A dynamical measure of the black hole mass in a quasar 11 billion years ago

Tight relationships exist in the local Universe between the central stellar properties of galaxies and the mass of their supermassive black hole (SMBH)1-3. These suggest that galaxies and black holes co-evolve, with the main regulation mechanism being energetic feedback from accretion onto the black hole during its quasar phase4-6. A crucial question is how the relationship between black holes and galaxies evolves with time; a key epoch to examine this relationship is at the peaks of star formation and black hole growth 8-12 billion years ago (redshifts 1-3)7. Here we report a dynamical measurement of the mass of the black hole in a luminous quasar at a redshift of 2, with a look back in time of 11 billion years, by spatially resolving the broad-line region (BLR). We detect a 40-μas (0.31-pc) spatial offset between the red and blue photocentres of the Hα line that traces the velocity gradient of a rotating BLR. The flux and differential phase spectra are well reproduced by a thick, moderately inclined disk of gas clouds within the sphere of influence of a central black hole with a mass of 3.2 × 108 solar masses. Molecular gas data reveal a dynamical mass for the host galaxy of 6 × 1011 solar masses, which indicates an undermassive black hole accreting at a super-Eddington rate. This suggests a host galaxy that grew faster than the SMBH, indicating a delay between galaxy and black hole formation for some systems.

Long-term assessment and target achievement of LDL-C and systolic blood pressure in primary care after acute coronary syndrome

Background

Hospital-based cardiac rehabilitation and risk factor control decreases the risk of recurrent events after acute coronary syndrome (ACS). Little is known on long-term assessment and target achievement after referral to primary care. Patients with diabetes, regardless of ACS, have yearly follow-up visits in primary care, whereas there is no structured follow-up after ACS for patients without diabetes.

Purpose

To describe long-term assessment and target achievement of LDL-C and systolic blood pressure (SBP) in ACS patients after referral to primary care. Further, to compare patients with and without diabetes at the time of index ACS.

Methods

A non-interventional population-based observational study of patients with first ever ACS in a Swedish region with 390,000 inhabitants. Data on clinical measurements after ACS were collected from the electronic medical records between 2012 and 2020. Patients were followed until new ACS event, death, moving out of the county, or end of study. Target levels studied were LDL-C <1.8 mmol/L and SBP <140 mmHg. The same assessments with the addition of target levels of HbA1c ≤70 mmol/mol were evaluated in patients with diabetes.

Results

Median follow-up was 2.9 years (inter quartile range [IQR]: 1.0–5.4) and 4,733 patients were detected. Median age was 72 years (IQR 63–80) and 34% were female. Follow-up data were available for 3,579 (76%) patients any time during the first, 2,891 (61%) during the second, and 2,308 (49%) during the third year after the index ACS event. The number of patients with diabetes was 1311 (28%), and of these 921, 723, and 562 could be followed for the first, second, and third year. During the first three years, 898 (19%) of all patients with available follow-up died.

The proportion of patients with assessments of LDL-C and SBP declined for each year of follow-up and target achievement was low (Table). Among patients with diabetes a larger proportion had measurements for LDL-C and SBP, while the target achievement was similar to that of the whole study population. HbA1c was measured equally frequently as SBP and was at target in 81% of patients with diabetes during the three years of follow-up (Table).

Conclusion

The proportion of patients with follow-up assessment and measurements in primary care declined each year after the index ACS event. Patients with diabetes had more frequent LDL-C and SBP measurements but the same low target achievement after an ACS compared with patients without diabetes. This could potentially be due to an increased focus on glycaemic control at these visits. A structured long-term follow-up for ACS patients in primary care might improve both assessment and target achievement and prevent recurrent ACS events.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AmgenSwedish Heart Lung Foundation

Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

The peppermint breath test benchmark for PTR-MS and SIFT-MS

A major challenge for breath research is the lack of standardization in sampling and analysis. To address this, a test that utilizes a standardized intervention and a defined study protocol has been proposed to explore disparities in breath research across different analytical platforms and to provide benchmark values for comparison. Specifically, thePeppermint Experimentinvolves the targeted analysis in exhaled breath of volatile constituents of peppermint oil after ingestion of the encapsulated oil. Data from thePeppermint Experimentperformed by proton transfer reaction mass spectrometry (PTR-MS) and selected ion flow tube mass spectrometry (SIFT-MS) are presented and discussed herein, including the product ions associated with the key peppermint volatiles, namely limonene,α- andβ-pinene, 1,8-cineole, menthol, menthone and menthofuran. The breath washout profiles of these compounds from 65 individuals were collected, comprising datasets from five PTR-MS and two SIFT-MS instruments. The washout profiles of these volatiles were evaluated by comparing the log-fold change over time of the product ion intensities associated with each volatile. Benchmark values were calculated from the lower 95% confidence interval of the linear time-to-washout regression analysis for all datasets combined. Benchmark washout values from PTR-MS analysis were 353 min for the sum of monoterpenes and 1,8-cineole (identical product ions), 173 min for menthol, 330 min for menthofuran, and 218 min for menthone; from SIFT-MS analysis values were 228 min for the sum of monoterpenes, 281 min for the sum of monoterpenes and 1,8-cineole, and 370 min for menthone plus 1,8-cineole. Large inter- and intra-dataset variations were observed, whereby the latter suggests that biological variability plays a key role in how the compounds are absorbed, metabolized and excreted from the body via breath. This variability seems large compared to the influence of sampling and analytical procedures, but further investigations are recommended to clarify the effects of these factors.

Engineering new limits to magnetostriction through metastability in iron-gallium alloys

Magnetostrictive materials transduce magnetic and mechanical energies and when combined with piezoelectric elements, evoke magnetoelectric transduction for high-sensitivity magnetic field sensors and energy-efficient beyond-CMOS technologies. The dearth of ductile, rare-earth-free materials with high magnetostrictive coefficients motivates the discovery of superior materials. Fe_1-xGa_x alloys are amongst the highest performing rare-earth-free magnetostrictive materials; however, magnetostriction becomes sharply suppressed beyond x = 19% due to the formation of a parasitic ordered intermetallic phase. Here, we harness epitaxy to extend the stability of the BCC Fe_1-xGa_x alloy to gallium compositions as high as x = 30% and in so doing dramatically boost the magnetostriction by as much as 10x relative to the bulk and 2x larger than canonical rare-earth based magnetostrictors. A Fe_1-xGa_x - [Pb(Mg_1/3Nb_2/3)O₃]_0.7-[PbTiO₃]_0.3 (PMN-PT) composite magnetoelectric shows robust 90° electrical switching of magnetic anisotropy and a converse magnetoelectric coefficient of 2.0 × 10^-5 s m^-1. When optimally scaled, this high coefficient implies stable switching at ~80 aJ per bit.

Increased risk of acute stroke among patients with severe COVID-19: a multicenter study and meta-analysis

BACKGROUND AND PURPOSE

Recent observations linked coronavirus disease 2019 (COVID-19) to thromboembolic complications possibly mediated by increased blood coagulability and inflammatory endothelial impairment. We aimed to define the risk of acute stroke in patients with severe and non-severe COVID-19.

