Low-cost 3D-printed anthropomorphic cardiac phantom, for computed tomography automatic left ventricle segmentation and volumetry - A pilot study

INTRODUCTION

Accurate cardiac left ventricle (LV) delineation is essential to CT-derived left ventricular ejection fraction (LVEF). To evaluate dose-reduction potential, an anatomically accurate heart phantom, with realistic X-ray attenuation is required. We demonstrated and tested a custom-made phantom using 3D-printing, and examined the influence of image noise on automatically measured LV volumes METHODS: A single coronary CT angiography (CCTA) dataset was segmented and converted to Standard Tessellation Language (STL) mesh, using open-source software. A 3D-printed model, with hollow left heart chambers, was printed and cavities filled with gelatinized contrast media. This was CT-scanned in an anthropomorphic chest phantom, at different exposure conditions. LV and "myocardium" noise and attenuation was measured. LV volume was automatically measured using two different methods. We calculated Spearmans' correlation of LV volume with noise and contrast-noise ratio respectively om 486 scans of the phantom. Source images were compared to one phantom series with similar parameters. This was done using Dice coefficient on LV short-axis segmentations.

RESULTS

Phantom "Myocardium" and LV attenuation was comparable to measurements on source images. Automatic volume measurement succeeded, with mean volume deviation to patient images less than 2 ml. There was a moderate correlation of volume with CNR, and strong correlation of volume with image noise. With papillary muscles included in LV volume, the correlation was positive, but negative when excluded. Variation of volumes was lowest at 90-100 kVp for both methods in the 486 repeat scans. The Dice coefficient was 0.87, indicating high overlap between the single phantom series and source scan. Cost of 3D-printer and materials was 400 and 30 Euro respectively.

CONCLUSION

Both anatomically and radiologically the phantom mimicked the source scans closely. LV volumetry was reliably performed with automatic algorithms.

IMPLICATIONS FOR PRACTICE

Patient-specific cardiac phantoms may be produced at minimal cost and can potentially be used for other anatomies and pathologies. This enables radiographic phantom studies without need for dedicated 3D-labs or expensive commercial phantoms.

Is animal welfare better on smaller dairy farms? Evidence from 3,085 dairy farms in Germany

The structural change toward larger (dairy) farms is often criticized because it supposedly has a negative effect on farm animal welfare. We investigated this criticism using cross-sectional survey data from 3,085 German dairy farms. Even though our sample was a convenience sample, it closely resembled the diverse structures of dairy farming in Germany and covered a wide range of dairy farm sizes (7 to 2,900 cows per farm, mean 122). We developed an animal welfare index (AWI) in close consultation with experts along the dairy value chain (e.g., farm animal welfare scientists, farmers, dairy representatives). Regression results showed that larger farms tended to achieve a better AWI than smaller farms in our data set. However, the effect size was small. Nevertheless, in contrast to the widespread assumption in public discussion, larger dairy herds are not necessarily associated with poorer animal welfare. In all herd size classes, we found a large variation of AWI between herds. Although this study focused on the effect of herd size, it is not the only factor affecting animal welfare levels on individual farms. Other variables that we included in the regression to describe the AWI indicate that the knowledge and skills of the farm manager and the amount of time that farms can devote to animals have a positive effect on the AWI. However, as with herd size, the effect size of other explanatory variables was small in absolute terms.

[Challenges of coronary catheterization after TAVR]

PURPOSE

Coronary catheterization after transcatheter aortic valve implantation (TAVR) may be challenging. The main objective of the study is to assess the feasibility of coronary catheterization and angioplasty according to each type of valve.

PATIENTS AND METHOD

We retrospectively studied coronary angiography or percutaneous angioplasty procedures after TAVR in two different centers. The catheterization success of coronary artery was evaluated according to the quality of engagement in ostium and opacification of the artery. Other indicators were collected including catheters used, fluoroscopy and angiography times, DAP and the volume of the contrast agent.

