Reduced heart failure-related healthcare costs with Furoscix versus in-hospital intravenous diuresis in heart failure patients: the FREEDOM-HF study

Aim: Compare heart failure (HF) costs of Furoscix use at home compared with inpatient intravenous (IV) diuresis. Patients & methods: Prospective, case control study of chronic HF patients presenting to emergency department (ED) with worsening congestion discharged to receive Furoscix 80 mg/10 ml 5-h subcutaneous infusion for ≤7 days. 30-day HF-related costs in Furoscix group derived from commercial claims database compared with matched historical patients hospitalized for <72 h. Results: Of 24 Furoscix patients, 1 (4.2%) was hospitalized in 30-day period. 66 control patients identified and were well-matched for age, sex, ejection fraction (EF), renal function and other comorbidities. Furoscix patients had reduced mean per patient HF-related healthcare cost of $16,995 (p < 0.001). Conclusion: Furoscix use was associated with significant reductions in 30-day HF-related healthcare costs versus matched hospitalized controls.

A51 INTESTINAL MICROBIOTA DETERMINES ARYL HYDROCARBON RECEPTOR ACTIVATION AND SUSCEPTIBILITY TO COLITIS

Background

Intestinal microbiota, diet, and the immune system have been proposed to contribute to the development of inflammatory bowel diseases (IBD). The aryl hydrocarbon receptor (AhR) is a critical regulator of intestinal immunity and mucosal barrier homeostasis that is activated by agonists such as host and microbial tryptophan metabolites. IBD patients have altered microbiota and reduced AhR agonists in intestinal content resulting in the downregulation of AhR. These findings necessitate further study to understand how diet-microbiota interactions contribute to intestinal inflammation.

Purpose

To study the influence of intestinal microbiota on tryptophan metabolism, AhR activation, and colitis severity.

Method

8- to 10-week-old germ-free C57BL/6 mice were colonized with cecal content of mice harbouring specific pathogen-free (SPF) or a limited and well-defined altered Schaedler flora (ASF) microbiota. Germ-free mice were used as controls. Three weeks following colonization, mucosal injury was induced in a subset of mice with dextran sulfate sodium (DSS) in drinking water for five days followed by two days of water recovery. Activation of AhR was measured in stool using an in vitro AhR luciferase reporter assay. Stool AhR agonists were determined using high-performance liquid chromatography coupled to high-resolution mass spectrometry. Colonic expression of AhR pathway genes Cyp1a1, Il22, Ahrr, Ahr, and Il17 was evaluated by RT-qPCR. Susceptibility to colitis was assessed by analysing stool consistency and stool blood, colonic microscopic damage, immune infiltration by immunohistochemistry, and pro-inflammatory gene expression (NanoString). Fecal microbiota was analysed by 16S rRNA gene sequencing (Illumina).

Result(s)

AhR agonists, AhR activation in vitro, and AhR pathway gene expression were elevated in mice colonized with SPF microbiota in comparison to mice colonized with ASF microbiota and germ-free mice. In ASF-colonized mice, DSS induced more severe inflammation than in SPF-colonized mice, as demonstrated by worsened mucosal injury, greater weight loss, and softer stools. SPF-colonized mice developed less mucosal immune cell infiltration and pro-inflammatory gene signaling.

Conclusion(s)

Our findings suggest that intestinal microbiota composition determines the metabolic capacity to degrade tryptophan into agonists that homeostatically activate AhR. When mucosal injury is induced, mice with elevated microbiota-derived AhR agonists and AhR activation develop less severe mucosal injury and signs of colitis. This study presents a useful tool for evaluating dietary and microbial therapies in the context of a microbiota with impaired tryptophan metabolism.