METHODS

We performed an observational, multicenter cohort study in four participating hospitals in Saxony, Germany to characterize consecutive patients with laboratory-confirmed COVID-19 who experienced acute stroke during hospitalization. Furthermore, we conducted a systematic review using PubMed/MEDLINE, Embase, Cochrane Library and bibliographies of identified papers following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines including data from observational studies of acute stroke in COVID-19 patients. Data were extracted by two independent reviewers and pooled with multicenter data to calculate risk ratios (RRs) and 95% confidence intervals (95% CIs) for acute stroke related to COVID-19 severity using a random-effects model. Between-study heterogeneity was assessed using Cochran's Q and I2 statistics. International Prospective Register of Systematic Reviews registration number: CRD42020187194.

RESULTS

Of 165 patients hospitalized for COVID-19 (49.1% males, median age = 67 years [57-79 years], 72.1% severe or critical) included in the multicenter study, overall stroke rate was 4.2% (95% CI: 1.9-8.7). Systematic literature search identified two observational studies involving 576 patients that were eligible for meta-analysis. Amongst 741 pooled COVID-19 patients, overall stroke rate was 2.9% (95% CI: 1.9-4.5). Risk of acute stroke was increased for patients with severe compared to non-severe COVID-19 (RR = 4.18, 95% CI: 1.7-10.25; P = 0.002) with no evidence of heterogeneity (I2  = 0%, P = 0.82).

CONCLUSIONS

Synthesized analysis of data from our multicenter study and previously published cohorts indicates that severity of COVID-19 is associated with an increased risk of acute stroke.

Use of simulation patients in the third section of the medical examination

In order to protect patients and students during the Covid 19 pandemic, the third section of the medical examination (M3) in Halle (Saale) was conducted in a modified form in accordance with the "Verordnung zur Abweichung von der Approbationsordnung für Ärzte bei einer epidemischen Lage von nationaler Tragweite" [1]. The one-day examination took place at the Dorothea Erxleben Learning Center (DELH) of the Martin Luther University Halle-Wittenberg on standardized simulation subjects. In contrast to previous years, all examiners were examined individually in internal medicine, surgery and their elective subject of the practical year. In the evaluations carried out, the standardized cases were assessed as consistent and fair by examiners and exam takers. Approximately 90% of the examiners could imagine to test a state examination with simulated patients again. After successful pilot testing, a study will be conducted in the coming exam to determine whether the substitution of real patients with simulated patients in the M3 exam can contribute to better standardization and objectivity while maintaining the same high level of acceptance in the exam. Whether the high acceptance will remain constant can only be checked in the course of the study.

Impact of growth kinetics on the interface morphology and magnetization in La1/3Sr2/3FeO3/La2/3Sr1/3MnO3 heterostructures

The ability to create atomically perfect, epitaxial heterostructures of correlated complex perovskite oxides using state-of-art thin film deposition techniques has generated new physical phenomena at engineered interfaces. Here we report on the impact of growth kinetics on the magnetic structure and exchange coupling at the interface in heterostructures combining layers of antiferromagnetic La_1/3Sr_2/3FeO₃ (LSFO) and ferromagnetic La_2/3Sr_1/3MnO₃ (LSMO) on (0 0 1)-oriented SrTiO₃ (STO) substrates. Two growth orders are investigated, (a) LSMO/LSFO/STO(0 0 1) and (b) LSFO/LSMO/STO(0 0 1), where the LSFO layer is grown by molecular beam epitaxy and the LSMO layer by high oxygen pressure sputtering. The interface has been investigated using electron microscopy and polarized neutron reflectometry. Interdiffusion over seven monolayers is observed in LSMO/LSFO (a) with an almost 50% reduction in magnetization at the interface and showing no exchange coupling. However, the exchange bias effect ([Formula: see text] mT at 10 K) could be realized when the interface is atomically sharp, as in LSFO/LSMO (b). Our study therefore reveals that, even for well ordered and lattice-matched structures, the kinetics involved in the growth processes drastically influences the interface quality with a strong correlation to the magnetic properties.

The Multiple Sclerosis Inventory of Cognition for Adolescents (MUSICADO): A brief screening instrument to assess cognitive dysfunction, fatigue and loss of health-related quality of life in pediatric-onset multiple sclerosis

OBJECTIVE

Screening for cognitive impairment (CI), fatigue and also Health-related quality of life (HRQoL) in patients with pediatric-onset multiple sclerosis (POMS) is of utmost importance in clinical practice. The aim of this study was to establish a new and validated pediatric screening tool "MUSICADO" that is easy to use and time economical.

METHODS

106 patients with POMS aged 12-18 years and 210 healthy controls (HCs) stratified for age and education underwent neuropsychological testing including a screening test "Multiple Sclerosis Inventory of Cognition" for adults and 8 standardized cognitive tests and established scales to assess fatigue and HRQoL.

RESULTS

The phonemic verbal fluency task (RWT "s-words"), the Trail Making Test A (TMT-A), and the Digit Span Forward discriminated significantly between patients and HCs (p = 0.000, respectively) and showed the highest proportion of test failure in patients (24.5%, 17.9%; 15.1%, respectively). Therefore, they were put together to form the cognitive part of the "MUSICADO". After applying a scoring algorithm with balanced weighting of the subtests and age and education correction and a cut-off score for impairment, 35.8% of patients were categorized to be cognitively impaired (specificity: 88.6%). Fatigue was detected in 37.1% of the patients (specificity: 94.0%) and loss of HRQoL in 41.8% (specificity 95.7%) with the screening version, respectively.

CONCLUSION

The MUSICADO is a newly designed brief and easy to use screening test to help to early identify CI, fatigue, and loss of HRQoL in patients with POMS as cut scores are provided for all three items. Further studies will have to show its usability in independent samples of patients with POMS.

P5325A possible paradoxical association between LDL-cholesterol in myocardial infarction patients and relation to major adverse outcomes - a 10-year nationwide cohort study

Background

Cardiovascular disease (CVD) risk increases with the level of LDL-cholesterol (LDL-C), and LDL-C lowering treatment improves prognosis. Less is known about LDL-C levels at myocardial infarction (MI) admission and long-term prognosis.

Purpose

To investigate admission LDL-C levels in relation to mortality, recurrent MI and baseline characteristics.

Methods

Patients admitted with an MI in Sweden and recorded in the MI-registry (SWEDEHEART) 2006–2016 were included and followed until 2018. Associations between baseline LDL-C, mortality and MI were assessed with Cox regression analysis, adjusting for risk factors (eg. age, diabetes, prior CV events) and lipid lowering therapy.

