test the effectiveness of an Internet case-finding strategy and identify factors associated with increased matching within a rare disease population.

Methods

Public web pages were created for consented participants. Matches made, time to each inquiry and match, and outcomes were recorded and analyzed using descriptive statistics. A Poisson regression model was run to identify characteristics associated with matches.

Results

385 participants were referred to the project and 158 had pages posted. 579 inquiries were received; 89.0% were from the general public and 24.7% resulted in a match. 81.6% of pages received at least one inquiry and 15.0% had at least one patient match. Primary symptom category of neurology, diagnosis, gene page, and photo were associated with increased matches (p ≤ 0.05).

Conclusions

This Internet case-finding strategy was of interest to patients, families, and clinicians, and similar patients were identified using this approach. Extending matchmaking efforts to the general public resulted in matches and suggests including this population in matchmaking activities can improve identification of similar patients.

Supplementary information

The online version contains supplementary material available at 10.1186/s13023-021-01825-1.

A 1D Lyman-alpha profile camera for plasma edge neutral studies on the DIII-D tokamak

A one dimensional, absolutely calibrated pinhole camera system was installed on the DIII-D tokamak to measure edge Lyman-alpha (Ly-α) emission from hydrogen isotopes, which can be used to infer neutral density and ionization rate profiles. The system is composed of two cameras, each providing a toroidal fan of 20 lines of sight, viewing the plasma edge on the inboard and outboard side of DIII-D. The cameras' views lie in a horizontal plane 77 cm below the midplane. At its tangency radius, each channel provides a radial resolution of ∼2 cm full width at half maximum (FWHM) with a total coverage of 22 cm. Each camera consists of a rectangular pinhole, Ly-α reflective mirror, narrow-band Ly-α transmission filter, and a 20 channel AXUV photodetector. The combined mirror and transmission filter have a FWHM of 5 nm, centered near the Ly-α wavelength of 121.6 nm and is capable of rejecting significant, parasitic carbon-III (C-III) emission from intrinsic plasma impurities. To provide a high spatial resolution measurement in a compact footprint, the camera utilizes advanced engineering and manufacturing techniques including 3D printing, high stability mirror mounts, and a novel alignment procedure. Absolutely calibrated, spatially resolved Ly-α brightness measurements utilize a bright, isolated line with low parasitic surface reflections and enable quantitative comparison to modeling to study divertor neutral leakage, main chamber fueling, and radial particle transport.

Absolute calibration of the Lyman-α measurement apparatus at DIII-D

The LLAMA (Lyman-Alpha Measurement Apparatus) diagnostic was recently installed on the DIII-D tokamak [Rosenthal et al., Rev. Sci. Instrum. (submitted) (2020)]. LLAMA is a pinhole camera system with a narrow band Bragg mirror, a bandpass interference filter, and an absolute extreme ultraviolet photodiode detector array, which measures the Ly-α brightness in the toroidal direction on the inboard, high field side (HFS) and outboard, low field side (LFS). This contribution presents a setup and a procedure for an absolute calibration near the Ly-α line at 121.6 nm. The LLAMA in-vacuum components are designed as a compact, transferable setup that can be mounted in an ex situ vacuum enclosure that is equipped with an absolutely calibrated Ly-α source. The spectral purity and stability of the Ly-α source are characterized using a vacuum ultraviolet spectrometer, while the Ly-α source brightness is measured by a NIST-calibrated photodiode. The non-uniform nature of the Ly-α source emission was overcome by performing a calibration procedure that scans the Ly-α source position and employs a numerical optimization to determine the emission pattern. Nominal and measured calibration factors are determined and compared, showing agreement within their uncertainties. A first conversion of the measured signal obtained from DIII-D indicates that the Ly-α brightness on the HFS and LFS is on the order of 10²⁰ Ph sr^-1 m^-2 s^-1. The established calibration setup and procedure will be regularly used to re-calibrate the LLAMA during DIII-D vents to monitor possible degradation of optical components and detectors.

Identifying risks for severity of neurological symptoms in Hungarian West Nile virus patients

BACKGROUND

West Nile virus (WNV) infections have become increasingly prevalent in certain European countries, including Hungary. Although most human infections do not cause severe symptoms, in approximately 1% of cases WNV infections can lead to severe WNV neuroinvasive disease (WNND) and death. The goal of our study was to assess the neurological status changes of WNV -infected patients admitted to inpatient care and to identify potential risk factors as underlying reasons for severe neurological outcome.