Please acknowledge all funding agencies by checking the applicable boxes below

CCC, CIHR

Disclosure of Interest

None Declared

Comparison of Cardiovascular Outcomes Between Dapagliflozin and Empagliflozin in Patients With Type 2 Diabetes: A Meta-Analysis

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are oral diabetes medications that enhance the excretion of glucose by preventing the renal proximal tubules from reabsorbing glucose, which lowers glucose levels in plasma. Currently, studies have shown that SGLT2 inhibitors have beneficial impacts on cardiovascular outcomes, but their effect varies between the individual SGLT2 inhibitors. Thus, the current meta-analysis was conducted to compare the efficacy of dapagliflozin and empagliflozin in preventing cardiovascular events in patients with type 2 diabetes. The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. A search of studies comparing cardiovascular events between dapagliflozin and empagliflozin in patients with type 2 diabetes published up to 1 July 2022 was done by two reviewers independently on PubMed, Embase and Cumulated Index to Nursing and Allied Health Literature (CINAHIL). The pre-specified primary endpoints were cardiovascular death, stroke, myocardial infarction and heart failure. Overall four studies were included in this meta-analysis. No significant difference was found in the incidence of myocardial infarction (risk ratio (RR)=0.81, 95% confidence interval (CI): 0.60-1.09), heart failure (RR=0.76, 95% CI: 0.56-1.04), cardiovascular mortality (RR=0.46, 95% CI: 0.18-1.20) and stroke (RR=1.07, 95% CI: 0.84-1.38) between dapagliflozin and empagliflozin. Results have shown that the risk of developing stroke, heart failure, myocardial infarction and cardiovascular death were not significantly different in the two groups.

Left ventricular outflow tract thrombus in a patient with COVID-19—a ticking time bomb: a case report

Background

Coronavirus disease 2019 (COVID-19) is a manifestation of severe acute respiratory syndrome coronavirus 2, which results in many different complications including left ventricular (LV) thrombi.

Case summary

We present a 30-year-old female presenting with chest pain and shortness of breath. Patient had an extensive history including heart failure with an ejection fraction 15–20% and COVID-19 2 months ago. Echocardiogram revealed a 3.3 cm ×  1.7 cm LV thrombus which was not present 4 months ago before her diagnosis of COVID-19. The LV thrombus embolized resulting in an embolus extending from the distal infrarenal abdominal aorta to the common iliac arteries bilaterally. Repeat COVID pre-procedure was positive. She underwent bilateral femoral artery cutdown, bilateral iliac artery embolectomy, superficial femoral artery embolectomy, and bilateral lower extremity fasciotomy. An extensive workup for the aetiology of the LV thrombus turned out to be negative and COVID-19 was deemed to be the aetiology of the thrombus. The patient was bridged from apixaban to warfarin and was successfully discharged within a few weeks.

Discussion

Hypercoagulability is a known complication of COVID-19 causing thrombi in various parts of the body including the LV. Early recognition with echocardiography, especially in patients with heart failure, and prompt treatment is key to avoid further complications such as embolization.

A48 OPTIMIZATION OF TRYPTOPHAN-CONTAINING DIETS TO ACTIVATE THE ARYL HYDROCARBON RECEPTOR AND REDUCE SUSCEPTIBILITY TO COLITIS

Background

The intestinal microbiota, diet, and the immune system have all been proposed to contribute to the development of inflammatory bowel disease (IBD). The aryl hydrocarbon receptor (AhR) is a critical regulator of intestinal immunity and mucosal barrier homeostasis that is activated by agonists such as diet-derived microbial tryptophan (Trp) metabolites. Increasing evidence suggests that IBD patients have reduced AhR agonists in intestinal content resulting in the downregulation of AhR-regulated genes. In mice, impaired Trp metabolism and AhR signaling translate to increased intestinal inflammation and injury during colitis. This finding highlights the utility of Trp dietary intervention to reduce the onset and progression of inflammation and injury in IBD.

Aims

To optimize a Trp-enriched diet formulation to increase AhR activation and reduce intestinal inflammation and injury in mouse models of colitis.

Methods

Three diet types with elevated Trp were explored: (1) free amino acid diet with added Trp, (2) purified protein diet with added Trp, and (3) purified high protein diet. Following three weeks of diet consumption by C57BL/6 mice, mucosal injury was induced with 2% dextran sulfate sodium in drinking water (DSS) before sacrifice. Susceptibility to colitis was assessed by analyzing stool consistency and blood, microscopic damage, immune infiltration by immunohistochemistry, and pro-inflammatory gene expression (NanoString). Activation of AhR was measured in feces using an in vitro AhR luciferase reporter assay. Colonic expression of AhR pathway genes Cyp1a1, Il22, Ahrr, and Il17 was evaluated by RT-qPCR. Fecal microbiota was analyzed by 16S rRNA gene sequencing (Illumina).