Results

Of 126,669 patients (median age: 70) admitted with MI, 26.2% (n=32,883) had ongoing statin therapy, and the median LDL-C was 2.96 (interquartile range 2.23, 3.74) mmol/L. During median follow-up of 4.2 years, 31,024 died and 17,896 had an MI (table). Patients with higher LDL-C were younger, had substantially fewer comorbidities such as diabetes and prior CVD (p<0.001). In this analysis there was an interaction with ongoing statin-use (p=0.0025). When dividing patients by LDL-C into quartiles, statin naive in the highest LDL-C quartile (3.95 mmol/L) had a lower risk of death compared to patients in the lowest quartile (2.62 mmol/L) HR 0.86 (95% CI 0.83–0.90). For patients with ongoing statin, the risk was also lower with higher LDL-C (2.84 mmol/L) compared to lower LDL-C (1.72 mmol/L) HR 0.88 (95% CI 0.81–0.96). No association was observed between LDL-C and recurrent MI.

Table 1. Event rate for mortality and myocardial infarction (MI) by LDL quartile groups Q1 Q2 Q3 Q4 LDL-C (mmol/L) Statin naive <2.62 2.62–3.26 3.26–3.95 >3.95 Ongoing <1.72 1.72–2.21 2.21–2.84 >2.84 Mortality Statin naive 0.074 (6553) 0.049 (4596) 0.037 (3706) 0.030 (2949) Ongoing 0.10 (3297) 0.075 (2769) 0.062 (2462) 0.055 (2157) MI Statin naive 0.034 (2808) 0.026 (2292) 0.024 (2269) 0.023 (2094) Ongoing 0.064 (1796) 0.055 (1792) 0.048 (1694) 0.044 (1557) Event/year (n of events) stratified by statin treatment at index event.

Conclusions

In this real-world population with over 126,000 patients and 10 years of follow-up, higher LDL-C at the time of the MI was associated with a markedly better prognosis in patients with and without prior statin therapy. This paradox may, despite adjustment, be caused by a substantially lower CVD baseline risk in patients with higher LDL-C pertaining to a lower burden of risk factors, younger age, and fewer prior CVD events as well as a highly treatable risk factor.

5130Association between degree of LDL-cholesterol decrease after a myocardial infarction and mortality - a nationwide cohort study

Background

In clinical trials, patients with myocardial infarction (MI) and elevated LDL-cholesterol (LDL-C) benefit the most from lipid lowering therapy, and more intensive LDL-C lowering therapy is associated with better prognosis.

Purpose

To investigate the association between degree of LDL-C lowering and prognosis in MI patients from a large real-world setting.

Methods

Patients admitted with an MI between 2006 and 2016 and registered in the Swedish MI-registry (SWEDEHEART) were followed until 2018. The difference in LDL-C between the MI hospitalization and a 6–10 week follow-up was measured. In multivariable Cox regression analysis adjusting for clinical risk factors (eg. age, diabetes, prior cardiovascular disease), the association between LDL-C change, mortality and recurrent MI was assessed using restricted cubic splines. Further, the patients were stratified according to quartile decrease in LDL-C from MI hospitalization to the follow-up.

Results

A total of 44,148 patients (median age: 64) had an LDL-C measured during the MI hospitalization and at follow-up. Of these, 9,905 (22.4%) had ongoing statin treatment prior to admission. The median LDL-C at the MI hospitalization was 2.96 (interquartile range 2.23, 3.74) mmol/L and the median decrease in LDL-C was 1.17 (0.37, 1.86) mmol/L. During a median follow-up of 3.9 years, 3,342 patients died and 3,210 had an MI. Patients with the highest quartile of LDL-C decrease (1.86 mmol/L) from index event to follow-up, had a lower risk of mortality, hazard ratio (HR) 0.59 (95% confidence interval [CI] 0.44–0.80) compared to those with the lowest quartile of LDL-C decrease (0.37 mmol/L) (figure). For MI, the corresponding HR was 0.83 (95% CI 0.68–1.02). Ongoing statin-use prior to admission did not alter the effect of LDL-C decrease and outcome in the analysis.

Conclusions

In this large nationwide cohort of MI patients, a gradually lower risk of death was observed in patients with larger decrease in LDL-C from index event to follow-up, regardless of statin use prior to admission. The same trend was observed for recurrent MI, although not reaching statistical significance. This confirms previous findings that efforts should be made to lower LDL-C after MI.

P6353Iron depletion in human cardiomyocytes cultured with sera from myocarditis patients

Background

Cardiac myocytes, which are particularly sensitive to disordered iron homeostasis, are the main cells affected in the course of myocarditis. Iron is essential for the proper maintenance of energy metabolism but also plays key role in inflammation and ROS production. We hypothesize that iron homeostasis might be involved in the pathophysiology of myocarditis.

Purpose

The aim of the study was to assess differences in the expression of key genes and proteins involved in iron homeostasis, cardiac malfunctioning, and protection against ROS in human cardiomyocytes (HCMs) cultured in the indirect model of myocarditis.

Methods

HCMs were cultured for 48 hours with 10% of sera from patients with acute myocarditis (n=11) and after 6 weeks of recovery, and also with sera from healthy controls (n=7). We analyzed expression of light and heavy ferritin chains [FTL, FTH], transferrin receptor 1 [TfR1], galectin 3 [LGALs3], TGFβ signaling [TGFβ1, TGFβ2, TGFβ3], glutathione peroxidase [GPX] and superoxide dismutase [SOD1] at the mRNA level using RTqPCR and at the protein level using Western bloting. We compared obtained data with the clinical characteristics of patients.

Results

In HCMs exposed to sera from myocarditis patients, in comparison to those treated with sera from healthy controls, we found a significant increase in an expression of TfR1 both at mRNA and protein level (p<0,01). We also observed that elevated expression of TfR1 in cells correlated with serum levels of total iron (R=-0,52; p<0,05), CRP (R=0,67; p<0,05), and NT-proBNP (R=0,55; p<0,05), suggesting increased iron demand in HCMs and its possible relation to inflammation and hemodynamic dysfunction in patients.

Moreover, we observed elevated expression of FTH and FTL at the mRNA level (both p<0,01) and its strong correlation with expression of TfR1 as well as with increased levels of CRP in sera. It could be explained by the double role of ferritin in iron storage and in inflammation.

Interestingly, we noticed detrimental effects of myocarditis sera on HCMs reflected by augmented expression of galectin 3 (p<0,01) and disturbances in TGFβ genes, in comparison to those treated with sera from healthy controls. Augmented expression of galectin 3 was strongly related to disturbed iron homeostasis, manifesting itself by correlations with TfR1 (R=0,77; p<0,05), FTH (R=0,92; p<0,05) and FTL (R=0,76; p<0,05).

In addition, HCMs treated with sera from myocarditis patients showed an increase in expression of ROS protective genes such as SOD1 and GPX (both p<0,01), indicating higher oxidative stress in these cells.

We noticed that gene expression profile was similar in HCMs treated with sera collected after 6 weeks of clinical recovery, suggesting that the negative impact of sera was preserved.

Conclusions

Malfunctioning of cardiomyocytes in course of myocarditis might be related to disturbances in the iron homeostasis.