METHODS

We conducted a retrospective chart review of 66 WNV-infected patients from four Hungarian medical centers. Patients' neurological status at hospital admission and at two follow-up intervals (1st follow-up, within 60-90 days and 2nd follow-up, within 150-180 days, after hospital discharge) were assessed. All of the 66 patients in the initial sample had some type of neurological symptoms and 56 patients were diagnosed with WNND. The modified Rankin Scale (mRS) and the West Nile Virus Neurological Index (WNV-N Index), a scoring system designed for the purpose of this study, were used for neurological status assessment. Patients were dichotomized into two categories, "moderately severe" and "severe" based on their neurological status. Descriptive analysis for sample description, stratified analysis for calculation of odds ratio (OR) and logistic regression for continuous input variables, were performed.

RESULTS

The average number of days between the onset of neurological symptoms and hospital admission (the neurological symptom interval) was 6.01 days. Complications during the hospital stay arose in almost a fifth of the patients (18.2%) and 5 patients died. Each day's increase in the neurological symptom interval significantly increased the risk for developing a severe neurological status following hospital admission (0.799-fold and 0.688-fold, based on the WNV-N Index and mRS, respectively). Patients' age, comorbidity, presence of complications and symptoms of malaise, and gait uncertainty were shown to be independent risk factors for severe neurological status.

CONCLUSIONS

Timely hospital admission of patients with neurological symptoms as well as risk assessment by clinicians - possibly with an optimal assessment tool for estimating neurological status- could improve the neurological outcome of WNV-infected patients.

Characterisation of the cerebrospinal fluid of horses with West Nile virus neuroinvasive disease

West Nile virus (WNV) is a zoonotic arbovirus transmitted by mosquitoes between wild birds (natural hosts) and other vertebrates. Horses and humans are incidental, dead-end hosts, but can develop severe neurological disorders. Owing to the close contact of cerebrospinal fluid (CSF) with the extracellular fluid of the brain, the analysis of CSF composition can reflect central nervous system (CNS) impairments enabling the diagnosis and understanding of various neurodegenerative CNS disorders. Our objective was to compare the findings from the CSF samples of horses with neuroinvasive WNV infection with those of healthy controls. We compared findings from fifteen CSF samples of 13 horses with acute WNV encephalomyelitis with those of 20 healthy controls. Protein, particular enzymes and ions, glucose and lactate showed abnormal levels in a significant number of WNV cases. None of the six horses with elevated glucose concentrations survived. Rather neutrophilic than mononuclear pleocytosis was identified with WNV infection. Neutrophils probably play a role in the development of inflammatory response and brain damage. Although elevated glucose levels reliably predicted the outcome, they might be the consequence of increased plasma levels and reflect general stress rather than CNS pathophysiology. The CSF findings of WNV encephalomyelitis patients are non-specific and variable but facilitate the differential diagnosis.

Impact assessment of the TFA regulation on fatty acid composition of foods in Hungary

Trans fatty acids are formed during the industrial processing of food, and are proven to be harmful for the human body. They have been associated with increased risk of cardiovascular disease, abdominal obesity, diabetes, and certain types of cancer. Decree 71/2013. (XI. 20.) of the Ministry of Human Capacities, which has been in force since 2014, defines the highest permitted amount of trans fats in food products placed on the market in Hungary. The impact of the decree on the industrially produced trans fatty acids (iTFA) availability and population intake was assessed in 2017. Results demonstrated that iTFA were replaced by other fatty acids due to the legislation. In 2019, we investigated food groups which had high measured TFA content before the regulation entered into force and compared the total fat and fatty acid profiles to the same brand or similar products being on the market afterwards. In collaboration with the World Health Organization, this was the first assessment to determine to which extent manufacturers increased saturated fat (SFA) content of foodstuffs to reduce iTFA content. In those product groups, which were identified as significant food sources of iTFA before introducing the regulation (biscuits, coffee creamers and flavorings, sweets, bakery products, confectionary, wafers, margarines) we found no significant changes in the total fat content, while in most foodstuffs the average proportion of SFA was higher after reformulation, as iTFA were mainly substituted with SFA in 61% of the products, with cis-MUFA in 25% and cis-PUFA in 14% of the products, respectively. Evidence from this analysis supports concerns that eliminating iTFA in certain foodstuffs leads to unwanted substitution with saturated fat, hence reducing the possible health benefits. Given the high SFA intake and the unfavourable cardiovascular statistics in Hungary, the consumption frequency and portion size control of these products are advised.