Results

AhR activation in vitro and colonic AhR pathway gene expression were elevated in mice fed diets containing added Trp (1 & 2) in comparison to mice fed a high protein diet (3). While all DSS-treated mice developed colitis, mice fed a purified protein diet with added Trp (2) were protected from severe colitis and developed less microscopic damage, immune cell infiltration, and pro-inflammatory gene signalling. Enriched Trp concentrations in the form of free amino acid (1) and high protein (3) diets were not associated with protection from inflammation and injury during colitis.

Conclusions

Our findings suggest that the addition of Trp to a conventional diet (2) may increase microbial tryptophan metabolites to ameliorate colitis severity and intestinal homeostasis through AhR activation. Despite having similar Trp concentrations, a Trp-enriched free amino acid diet (1) and a high protein diet (3) do not improve colitis severity. Thus, both the diet formulation and the availability of Trp should be considered when designing dietary interventions for the treatment of colitis through AhR activation.

Funding Agencies

CCC, CIHRFarncombe Family Digestive Health Research Institute, Douglas Family Chair in Gastroenterology Research, Biocodex Microbiota Foundation

RV lead placement - A forgotten cause of right heart failure

Introduction

Cardiac implantable electronic devices (CIEDs) have opened new doors, improving the quality, and increasing the duration of life by providing support of heart rate, atrioventricular and interventricular synchrony, thereby preventing sudden cardiac death. Nevertheless, these devices can pose some risks to the patients, including pacemaker-mediated cardiomyopathy and endocarditis.

Case presentation

We elucidate the case of a patient who had severe Tricuspid Regurgitation as a result of single chamber Implantable Cardioverter Defibrillator (ICD) placement which led to right heart failure (RHF). His chief complaints were generalized fatigability and difficulty climbing steps at home. He also had orthopnea but denies paroxysmal nocturnal dyspnea. Despite using home diuretic regimen (Torsemide 40 gm daily), his continued to increase. He did not respond well to intravenous diuretics that time so decision was made to start Aquapheresis to which he responded very well

Discussion

TV dysfunction associated with CIED leads can be investigated and diagnosed using different techniques. These pillars of diagnostic tests include two-dimensional (2D), 3D, and Doppler echocardiography. Presence of holosystolic hepatic vein flow reversal is key in diagnosing severe TR, whereas normal antegrade systolic flow excludes the possibility of moderate and severe TR.

Conclusion

CIED leads causing tricuspid valve impairment has become increasingly recognized over the recent times; however, the evidence underlying this trend has been derived primarily from retrospective analyses. In order to circumvent these issues, leadless pacemakers and subcutaneous ICD devices should be considered.

•CIED leads causing TV dysfunction has gained increasing recognition recently but all evidence supporting this premise emanates from retrospective analyses.

•When clinical, hemodynamic, and echocardiographic assessment provides compelling evidence of lead related severe TR, corrective intervention should be provided in a timely fashion, before the onset of severe annular and chamber dilation and severe RV dysfunction because, by that time, the lead itself will no longer be the problem, and the extant problem may not be as amenable to corrective intervention.

•Leadless pacemakers and subcutaneous ICD devices likely to be associated with a reduction in lead-related cardiac dysfunction.