Acknowledgement/Funding

The present study was financially supported by the National Science Centre (Krakow, Poland; grant no. 2014/13/B/NZ5/03146)

P828Low-density lipoprotein cholesterol lowering therapy and target level attainment after a recent myocardial infarction - nationwide cohort study

Background

Lowering low-density lipoprotein cholesterol (LDL-C) reduces the risk of cardiovascular disease after a myocardial infarction (MI). The European Society of Cardiology (ESC) guidelines recommend lipid lowering therapy to reach LDL-C treatment targets after an MI.

Purpose

To assess LDL-C target level attainment according to the ESC guidelines among patients with a recent MI in Sweden.

Methods

We used data from nationwide registers in Sweden and included patients aged 18–74 years admitted to a hospital with MI (1 January 2013–1 October 2016). Among patients who were alive and had LDL-C data available, we assessed LDL-C target achievement at 6–10 weeks (n=21,505) and 12–14 months (n=17,957) after the MI by category of lipid lowering therapy (no statin; low/moderate-intensity statins; high-intensity statins; any statin plus ezetimibe). The target was defined as an LDL-C of <1.8 mmol/L and a ≥50% reduction from the baseline if LDL-C was 1.8–3.5 mmol/L and the patient was not already receiving statins.

Results

Most patients were treated with high-intensity statin monotherapy (84.2% and 72.0%) or any statin with ezetimibe (2.1% and 10.4%) at 6–10 weeks and 12–14 months after the MI, respectively. In total, 37.7% (6–10 weeks) and 38.3% (12–14 months) had attained their LDL-C target. The proportion of patients attaining their LDL-C target at 6–10 weeks was 12% (no statin), 30% (low/moderate-intensity statins), 39% (high-intensity statins), and 49% (any statin plus ezetimibe). The corresponding numbers at 12–14 months were 16% (no statin), 29% (low/moderate-intensity statins), 39% (high-intensity statins), and 58% (any statin plus ezetimibe). A total of 11.8% at 6–10 weeks and 12.3% at 12–14 months reached an LDL-C level of <1.8 mmol/L, but did not reach their LDL-C target level due to the ≥50% reduction criteria. (Figure 1)

Figure 1

Conclusions

In this large population-based study using nationwide data, more than half of patients with a recent MI did not achieve the ESC guidelines LDL-C target levels, despite a large proportion with high-intensity statin therapy. In patients treated with statins and ezetimibe, four out of ten did not reach the ESC LDL-C target level. Our findings indicate that there may be a need for additional LDL-C lowering therapy if the target level is to be attained in all patients.

Acknowledgement/Funding

This project was supported by funding from Merck Sharp & Dohme.

[Intensive care aspects of autoimmune encephalitis]

Autoimmune encephalitis is a rare, rapidly progressive and potentially severe inflammatory brain disease, usually mediated by autoantibodies. Frequently, the affected patients go through various phases of the disease with prodromi, neuropsychological abnormalities, severe neurological and autonomic disorders and usually long reconvalescence. In up to 85% of patients intensive care treatment is necessary, especially in the group of anti-NMDA receptor encephalitis (NMDA-RE). Typical problems during ICU stay include: severe qualitative and quantitative disturbances of consciousness, autonomic dysfunction, epileptic seizures/epileptic status, treatment-refractory movement disorders, as well as ventilation and weaning problems requiring tracheotomy. But also ethical conflicts and general ICU complications such as sepsis, the need for resuscitation, as well as surgical and psychiatric complications occur. The outcome is highly heterogeneous with a range from complete recovery to the most severe, persistent disorders of consciousness with extensive care and death. Mortality data also vary at between 12% and 40%. Patients requiring mechanical ventilation and tracheostomy and with sepsis and autonomic dysfunction are prone to worse outcomes. A large part of the presented data refers to a recently published multicenter, Germany-wide retrospective cohort study and brought into the context of existing literature.

Comparative analysis of volatile organic compounds for the classification and identification of mycobacterial species

Background

Species of Mycobacteriaceae cause serious zoonotic diseases in mammals, for example tuberculosis in humans, dogs, parrots, and elephants (caused by Mycobacterium tuberculosis) and in ruminants and humans (caused by M. bovis and M. caprae). Pulmonary diseases, lymphadenitis, skin diseases, and disseminated diseases can be caused by non-tuberculous mycobacteria (NTM). Diagnosis and differentiation among Mycobacterium species are currently done by culture isolation. The established diagnostic protocols comprise several steps that allow species identification. Detecting volatile organic compounds (VOCs) above bacterial cultures is a promising approach towards accelerating species identification via culture isolation. The aims of this project were to analyse VOCs in the headspace above 13 different species of mycobacteria, to define VOC profiles that are unique for each species, and to compile a set of substances that indicate the presence of growing mycobacteria in general.

Materials & methods

VOCs were measured in the headspace above 17 different mycobacterial strains, all cultivated on Herrold’s Egg Yolk Medium and above pure media slants that served as controls. For pre-concentration of VOCs, needle-trap micro-extraction was employed. Samples were subsequently analysed using gas chromatography-mass spectrometry. All volatiles were identified and calibrated by analysing pure reference substances.

Results

More than 130 VOCs were detected in headspace above mycobacteria-inoculated and control slants. Results confirmed significant VOC emissions above all mycobacterial species that had grown well. Concentration changes were measurable in vials with visually assessed bacterial growth and vials without apparent growth. VOCs above mycobacterial cultures could be grouped into substances that were either higher or equally concentrated, lower or equally concentrated, or both as those above control slants. Hence, we were able to identify 17 substances as potential biomarkers of the presence of growing mycobacteria in general.

Conclusions

This study revealed species-specific VOC profiles for eleven species of mycobacteria that showed visually apparent bacterial growth at the time point of analysis.

Smell of cells: Volatile profiling of stem- and non-stem cell proliferation

Bacterial and cell cultures are known to emit a large number of volatile organic compounds (VOCs). Conventional biochemical methods are often destructive, time-consuming and expensive. In contrast, VOC analysis of headspace over cultures may offer a non-destructive alternative for the monitoring of cell proliferation and metabolism. VOC profiles from cultures of murine pluripotent stem cells and fibroblasts were assessed every 24 h for 3 days. Pure cell media were measured as parallel controls. VOC analysis was highly standardized with respect to time of measurement and phases of cell growth. Cultures were grown in custom-made inert boxes. In order to determine the effects of fresh media supply on VOC emissions, both cell types were cultured with and without daily media exchange. VOCs from headspace were preconcentrated by means of needle trap micro-extraction and analysed by gas chromatography-mass spectrometry (GC-MS). Murine pluripotent stem cells emitted increasing concentrations of thiirane and methyl-methoxy-hydroxy-methyl-amine (MMHA). Substance concentration correlated with cell numbers. Murine fibroblasts did not emit thiirane or MMHA. Concentrations of aldehydes, especially benzaldehyde, were lower in both cell cultures than in pure media samples. Daily media exchange resulted in higher cell numbers, but had no major effects on VOC concentrations emitted from the cells. Investigation and monitoring of volatile substances such as thiirane and MMHA may enhance the understanding of stem cell properties and lead to a destruction-free characterization of pluripotent stem cells.