Key messages

Monitoring the changes of food composition is important in order to evaluate the effect of the regulation. Manufacturers should be encouraged to reduce the SFA content to a technologically feasible level.

Extraordinary increase in West Nile virus cases and first confirmed human Usutu virus infection in Hungary, 2018

BackgroundDuring the 2018 WNV transmission season, similarly to other endemic areas in Europe, a large number of human West Nile virus (WNV) infections were reported in Hungary.AimsWe summarise the epidemiological and laboratory findings of the 2018 transmission season and expand experiences in flavivirus differential diagnostics.MethodsEvery patient with clinical suspicion of acute WNV infection was in parallel tested for WNV, tick-borne encephalitis virus and Usutu virus (USUV) by serological methods. Sera, whole blood and urine samples were also tested for the presence of viral nucleic acid.ResultsUntil the end of December 2018, 215 locally acquired and 10 imported human WNV infections were notified in Hungary. All reported cases were symptomatic; most of them exhibited neurological symptoms. In a large proportion of tested individuals, whole blood was the most appropriate sample type for viral nucleic acid detection, but because whole blood samples were not always available, testing of urine samples also extended diagnostic possibilities. In addition, the first human USUV infection was confirmed in 2018 in a patient with aseptic meningitis. Serological cross-reactions with WNV in different serological assays were experienced, but subsequent molecular biological testing and sequence analysis identified Europe lineage 2 USUV infection.ConclusionCareful interpretation and simultaneous application of different laboratory methods are necessary to avoid misdiagnosis of human USUV cases. Expansion of the laboratory-confirmed case definition criteria for detection of viral RNA in any clinical specimens to include urine samples could increase diagnostic sensitivity.

STUDY OF CHITINASE AND CHITINOLYTIC ACTIVITY OF LACTOBACILLUS STRAINS

The increasing consumer demand for less processed and more natural food products – while improving those products’ quality, safety, and shelf-life – has raised the necessity of chemical preservative replacement. Biopreservation refers to extended storage life and enhanced safety of foods using the natural microflora and (or) their antibacterial products. Chitinolytic enzymes are of biotechnological interest, since their substrate, chitin, is a major structural component of the cell wall of fungi, which are the main cause of the spoilage of food and raw plant material. Among the several organisms, many bacteria produce chitinolytic enzymes, however, this behaviour is not general. The chitinase activity of the lactic acid bacteria is scarcely known and studied.

The aim of the present study was to select Lactobacillus strains that have genes encoding chitinase, furthermore, to detect expressed enzymes and to characterise their chitinase activity. Taking into consideration the importance of chitin-bindig proteins (CBPs) in the chitinase activity, CBPs were also examined. Five Lactobacillus strains out of 43 strains from 12 different species were selected by their chitinase coding gene. The presence of the chitinase and chitin-biding protein production were confirmed, however, no chitinolytic activity has been identified.

1642 Mitral annulus disjunction, a rare form of focal arrhythmogenic cardiomyopathy

Funding Acknowledgements

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

The rate of sudden cardiac death in mitral valve prolapse (MVP) patients is roughly twice that observed in the general population. Arrhythmogenic bileaflet MVP syndrome has been recently described and mitral annulus disjunction (MAD) has been found associated with papillary muscle fibrosis and ventricular arrhythmias even without severe mitral regurgitation. An underlying primary structural myocardial disease might be expected and the non-invasive imaging techniques are playing an increasingly important role in the detection of myocardial fibrosis as a focal arrhythmogenic substrate. Standard 2D-, 3D- and speckle tracking echocardiography and cardiac MRI can help to differentiate between the benign and malignant forms of MVP.