The impact of peripheral arterial disease on left ventricular assist device implantation: A propensity-matched analysis of the nationwide inpatient sample database

Left ventricular assist device (LVAD) candidacy screening includes evaluation for peripheral arterial disease (PAD). However, given current evidence, the impact of PAD on post-LVAD complications remains unknown. The National Inpatient Sample (NIS) database (2002-2017) was utilized to identify all LVAD cases. The in-hospital safety endpoints included major cardiovascular adverse events and its components. A propensity-matched analysis was used to obtain adjusted odds ratios (aOR). A subgroup analysis of patients with diabetes mellitus (DM) with PAD was also performed. A total of 27 424 patients with LVAD implantation (PAD: 516 [1.8%] and no-PAD 26 908 [98.2%]) were included. There were significant intergroup differences in the demographics and baseline comorbidities. A weighted sample of 1053 (no-PAD 537, PAD 516) propensity-matched population was selected. The adjusted odds for in-hospital mortality (aOR 1.7; 95% CI, 1.2-2.44, P = .004) were found to be significantly higher for LVAD-patients with PAD. There was no significant difference in the adjusted odds of MACE (aOR 1.16, 95% CI 0.87-1.5), postprocedure bleeding (aOR 0.88, 95% CI 0.62-1.26, P = .54) and risk of pneumonia (aOR 0.67, 95% CI 0.44-1.15, P = .63) between the two groups. A selected cohort of DM-only population (7339) consistently showed a higher adjusted mortality rate in PAD patients with LVAD implantation (aOR 2.3, 95% CI 1.2-4.47, P = .01). The rate of MACE (P = .17), myocardial infarction (P = .12), stroke (P = .60), postprocedural (0.10), and major bleeding (P = .51) remained identical between patients with PAD and those with no-PAD. PAD confers an increased risk of in-hospital all-cause mortality in patients undergoing LVAD implantation. This risk increases further in patients with a concomitant diagnosis of DM.

Safety and efficacy of soluble guanylate cyclase stimulators in patients with heart failure: A systematic review and meta-analysis

BACKGROUND

The utility of novel oral soluble guanylate cyclase (sGC) stimulators (vericiguat and riociguat), in patients with reduced or preserved ejection fraction heart failure (HFrEF/HFpEF) is currently unclear.

AIM

To determine the efficacy and safety of sGC stimulators in HF patients.

METHODS

Multiple databases were searched to identify relevant randomized controlled trials (RCTs). Data on the safety and efficacy of sGC stimulators were compared using relative risk ratio (RR) on a random effect model.

RESULTS

Six RCTs, comprising 5604 patients (2801 in sGC stimulator group and 2803 placebo group) were included. The primary endpoint (a composite of cardiovascular mortality and first HF-related hospitalization) was significantly reduced in patients receiving sGC stimulators compared to placebo [RR 0.92, 95% confidence interval (CI): 0.85-0.99, P = 0.02]. The incidence of total HF-related hospitalizations were also lower in sGC group (RR 0.91, 95%CI: 0.86-0.96, P = 0.0009), however, sGC stimulators had no impact on all-cause mortality (RR 0.96, 95%CI: 0.86-1.07, P = 0.45) or cardiovascular mortality (RR 0.94, 95%CI: 0.83-1.06, P = 0.29). The overall safety endpoint (a composite of hypotension and syncope) was also similar between the two groups (RR 1.50, 95%CI: 0.93-2.42, P = 0.10). By contrast, a stratified subgroup analysis adjusted by type of sGC stimulator and HF (vericiguat vs riociguat and HFrEF vs HFpEF) showed near identical rates for all safety and efficacy endpoints between the two groups at a mean follow-up of 19 wk. For the primary composite endpoint, the number needed to treat was 35, the number needed to harm was 44.

CONCLUSION

The use of vericiguat and riociguat in conjunction with standard HF therapy, shows no benefit in terms of decreasing HF-related hospitalizations or mortality.

Quality of life and treatment preference for ventricular assist device therapy in ambulatory advanced heart failure: A report from the REVIVAL study

BACKGROUND

The Registry Evaluation of Vital Information for Ventricular Assist Devices (VADs) in Ambulatory Life study is a prospective multicenter cohort of 400 ambulatory patients with advanced chronic systolic heart failure (HF). The aim of the study is to better understand disease trajectory and optimal timing of advanced HF therapies. We examined patient health-related quality of life (HRQOL) data collected at enrollment and their association with patient treatment preferences for VAD placement.