Influence of texture and grain misorientation on the ionic conduction in multilayered solid electrolytes – interface strain effects in competition with blocking grain boundaries

We investigate the relaxation of mismatch induced interface strain as a function of the texture and its influence on the ionic conductivity in YSZ/Er₂O₃ multilayer thin films.

Clinical outcomes of conventional surgery versus MitraClip® therapy for moderate to severe symptomatic mitral valve regurgitation in the elderly population: an institutional experience

Background

The aim of this study was to compare treatment of moderate to severe symptomatic mitral regurgitation (MR) with either conventional surgery or the mitral valve edge-to-edge device (MitraClip®) in very elderly patients. The newly introduced MitraClip device has demonstrated promising acute results in treating this patient cohort. Also noteworthy is the fact that patients who otherwise would have been denied surgery are increasingly referred for treatment with the MitraClip device. We sought to review our institutional experience, comparing outcomes in both surgical and MitraClip arms of treatment in the elderly population with symptomatic MR.

Methods

From October 2008 through October 2014, 136 consecutive patients aged ≥ 80 with moderate to severe symptomatic MR were scheduled for either conventional surgery or MitraClip intervention. 56 patients ≥ 80 were operated for symptomatic MR and 80 patients ≥ 80 were treated with the mitraClip device. Patients suitable for this study were identified from our hospital database. Patients ≥80 with moderate/severe symptomatic MR treated with either conventional surgery or the MitraClip device were eligible for our analysis. We compared the surgical patient cohort with the mitraClip patient cohort after eliminating patients that did not meet our inclusion criteria. Forty-two patients were identified from the conventional cohort who were then compared with 42 patients from the mitraClip cohort. Forty-two patients (50%) underwent mitral valve repair or replacement (40.5% functional MR, 59.5% organic/mixed MR) and 42 patients (50%) underwent MitraClip intervention (50% functional MR, 50% organic/mixed MR). Associated procedures in the conventional surgical group were myocardial revascularization 38%, pulmonary vein ablation 23.8%, left atrial appendage resection 52.4% and PFO occlusion 11.9%.

Results

Patients who underwent MitraClip treatment were though slightly older but the differences did not attain statistical significance (mean, 82.2 ± 1.65 vs 81.7 ± 1.35 years, p = 0,100), had lower LVEF (mean, 47.6 ± 14.2 vs 53.4 ± 14.3, p = 0.072), lower logistic EuroScore II (mean, 11.3 ± 5.63 vs 12.1 ± 10.6, p = 0.655) but higher STS risk score (mean, 11.8 ± 6.7 vs 8.1 ± 5.6, p = 0.008) respectively compared to surgical patients. Procedural success was 100% vs 96% in surgery and MitraClip groups respectively. Thirty -day mortality was 7.1% vs 4.8% (p = 1.000) in surgery and MitraClip group respectively. Residual postoperative MR ≥2 at discharge was present in none of the patients treated surgically, whereas this was the case in 10 (23.8%) patients treated with the MitraClip device. At 1 year a cumulative number of four (9.52%) patients died in the surgical group vs 9 (21.4%) patients who died in the MitraClip group.

Conclusions

Elderly patients presenting with moderate to severe symptomatic MR may either be treated by conventional surgery or with the MitraClip device with acceptable acute outcomes. The decision for treatment with the MitraClip device should not depend on age alone rather on cumulative risk of conventional surgery. Concomitant cardiac pathologies, often times treated simultaneously during surgery for symptomatic MR may be omitted, if patients are scheduled outright to MitraClip treatment. The effect of concomitant cardiac pathologies left untreated at the time of interventional mitral valve repair on outcome after MitraClip therapy remain widely unknown.

Growth, characterization, and transport properties of ternary (Bi1-x Sb x )2Te3 topological insulator layers

Ternary (Bi_1-x Sb _x )₂Te₃ films with an Sb content between 0 and 100% were deposited on a Si(1 1 1) substrate by means of molecular beam epitaxy. X-ray diffraction measurements confirm single crystal growth in all cases. The Sb content is determined by x-ray photoelectron spectroscopy. Consistent values of the Sb content are obtained from Raman spectroscopy. Scanning Raman spectroscopy reveals that the (Bi_1-x Sb _x )₂Te₃ layers with an intermediate Sb content show spatial composition inhomogeneities. The observed spectra broadening in angular-resolved photoemission spectroscopy (ARPES) is also attributed to this phenomena. Upon increasing the Sb content from x  =  0 to 1 the ARPES measurements show a shift of the Fermi level from the conduction band to the valence band. This shift is also confirmed by corresponding magnetotransport measurements where the conductance changes from n- to p-type. In this transition region, an increase of the resistivity is found, indicating a location of the Fermi level within the band gap region. More detailed measurements in the transition region reveals that the transport takes place in two independent channels. By means of a gate electrode the transport can be changed from n- to p-type, thus allowing a tuning of the Fermi level within the topologically protected surface states.

Adiabatic Edge Channel Transport in a Nanowire Quantum Point Contact Register

We report on a prototype device geometry where a number of quantum point contacts are connected in series in a single quasi-ballistic InAs nanowire. At finite magnetic field the backscattering length is increased up to the micron-scale and the quantum point contacts are connected adiabatically. Hence, several input gates can control the outcome of a ballistic logic operation. The absence of backscattering is explained in terms of selective population of spatially separated edge channels. Evidence is provided by regular Aharonov-Bohm-type conductance oscillations in transverse magnetic fields, in agreement with magnetoconductance calculations. The observation of the Shubnikov-de Haas effect at large magnetic fields corroborates the existence of spatially separated edge channels and provides a new means for nanowire characterization.

Ballistic Transport and Exchange Interaction in InAs Nanowire Quantum Point Contacts

One-dimensional ballistic transport is demonstrated for a high-mobility InAs nanowire device. Unlike conventional quantum point contacts (QPCs) created in a two-dimensional electron gas, the nanowire QPCs represent one-dimensional constrictions formed inside a quasi-one-dimensional conductor. For each QPC, the local subband occupation can be controlled individually between zero and up to six degenerate modes. At large out-of-plane magnetic fields Landau quantization and Zeeman splitting emerge and comprehensive voltage bias spectroscopy is performed. Confinement-induced quenching of the orbital motion gives rise to significantly modified subband-dependent Landé g factors. A pronounced g factor enhancement related to Coulomb exchange interaction is reported. Many-body effects of that kind also manifest in the observation of the 0.7·2e(2)/h conductance anomaly, commonly found in planar devices.

Abstract P4-13-07: Impact of physical activity/exercise on adverse events and quality of life during treatment with everolimus and exemestane for ER+ women - Results of the 3rd interim analysis of BRAWO

Introduction

BRAWO is a non-interventional study collecting data of 3000 breast cancer patients treated with everolimus and exemestane (advanced or metastatic, hormone-receptor-positive, HER2-negative breast cancer). We introduce results of the 3rd preplanned interim analysis with data cut-off 08/01/ 2015, including 1300 patients. Since physical activity/exercise was reported to influence side effects as well as quality of life (QoL) of various cancer types and therapies, this analysis focuses on the impact of the physical activity/exercise history, development on adverse effects (AE) of the medical treatment and QoL.