A 52-year-old man with a history of hypertension was referred for evaluation of frequent palpitations and presyncope. Ambulatory Holter monitoring showed paroxysmal atrial fibrillation and non-sustained ventricular tachycardias. Dilated left ventricle (LVEDD: 65mm, LVESD: 45 mm) and left atrium (LAVi: 52mL/m2), moderately reduced left ventricular (LV) systolic function (LVEF: 42%), and reduced LV global longitudinal strain (GLS: -13.5%) with severely decreased segmental longitudinal strain in the basal inferolateral segment were measured by transthoracic echocardiography. The diastolic function was preserved, however Pickelhaube sign was noticed in the lateral mitral annulus TDI curves. MAD (17 mm) and curling motion of the inferolateral basal segment of the left ventricle was observed. Transesophageal echocardiography showed bileaflet mitral valve prolapse with the involvement of all the six scallops (mitral valve prolapse volume: 10.2 mL). Severe mitral regurgitation (3D vena contracta area: 1cm2) and extremely dilated and dyskinetic mitral annulus (diameters: 55x72x12 mm, area: 34 cm2) was measured by 3D echocardiography. MRI showed transmural late gadolinium enhancement in the underlying myocardium of both papillary muscles and midmyocardial enhancement in the basal inferior, inferolateral and anteroseptal LV segments. During electrophysiology study ventricular fibrillation was easily induced and ICD was placed for primary prevention of sudden cardiac death. The patient was referred to the heart surgeon for mitral valve replacement.

This case highlights the importance of early recognition of MAD and arrhythmogenic MVP syndrome using novel non-invasive imaging techniques. The presence of MAD, the curling motion of the inferolateral basal LV segment, the Pickelhaube sign, the decreased LVEF and GLS, the characteristic segmental longitudinal strain pattern and the presence of late enhancement in the papillary muscles and the surrounding myocardium could be warning signs of the malignant form of MVP.

Abstract 1642 Figure. CMR images of arrhythmogenic MAD

[The occurrence of neuroinvasive symptoms caused by the West Nile virus at an emergency center]

Introduction: According to the European Centre for Disease Prevention and Control, the prevalence of neuroinvasive symptoms caused by the West Nile virus (WNV) has significantly increased in the past years throughout Europe, including Hungary. The rise may be attributed to changes in precipitation and climate. The WNV zoonosis is spread by mosquitoes. It is mostly asymptomatic, flu-like symptoms occur in 20% of the cases and in less than 1% a neuroinvasive disease with a lethal outcome may develop. Aim: Our aim was to demonstrate the neuroinvasive symptomatology and the diagnosis and treatment of WNV infections by describing our patient cases as well as to resolve differential diagnostic dilemmas. Method: We report the cases of 4 patients treated at the "Moritz Kaposi" Somogy County Hospital between the 31st July and 4th September, 2018, with WNV, whose diagnoses were confirmed by serological and molecular biological methods. An epidemiological overview of WNV infections was also given. Results: Four patients were confirmed to have had WNV infection in the given time period. A wide range of neurological symptoms were observed in each patient and death occurred in one case. The patients were elderly with a number of comorbidities. Conclusions: The appearance of more severe, neuroinvasive symptoms following WNV infections is also characteristic of Hungary. The treatment of the infection is supportive, including giving pain relievers and the management of secondary infections. It is important to consider the possibility of a WNV infection in the case of a neurological disease of unknown origin, particularly if the symptoms indicate encephalitis. Orv Hetil. 2019; 160(51): 2026-2035.

Imported Zika virus infections in Hungary between 2016 and 2018

Zika virus is a mosquito-borne flavivirus with significant public health concern due to its association with neurological symptoms and intrauterine malformations. Although it is endemic in tropical and subtropical areas, sexual transmission raises the possibility of autochthonous spreading elsewhere. We describe the first laboratory diagnosed imported Zika-infections of Hungary, to highlight the challenges of microbiological identification of the pathogen, caused by serological cross-reactivity and short viremia. Serological examination was carried out using indirect immunofluorescent assay and enzyme-linked immunosorbent assay. Plaque-reduction neutralization test was used for verification purposes. A wide range of clinical specimens: serum, whole-blood, urine, saliva, and semen were analyzed by molecular methods, and sequencing was applied in case of PCR positive results to identify the virus strain. Zika-infected patients with previous vaccination against flaviviruses or possible flavivirus infection in the past showed high serological cross-reactivity, and even cross-neutralizing antibodies were observed. Zika virus RNA could be detected in urine specimen in case of two patients, and in EDTA-anticoagulated whole-blood sample of one patient. The detected strains belong to the Asian lineage of the virus. We presume that serological investigation of imported Zika virus could be altered by infections, vaccination of endemic flaviviruses in Hungary and vice versa.