METHODS

Baseline assessment of HRQOL included the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the EuroQol EQ-5D-3L Visual Analogue Scale (VAS), along with patient self-assessment of remaining life (PSARL). Descriptive statistics were used to present baseline HRQOL data and Spearman correlation tests to assess the association between KCCQ, VAS, and VAD treatment preference with patient clinical characteristics of interest.

RESULTS

The median age was 60 years, 75% were male, and the median left ventricular ejection fraction was 20%. The median (25th percentile, 75th percentile), baseline KCCQ summary score was 64 (48, 78), VAS score 65 (50, 75), and PSARL 7 years (5, 10). There were statistically significant associations of baseline KCCQ and VAS with New York Heart Association class and Interagency Registry of Mechanically Assisted Circulatory Support profile (p < 0.005 for all comparisons). Baseline KCCQ and VAS revealed a modest association with PSARL (correlation = 0.45 and 0.35, respectively; p < 0.001), and many patients were overly optimistic about their expected survival. VAD treatment preference was associated with KCCQ scores (p < 0.031), but the absolute differences were small. VAD treatment preference was independent of other key clinical characteristics such as subject age, VAS, and PSARL.

CONCLUSIONS

We found a lack of strong association between HRQOL and patient preference for VAD therapy. Better understanding of patients' perceptions of their illness and how this relates to HRQOL outcomes, clinician risk assessment, and patient decision-making is needed. This may in turn allow better guidance toward available HF therapies in this vulnerable population.

A feasibility study on the determination of 90Sr food-chain transfer using stable strontium as a surrogate and neutron activation analysis

We evaluated the applicability of neutron activation analysis for investigating the potential mobility of ⁹⁰Sr in a pasture area in Hungary. To measure strontium concentrations, we made use of the ⁸⁴Sr(n,γ)⁸⁵Sr radiative capture reaction using neutron activation analysis and performed gamma spectroscopy using Compton-suppression techniques on the resulting 514.0 keV gamma ray. Our values for soil-to-plant transfer factors value of 1.6 (2.2) kg kg^-1 were in agreement with recommended values from the ICRP and IAEA, as well as similar studies performed by independent researchers. Our values for plant-to-animal transfer coefficients and concentration ratios varied from suggested values by several orders of magnitude to agreement with other values. Based on our results the utilized transfer of stable strontium could not be regarded as a convenient substitute to help clarify the long-term transfer of radioactive strontium in the environment, because short term dosing was applied. Neutron activation analysis provides a unique niche as a technique with very little chemical processing and short sample analysis times.

Flexible sample cell for real-time GISAXS, GIWAXS and XRR: design and construction

Since the properties of functional materials are highly dependent on their specific structure, and since the structural changes, for example during crystallization, induced by coating and annealing processes are significant, the study of structure and its formation is of interest for fundamental and applied science. However, structure analysis is often limited to ex situ determination of final states due to the lack of specialized sample cells that enable real-time investigations. The lack of such cells is mainly due to their fairly complex design and geometrical restrictions defined by the beamline setups. To overcome this obstacle, an advanced sample cell has been designed and constructed; it combines automated doctor blading, solvent vapor annealing and sample hydration with real-time grazing-incidence wide- and small-angle scattering (GIWAXS/GISAXS) and X-ray reflectivity (XRR). The sample cell has limited spatial requirements and is therefore widely usable at beamlines and laboratory-scale instruments. The cell is fully automatized and remains portable, including the necessary electronics. In addition, the cell can be used by interested scientists in cooperation with the Institute for Crystallography and Structural Physics and is expandable with regard to optical secondary probes. Exemplary research studies are presented, in the form of coating of P3HT:PC₆₁PM thin films, solvent vapor annealing of DRCN5T:PC₇₁BM thin films, and hydration of supported phospholipid multilayers, to demonstrate the capabilities of the in situ cell.

[Treatment of supine position-related obstructive sleep apnea with smartphone applications]

BACKGROUND

Positional obstructive sleep apnea (POSA) is common in mild and moderate forms of obstructive sleep apnea (OSA). Two smartphone applications (apps) professing to avoid the supine position (SP) are available: for Android the "Apnea Sleep Position Trainer" and for iOS the "SomnoPose-Sleep Position Monitor". The smartphone needs to be attached to the chest to recognize SP, which then triggers a vibration alarm. This is intended to encourage the patient to change position and the vibration stops as soon as SP is left. These apps, however, have not yet undergone a systematic evaluation.