Methods

Patients were asked to complete the EORTC QLQ-C30 QoL questionnaire and visual analogue scales (VAS-KAS) measuring their present-, past ten year- and lifetime physical activity/exercise level. To differentiate between activity/exercise levels, VAS were divided in three equal components (inactive, somewhat active, very active). Questionnaires and information about AE (e. g. stomatitis, fatigue, nausea, diarrhea, etc.) were collected before starting the medical treatment and were repeated each three months. Logistic regression model was used to estimate the impact of baseline physical activity/exercise on AE at any time point of the therapy. ANOVA models were used to calculate the impact of the baseline activity/exercise level on QoL at the last completed data set of each patient.

Results

Median age of patients was 66 years, median weight was 70 kg, median BMI was 25.9, median time since primary diagnosis was 6.2 years, and 54.4% had visceral metastases at baseline. The median PFS for the first 1300 patients was 7.1 months (95% CI, 6.5-8.0). Patients who reported to be very active (exercise) at the week prior to baseline (4.4%) showed significant lower numbers of AE compared to patients who indicate to be somewhat (14.8%) or inactive (80.8%). In contrast to the exercise level, physical activity in everyday life did not affect the AE incidence. Neither lifetime nor past ten year activity/exercise level is associated with the occurrence of AE. Regarding QoL, very active as well as somewhat active women (measured at baseline for almost each time period) showed significant higher QoL values compared to inactive women during the last assessment before death/progress.

Conclusion

Exercise prior to medical treatment with Everolimus and Exemestane may impact AE during therapy. Since physical activity did not show such a relation, this analysis highlights the importance of specific guidelines for preventive/rehabilitative exercise programs. More knowledge about dose-response relationships is needed. Furthermore a livelong healthy, "active" lifestyle may increase QoL, even in patients with advanced and terminal breast cancer disease.

Citation Format: Bloch W, Baumann F, Zimmer P, Grischke E-M, Fasching PA, Decker T, Uleer C, Schneeweiss A, Salat C, Wimberger P, Mundhenke C, Förster F, Kluth-Pepper B, Schubert J, Tesch H, Schütz F, Lüftner D, Jackisch C. Impact of physical activity/exercise on adverse events and quality of life during treatment with everolimus and exemestane for ER+ women - Results of the 3rd interim analysis of BRAWO. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-07.

Abstract P4-13-06: Results of the 3rd interim analysis of the non-interventional trial BRAWO – Subanalysis of patients &lt;70 years and ≥ 70 years

Background

BRAWO is a German non-interventional study of 3000 patients (pts) with advanced/metastatic, hormone-receptor-positive and HER2-negative breast cancer treated with everolimus and exemestane (EVE+EXE). The pivotal BOLERO-2 trial demonstrated that adding EVE to EXE improved PFS over EXE and was generally well tolerated in elderly patients with HR+ advanced breast cancer (&gt;65 years as well as &gt;70 years). Here we describe data of elderly patients treated with EVE+EXE in daily clinical routine.

Methods

We report data of the 3rd preplanned interim analysis (IA) of the first 1300 pts documented in BRAWO. Patient and disease characteristics in elderly patients (≥ 70 years, n=485) and patients &lt;70 years (n=813) are described. Furthermore, safety and efficacy data for both subgroups are described.

Results

At time of data cut-off, 71% pts had discontinued the study, 29% were still ongoing. Patient and disease characteristics were comparable in both groups except for: median age (60y (range: 20-69y) vs. 75y (range 70-93y)), median time since 1st diagnosis (6.4y &lt;70y vs. 8.8y ≥70 y), ECOG performance status 0 (56.6% &lt;70y vs. 37.0% ≥70 y), and younger pts seemed to have less comorbidities (charlson comorbidity index (CCI)=0: 80.9% vs. 67.4%). The distribution of patients by therapy line was similar as well as tumor grading, hormone receptor status, Ki67-status and metastasis localization.

More patients in the older group received fulvestrant (20.6% vs. 16.2%), in the younger group more patients received chemotherapy (20.3% vs. 14.2%) as last antineoplastic therapy. In general, more patients in the older subgroup did not receive any chemotherapy as pretreatment (53.6% vs 40.2%).

More patients in the subgroup ≥70y received 5mg EVE as starting dose (30.3% vs. 20.8%) and had 5mg as end dose (37.9% vs. 26.9%). Median PFS was 7.1 months in the overall population, 7.0 months (6.5, 8.0; 95%CI) for pts &lt;70y and 7.3 months (6.3, 8.6; 95%CI) for pts ≥70y. Kaplan Meier estimates for median treatment duration were longer for younger pts (167.0 days (155.0, 191.0; 95%CI vs. 128.0 days (112.0, 152.0; 95%CI)). Incidence and severity of stomatitis were comparable across subgroups (Table 1). Quality of life analysis revealed no significant differences between older and younger pts.

Table 1: Incidence and severity of stomatitis

Patient Characteristics&lt; 70 years (n=813)≥ 70 years (n=485)Stomatitis  Number of patients with at least one Stomatitis Event (based on stomatitis questionnaires)339 (41.7%)200 (41.2%)Grade 1181 (22.3%)95 (19.6%)Grade 2119 (14.6%)79 (16.3%)Grade 319 (2.3%)11 (2.3%)unknown20 (2.5%)15 (3.1%)Number of Stomatitis Events431 (100.0%)252 (100%)Grade 1237 (55.0%)125 (49.6%)Grade 2136 (31.6%)87 (34.5%)Grade 319 (4.4%)13 (5.2%)

Discussion

The data described here show that EVE+EXE treatment is effective and safe for elderly patients in daily clinical routine. This is consistent with data from an exploratory analysis of the pivotal BOLERO-2 trial, where the same differences in baseline characteristics were observed for elderly pts compared to younger pts as in BRAWO. Efficacy was also comparable to elderly pts in BOLERO-2 (mPFS 6.8 months for EVE+EXE in pts ≥70 years).

Citation Format: Tesch H, Grischke E-M, Fasching PA, Decker T, Uleer C, Schneeweiss A, Salat C, Wimberger P, Mundhenke C, Förster F, Kluth-Pepper B, Schubert J, Bloch W, Jackisch C, Schütz F, Lüftner D. Results of the 3rd interim analysis of the non-interventional trial BRAWO – Subanalysis of patients &lt;70 years and ≥ 70 years. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-06.

Percutaneous mitral repair with the MitraClip system in patients with mild-to-moderate and severe heart failure: a single-centre experience

AIMS

Edge-to-edge repair of mitral regurgitation (MR) with the MitraClip(®) (MC) system is increasingly applied in advanced heart failure. Our objective was to compare outcomes in patients with mild-to-moderate and severe systolic heart failure.