Beliefs About Medicines: Differences in cholesterol treatment adherence among the Visegrad countries

Background

Raised cholesterol is a risk factor for cerebrovascular and cardiovascular diseases. New cholesterol guidelines highlight more personalized risk assessments and new cholesterol-lowering drugs for people at the highest risk for cardiovascular disease.

Methods

The aim of our study was to investigate the possible differences in the beliefs about the necessity and concerns regarding lipid-lowering drugs among the Visegrad Group countries. For this the Beliefs About Medicines Questionnaire (BMQ-Specific) was used. The statistical analyses included 235 Czech, 205 Hungarian, 200 Polish, and 200 Slovak respondents, all of who were taking cholesterol lowering drugs.

Results

After comparing the answers of the citizens of the Visegrad Group countries, no statistically significant difference could be found regarding the concerns about the lipid-lowering drugs. However, related to the beliefs in necessity, a significant difference was shown between Poland and Hungary for the benefit of Polish participants. These results suggest, that the citizens of Visegrad Group countries do not differ regarding their beliefs about the fear of the treatment, while the beliefs about benefits are the most emphasized among the Polish citizens and less among the Hungarian citizens.

Conclusions

While policy makers in the Visegrad Group countries can use the same strategy to address the concerns regarding cholesterol lowering medication, the reasons behind the difference in the beliefs in necessity should be further investigated in order to implement country specific interventions.

The research was funded by the GINOP-2.3.2-15-2016-00005 project which is co-financed by

the European Union under the European Regional Development Fund.

Key messages

No differences exist regarding the concerns for cholesterol lowering medication among the Visegrad Group countries. Concerning necessity significant differences were observed among the same countries, which prompts further research questions.

West Nile Virus Seroprevalence Among Blood Donors in Hungary

Background and Objectives: West Nile virus (WNV) is one of the most important viral zoonotic infections in Hungary; however, no transfusion-transmitted WNV infections have been confirmed so far. In 2016, the number of clinical cases of WNV reported was 44, but the seasonal WNV screening of whole-blood donors has not yet been implemented. Our aims were to assess the WNV RNA reactivity and the prevalence of WNV-specific antibodies in the samples of blood donors collected in 2016. Materials and Methods: WNV RNA with Cobas TaqScreen and anti-WNV antibody determination from plasma samples of 2112 donors was performed. Cross-reactivity to tick-borne encephalitis virus was excluded. WNV neutralization test was used for the confirmation of anti-WNV IgG reactive results, and the presence of anti-WNV IgM antibodies was also determined. Results: None of the samples showed WNV RNA reactivity. The total weighted anti-WNV IgG prevalence was 2.34% (95% confidence interval 1.65-3.03), and in addition, three donors were found to be IgM positive. There was a comparable tendency between the data of WNV seroprevalence and cumulative incidence in six out of seven statistical regions in Hungary. Conclusion: Our results show a comparable data with publications that estimated the WNV seroprevalence in some other European endemic areas. As protective measures, both the 30-day deferral of blood donors who spent at least 24 h in WNV-exposed areas and the exclusion of affected Hungarian territories from blood donation are enforced by the Hungarian National Blood Transfusion Service. Our study is the first comprehensive serological survey to obtain actual data about WNV seroprevalence in the Hungarian human population.

A multimodal pathway including the basal ganglia in the feline brain

The purpose of this paper is to give an overview of our present knowledge about the feline tecto-thalamo-basal ganglia cortical sensory pathway. We reviewed morphological and electrophysiological studies of the cortical areas, located in ventral bank of the anterior ectosylvian sulcus as well as the region of the insular cortex, the suprageniculate nucleus of the thalamus, caudate nucleus, and the substantia nigra. Microelectrode studies revealed common receptive field properties in all these structures. The receptive fields were extremely large and multisensory, with pronounced sensitivity to motion of visual stimuli. They often demonstrated directional and velocity selectivity. Preference for small visual stimuli was also a frequent finding. However, orientation sensitivity was absent. It became obvious that the structures of the investigated sensory loop exhibit a unique kind of information processing, not found anywhere else in the feline visual system.