METHODS

Adult patients with polysomnographically diagnosed POSA were invited to participate in the study. POSA was defined as an apnea-hypopnea index (AHI) in SP >10, with AHI in a lateral position <10 and doubling of the AHI in SP. After 1 month, a control polysomnography (PSG) was performed and compliance (at least 4 h/night on 5 of 7 days) was evaluated after 6 months by phone. A sufficient therapy was defined as reduction in SP to <10% of the total sleep time and to an overall AHI <10.

RESULTS

Although 57 patients entered the study, 24 did not appear to the PSG control; therefore, 33 patients finished the study, of whom 25 were treated successfully. The overall AHI in 33 patients was reduced from 14.5 ± 9.0 to 9.5 ± 12.6 and the time in SP decreased significantly from 71.1 ± 50.5 to 25.4 ± 65.0 min. Compliance among the 25 continuously treated patients after 6 months was 79.2%.

CONCLUSION

Both smartphone apps have the capability to prevent PS in POSA patients and can potentially offer a cost-effective option in the treatment of POSA.

Calibration of the microcalorimeter spectrometer on-board the Hitomi (Astro-H) observatory (invited)

The Hitomi Soft X-ray Spectrometer (SXS) was a pioneering non-dispersive imaging x-ray spectrometer with 5 eV FWHM energy resolution, consisting of an array of 36 silicon-thermistor microcalorimeters at the focus of a high-throughput soft x-ray telescope. The instrument enabled astrophysical plasma diagnostics in the 0.3-12 keV band. We introduce the SXS calibration strategy and corresponding ground calibration measurements that took place from 2012-2015, including both the characterization of the microcalorimeter array and measurements of the x-ray transmission of optical blocking filters.

Identification of a haplotype associated with cholesterol deficiency and increased juvenile mortality in Holstein cattle

Over the last decades, several genetic disorders have been discovered in cattle. However, the genetic background of disorders in calves is less reported. Recently, German cattle farmers reported on calves from specific matings with chronic diarrhea and retarded growth of unknown etiology. Affected calves did not respond to any medical treatment and died within the first months of life. These calves were underdeveloped in weight and showed progressive and severe emaciation despite of normal feed intake. Hallmark findings of the blood biochemical analysis were pronounced hypocholesterolemia and deficiency of fat-soluble vitamins. Results of the clinical and blood biochemical examination had striking similarities with findings reported in human hypobetalipoproteinemia. Postmortem examination revealed near-complete atrophy of the body fat reserves including the spinal canal and bone marrow. To identify the causal region, we performed a genome-wide association study with 9 affected and 21,077 control animals genotyped with the Illumina BovineSNP50 BeadChip (Illumina Inc., San Diego, CA), revealing a strong association signal on BTA 11. Subsequent autozygosity mapping identified a disease-associated haplotype encompassing 1.01 Mb. The segment of extended homozygosity contains 6 transcripts, among them the gene APOB, which is causal for cholesterol disorders in humans. However, results from multi-sample variant calling of 1 affected and 47 unaffected animals did not detect any putative causal mutation. The disease-associated haplotype has an important adverse effect on calf mortality in the homozygous state when comparing survival rates of risk matings vs. non-risk matings. Blood cholesterol values of animals are significantly associated with the carrier status indicating a codominant inheritance. The frequency of the haplotype in the current Holstein population was estimated to be 4.2%. This study describes the identification and phenotypic manifestation of a new Holstein haplotype characterized by pronounced hypocholesterolemia, chronic emaciation, growth retardation, and increased mortality in young cattle, denominated as cholesterol deficiency haplotype. Our genomic investigations and phenotypic examinations provide additional evidence for a mutation within the APOB gene causing cholesterol deficiency in Holstein cattle.