METHODS AND RESULTS

Between February 2010 and July 2012, 121 patients with MR of at least grade 3+ and a mean EuroSCORE II of 10.6% underwent MC implantation. Thirty-nine had a left ventricular ejection fraction (LVEF) of ≤30% (group A) and 82 of >30% (group B). Procedural success was comparable in both groups (100% vs. 95.2%) with multiple (>2) clip implantation in 34% and 25% of patients, respectively. At 12 months, absolute reduction in MR grade (2.3 vs. 2.2) and relative reduction in mitral valve orifice area (48% vs. 42%) were also comparable. New York Heart Association class had improved independent from baseline LVEF (P < 0.001). In-hospital mortality was low in both groups (2.6% vs. 2.4%), but there was a strong trend for higher 12-month mortality in group A (34% vs. 18%, P = 0.05) with no significant difference in the overall rate of major adverse cerebrovascular and cardiac events (36.8% vs. 28.9%, P = 0.38). On multivariate analysis, MR grade after repair was the strongest predictor of mortality (OR 2.121, 95% CI 1.095-4.109), whereas systolic impairment was no independent predictor.

CONCLUSIONS

Percutaneous mitral valve repair led to comparable symptomatic improvement in patients with mild-to-moderately or severely reduced LV function. LV-EF < 30% was not an independent predictor of short-term mortality, which was mainly governed by residual MR after repair.

The human volatilome: volatile organic compounds (VOCs) in exhaled breath, skin emanations, urine, feces and saliva

Breath analysis is a young field of research with its roots in antiquity. Antoine Lavoisier discovered carbon dioxide in exhaled breath during the period 1777-1783, Wilhelm (Vilém) Petters discovered acetone in breath in 1857 and Johannes Müller reported the first quantitative measurements of acetone in 1898. A recent review reported 1765 volatile compounds appearing in exhaled breath, skin emanations, urine, saliva, human breast milk, blood and feces. For a large number of compounds, real-time analysis of exhaled breath or skin emanations has been performed, e.g., during exertion of effort on a stationary bicycle or during sleep. Volatile compounds in exhaled breath, which record historical exposure, are called the 'exposome'. Changes in biogenic volatile organic compound concentrations can be used to mirror metabolic or (patho)physiological processes in the whole body or blood concentrations of drugs (e.g. propofol) in clinical settings-even during artificial ventilation or during surgery. Also compounds released by bacterial strains like Pseudomonas aeruginosa or Streptococcus pneumonia could be very interesting. Methyl methacrylate (CAS 80-62-6), for example, was observed in the headspace of Streptococcus pneumonia in concentrations up to 1420 ppb. Fecal volatiles have been implicated in differentiating certain infectious bowel diseases such as Clostridium difficile, Campylobacter, Salmonella and Cholera. They have also been used to differentiate other non-infectious conditions such as irritable bowel syndrome and inflammatory bowel disease. In addition, alterations in urine volatiles have been used to detect urinary tract infections, bladder, prostate and other cancers. Peroxidation of lipids and other biomolecules by reactive oxygen species produce volatile compounds like ethane and 1-pentane. Noninvasive detection and therapeutic monitoring of oxidative stress would be highly desirable in autoimmunological, neurological, inflammatory diseases and cancer, but also during surgery and in intensive care units. The investigation of cell cultures opens up new possibilities for elucidation of the biochemical background of volatile compounds. In future studies, combined investigations of a particular compound with regard to human matrices such as breath, urine, saliva and cell culture investigations will lead to novel scientific progress in the field.

Analysis of exhaled breath for disease detection

Breath analysis is a young field of research with great clinical potential. As a result of this interest, researchers have developed new analytical techniques that permit real-time analysis of exhaled breath with breath-to-breath resolution in addition to the conventional central laboratory methods using gas chromatography-mass spectrometry. Breath tests are based on endogenously produced volatiles, metabolites of ingested precursors, metabolites produced by bacteria in the gut or the airways, or volatiles appearing after environmental exposure. The composition of exhaled breath may contain valuable information for patients presenting with asthma, renal and liver diseases, lung cancer, chronic obstructive pulmonary disease, inflammatory lung disease, or metabolic disorders. In addition, oxidative stress status may be monitored via volatile products of lipid peroxidation. Measurement of enzyme activity provides phenotypic information important in personalized medicine, whereas breath measurements provide insight into perturbations of the human exposome and can be interpreted as preclinical signals of adverse outcome pathways.

Staged total percutaneous treatment of aortic valve pathology and mitral regurgitation: institutional experience

OBJECTIVES

To summarize our single Institution experience with staged total percutaneous management of aorto-mitral pathology.

BACKGROUND

Percutaneous treatment of aortic valve stenosis (AVS) and mitral valve regurgitation (MVR) has been recently proposed for patients at high surgical risk.

METHODS

Data concerning consecutive patients undergoing percutaneous transcatheter AV implantation (TAVI) followed by MV repair with MitraClip® were prospectively collected and analyzed.

RESULTS

From January 2010 to February 2012 a total of 254 patients were referred to undergo TAVI in our Institution. Seventeen (6.7%) had preoperative severe MVR that remained unchanged after TAVI. Due to exacerbation of symptoms 12 patients were subsequently submitted to MV repair with the MitraClip® device. Mean age was 79 years (72-86 years), median Ambler score was 30.1 (17.2-42.6) and EuroSCORE 22.3 (10.2-48.6). Procedural success rate was 100%. Postprocedural hospitalization was 7.1 ± 2.7 and 4.6 ± 0.9 days after TAVI and MV repair, respectively. Six months follow-up echocardiography confirms improvement in LV-EF (37.2 ± 9.9 vs. 43.5 ± 10.7, P < 0.0001). No patient presents MVR exceeding grade I(+) or prosthetic aortic insufficiency > I grade and all patients experienced an improvement in functional status.

CONCLUSIONS

Percutaneous treatment of AVS and MVR is feasible and safe. A tailored approach should be considered to treat firstly the AVS and subsequently the MVR when severe MV dysfunction and symptoms persist. Short-term durability of this combined percutaneous approach seems encouraging and justifies the economical burden to treat patients that have no other option.

[Local flaps for the closure of facial defects]

Local flaps for the closure of facial defects after trauma, tumor resection or due to malformations have been well known since ancient times and allow good to satisfying functional and aesthetic results. Based on the characteristics of skin and soft tissue nearly all clinical situations can be resolved by stretching, rotating and transposing flaps depending on the localization. A good surgical technique is essential for the success. The basic principles are briefly described and suggestions for the application of flaps to different localizations are given. For analgesia local anesthesia is sufficient. As could be demonstrated multitudinously the method is ideal for closure of small to large defects in the face; therefore, microvascular surgery can be extremely restricted in treating defects of the face.

Percutaneous mitral valve repair with the MitraClip system: perioperative and 1-year follow-up results using standard or multiple clipping strategy

OBJECTIVES

The purpose of this study was to compare outcomes using standard clipping (SC) (one to two clips) or multiple clipping (MC) (more than two clips).

BACKGROUND

MitraClip implantation using MC has been proposed to treat severe mitral regurgitation (MR) in high-risk patients.

METHODS AND RESULTS

A tailored strategy was used implanting as many clips as required to eliminate MR. A total of 85 consecutive patients [78 ± 6 years, 48 men (56.5%) ] with MR (grade 3+ or 4+) were included. EuroSCORE was 24 ± 12 (2.5-56.3) and STS-score 12 ± 7 (1.2-31.2). SC was used in 61 (71.8%) and MC in 24 (28.2%) patients. Patients in MC group had larger mitral valve (MV) annuli (P = 0.025), MV orifice areas (MVOA) (P = 0.01), and MR degree (P = 0.005). Successful clip placement was achieved in 82 patients (96.5%). At discharge, no patient had grade 4+ MR. MR 3+ presented in 4 patients (7.0%) in the SC group and in 1 (4.5%) in the MC group (P = 0.72). There were 3 (3.5%) in-hospital deaths. Follow up (211 ± 173 days, range 4-652) echocardiography confirmed similar MVOA (P = 0.83) and MV gradients (P = 0.54) in the both groups. At linear regression there was no independent correlation between clips number and postoperative MVOA/gradient. One-year survival was 71.1% without difference between groups (P = 0.74).

CONCLUSION

Although the hemodynamic and anatomical basis of MR may differ, every procedure should aim at eliminating MR. In some patients this goal can be achieved using MC with minimized risk of MV stenosis if preoperative anatomy/mechanism of MV regurgitation are adequately assessed.

Telomerase activity and telomere length in different areas of renal cell carcinoma

Telomerase activity and telomere length were analyzed in a total of 59 surgically removed primary renal cell carcinoma (RCC). The study includes tissue from the centre of the tumor, several different peripheral tumor areas, metastases and secondary tumors. None of the normal renal cortex tissues used as control exhibited telomerase activity. In contrast, telomerase activity was detected in 55 out df 59 (=93%) tested primary RCC. There was no case with intratumoral heterogeneity concerning the telomerase activity status. All metastases and secondary tumors were telomerase-positive. In the four telomerase deficient tumors all measured telomeric repeat fragments were shortened in comparison to the normal tissue. As these patients exhibit no metastases or secondary tumors a less malignant variant of RCC is supposed. There was no correlation between telomerase activity and specific histopathological subtypes of RCC or specific chromosomal aberrations. As telomerase activity is not associated with advanced stages of tumors it may be an important early event in the development of RCC. Thus, telomerase activity may be a prevalent marker for early and late stages of all subtypes of RCC.

Prognostic impact of meningeal dissemination in primary CNS lymphoma (PCNSL): experience from the G-PCNSL-SG1 trial

BACKGROUND

We evaluated the frequency and prognostic impact of meningeal dissemination (MD) in immunocompetent adult patients with primary central nervous system lymphoma treated in a randomized phase III trial.

PATIENTS AND METHODS

MD was evaluated at study entry and defined by lymphoma proof in the meningeal compartment detected by at least one of the following methods: cerebrospinal fluid (CSF) cytomorphology, detection of clonal B cells by IgH PCR in CSF or contrast enhancement of the leptomeninges on magnetic resonance imaging (MRI).

RESULTS

Data on MD were available in 415 patients, of those, MD was detected in 65 (15.7%): in 44/361 (12.2%) by CSF cytomorphology, in 16/152 (10.5%) by PCR and in 17/415 (4.1%) by MRI. Major patients' characteristics and therapy did not significantly differ between patients with MD (MD+) versus those without MD (MD-). There was a significant correlation of MD with CSF pleocytosis (>5/μl; P < 0.0001), but no correlation with CSF protein elevation (>45 mg/dl). Median progression-free survival was 6.7 months [95% confidence interval (CI) 0-14.5] in MD+ and 8.3 months (5.7-10.8) in MD- patients (P = 0.95); median overall survival was 21.5 months (95% CI 16.8-26.1) and 24.9 months (17.5-32.3), respectively (P = 0.98).

CONCLUSION

MD was detected infrequently and had no impact on outcome in this trial.

Correlation of expression of hypoxia-related proteins with prognosis in oral squamous cell carcinoma patients

INTRODUCTION

Hypoxia plays a major role in tumor progression, therapy resistance and for prognosis of oral squamous cell carcinoma (OSCC). The crucial step as a response to hypoxia is the activation and stabilization of the alpha subunit of hypoxia inducible factor 1 (HIF-1α). HIF-1: HIF-1 regulates the expression of different genes to adapt the tumor cells to reduced oxygenation. The HIF-1 system is intrinsic regulated by von Hippel-Lindau protein (pVHL). Main downstream proteins are the glucose transporter 1 (GLUT-1), carbonic anhydrase IX (CAIX), and vascular endothelial growth factor (VEGF). For therapeutical stratification in OSCC, it is important to understand the mechanism caused by hypoxic stress and to comprehend the resulting adaptive process in cancer cells. Therefore, an overview of HIF-1α-depending protein expression, focussed on the expression of GLUT-1, CAIX, and VEGF and their prognostic significance in OSCC is given.

CONCLUSION

Several unique roles of hypoxic pathway in the context of tumor progression are described in this review. As a consequence, a marker panel is proposed to allow a more individualized prognosis in OSCC patients. This marker panel should include beside HIF-1α, pVHL, and GLUT-1.

Early molecular and cytogenetic response is predictive for long-term progression-free and overall survival in chronic myeloid leukemia (CML)

In the face of competing first-line treatment options for CML, early prediction of prognosis on imatinib is desirable to assure favorable survival or otherwise consider the use of a second-generation tyrosine kinase inhibitor (TKI). A total of 1303 newly diagnosed imatinib-treated patients (pts) were investigated to correlate molecular and cytogenetic response at 3 and 6 months with progression-free and overall survival (PFS, OS). The persistence of BCR-ABL transcript levels >10% according to the international scale (BCR-ABL(IS)) at 3 months separated a high-risk group (28% of pts; 5-year OS: 87%) from a group with >1-10% BCR-ABL(IS) (41% of pts; 5-year OS: 94%; P=0.012) and from a group with ≤1% BCR-ABL(IS) (31% of pts; 5-year OS: 97%; P=0.004). Cytogenetics identified high-risk pts by >35% Philadelphia chromosome-positive metaphases (Ph+, 27% of pts; 5-year OS: 87%) compared with ≤35% Ph+ (73% of pts; 5-year OS: 95%; P=0.036). At 6 months, >1% BCR-ABL(IS) (37% of pts; 5-year OS: 89%) was associated with inferior survival compared with ≤1% (63% of pts; 5-year OS: 97%; P<0.001) and correspondingly >0% Ph+ (34% of pts; 5-year OS: 91%) compared with 0% Ph+ (66% of pts; 5-year OS: 97%; P=0.015). Treatment optimization is recommended for pts missing these landmarks.