MR and other imaging methods in the investigation of mycetomas

Purpose: To report features of mycetomas (actino- and eumycetoma infection), which belong to the so-called rare bone infections, as evaluated by MR and other imaging methods and to assess chemotherapy treatment.

Material and Methods: Twenty patients (average age 57 years) were diagnosed by different modalities. Analyses of 57 plain films, 31 three-phase bone scans, 28 CT and 35 MR examinations were performed. The MR protocol included T1-weighting without and with contrast, T2-weighted, proton density and fat suppressing sequences.

Results: Signs of chronic osteomyelitis were seen in plain films of 10 patients (50%), but the healing process was difficult to assess. Bone scintigraphy was positive in 12 patients (60%). In 14 patients (70%), CT could demonstrate bone lesions, but the healing process was difficult to estimate in 4 patients. MR imaging provided accurate diagnostic information in 15 cases (75%). In 16 patients (80%), small lesions could be identified due to grains, which seemed to differentiate mycetoma from other infections and tumorous lesions. MR examination gave definitive answer about the healing process in 18 cases (90%).

Conclusion: MR investigation was superior to the other imaging techniques in the evaluation of mycetoma and the assessment of therapy.

Precision Measurement of the Helium Flux in Primary Cosmic Rays of Rigidities 1.9 GV to 3 TV with the Alpha Magnetic Spectrometer on the International Space Station

Knowledge of the precise rigidity dependence of the helium flux is important in understanding the origin, acceleration, and propagation of cosmic rays. A precise measurement of the helium flux in primary cosmic rays with rigidity (momentum/charge) from 1.9 GV to 3 TV based on 50 million events is presented and compared to the proton flux. The detailed variation with rigidity of the helium flux spectral index is presented for the first time. The spectral index progressively hardens at rigidities larger than 100 GV. The rigidity dependence of the helium flux spectral index is similar to that of the proton spectral index though the magnitudes are different. Remarkably, the spectral index of the proton to helium flux ratio increases with rigidity up to 45 GV and then becomes constant; the flux ratio above 45 GV is well described by a single power law.

Precision Measurement of the Proton Flux in Primary Cosmic Rays from Rigidity 1 GV to 1.8 TV with the Alpha Magnetic Spectrometer on the International Space Station

A precise measurement of the proton flux in primary cosmic rays with rigidity (momentum/charge) from 1 GV to 1.8 TV is presented based on 300 million events. Knowledge of the rigidity dependence of the proton flux is important in understanding the origin, acceleration, and propagation of cosmic rays. We present the detailed variation with rigidity of the flux spectral index for the first time. The spectral index progressively hardens at high rigidities.

Characterization of large deletions in the DHCR7 gene

Pathogenic variants in the DHCR7 gene cause Smith-Lemli-Opitz syndrome (SLOS), a defect of cholesterol biosynthesis resulting in an autosomal recessive congenital metabolic malformation disorder. In approximately 4% of patients, the second mutation remains unidentified. In this study, 12 SLOS patients diagnosed clinically and/or by elevated 7-dehydrocholesterol (7-DHC) have been investigated by customized multiplex ligation-dependent probe amplification (MLPA) analysis, because only one DHCR7 sequence variant has been detected. Two unrelated patients of this cohort carry different large deletions in the DHCR7 gene. One patient showed a deletion of exons 3-6. The second patient has a deletion of exons 1 and 2 (non-coding) and lacks the major part of the promoter. These two patients show typical clinical and biochemical phenotypes of SLOS. Second disease-causing mutations are p.(Arg352Trp) and p.(Thr93Met), respectively. Deletion breakpoints were characterized successfully in both cases. Such large deletions are rare in the DHCR7 gene but will resolve some of the patients in whom a second mutation has not been detected.

High statistics measurement of the positron fraction in primary cosmic rays of 0.5-500 GeV with the alpha magnetic spectrometer on the international space station

A precision measurement by AMS of the positron fraction in primary cosmic rays in the energy range from 0.5 to 500 GeV based on 10.9 million positron and electron events is presented. This measurement extends the energy range of our previous observation and increases its precision. The new results show, for the first time, that above ∼200  GeV the positron fraction no longer exhibits an increase with energy.