RESULTS

Among 1512 TAVR procedures, 33 patients were included. The Sapien 3® valve was implanted in 22 patients and the Evolut® in 11 patients (7 Evolut-R® and 4 Evolut Pro®). Coronary angiography with selective or partially selective catheterization has been successfully performed in all patients with a Sapien 3® valve. In the Evolut® group we identified 3 cases of non-selective catheterization for the right coronary and 1 case for the left coronary. Standard Judkins catheters seem to be the most suitable for both types of valve with very good efficiency.

CONCLUSION

The results of our study is promising for the future of TAVR with a coronary catheterization success rate close to 100% with some difficulties for the Evolut® supra-annular valves. Special attention should be paid to the technique of implantation and orientation of cups in the aortic sinus.

Primary hemostatic disorders drive early and late major bleedings of patients with atrial fibrillation after transcatheter aortic valve replacement

Introduction

Patients with atrial fibrillation (AF) are likely to have multiple co-morbidities and receive anticoagulants after TAVR, which lead to a poor prognosis including bleeding events. Closure time adenosine diphosphate (CT-ADP) is a primary hemostasis point-of-care test used as a surrogate marker of high molecular weight (HMW) multimers defect of Von Willebrand factor (VWF). Our prior studies suggest that prolongation of CT-ADP (>180 seconds) after TAVR is a major determinant of early and late major/life-threatening bleeding complications (MLBCs).

Purpose

To evaluate the impact of post-procedural CT-ADP >180sec on bleeding events in AF patients.

Methods

We included 878 patients from our prospective TAVR registry between 2010 and 2019. Bleeding complications were assessed according to the VARC-2 (Valve Academic Research Consortium-2) criteria. Major adverse cardiac and cerebrovascular events (MACCE) was defined as a composite of all-cause death, myocardial infarction, stroke, and heart failure hospitalization within 1-year after TAVR. Ongoing primary haemostasis disorder was defined by post-procedure CT-ADP >180sec. Primary endpoint was the occurrence of MLBCs during the first year and the second endpoint was 1-year MACCE.

Results

Patients with AF had a higher incidence of all-cause mortality (15% vs. 8%, p=0.002), MACCE (29% vs. 20%, p=0.002), and MLBCs (20% vs. 12%, p=0.001) within 1-year compared to non-AF patients. When the cohort was split into 4 subgroups according to AF and CT-ADP >180sec, patients with AF and CT-ADP >180sec had the highest risk of MLBCs (log-rank test; p<0.001) (Figure). Multivariate Cox regression analysis confirmed that the patients with AF and CT-ADP >180sec had 4.6-fold higher risk of MLBCs within 1 year compared to non-AF patients with CT-ADP ≤180sec (hazard ratio: 4.60; 95% confidence interval: 2.18 - 9.68; p<0.001).

Conclusion

Among TAVR patients, AF with post-procedural CT-ADP >180 sec was identified as a strong independent predictor of MLBCs at 1-year follow-up. Our study suggest that persistent primary haemostasis disorders contribute to a higher risk of bleeding events particularly in AF patients and may be considered for a tailored and risk-adjusted antithrombotic therapy after TAVR.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Dr Matsushita received a grant from Edwards Lifesciences.

Utility and safety of the MANTA device for access site closure after removal of the mechanical hemodynamic support device Impella on the intensive care unit

Background

The percutaneously implanted hemodynamic mechanical support devices Impella are commonly used in patients at risk for or with cardiogenic shock (CS). Impella removal after hemodynamic stabilization on the intensive care unit (ICU) remains a major challenge and is prone to high rates of bleeding and vascular complications.

Purpose

It is unknown if the use of the novel large-bore access closure device MANTA® is safe and facilitates access management compared to manual compression.

Methods

Between January 2017 and December 2020, 172 CS patients were treated with an Impella® device at our centre. Of those, in 89 patients the Impella® was removed on the ICU and access site management occurred with either MANTA® device or manual compression. The criteria for MANTA® 14 french device deployment included: (i) femoral artery Diameter >6mm and (ii) absence of significant peripheral arterial disease (PAD). Bleeding and vascular access site complications were assessed and adjudicated according to the Valve Academic Research Consortium-2 (VARC-2) criteria.

Results

Among the 89 included patients, Impella® removal was performed using the MANTA® device in 31 cases and manual compression in 58 cases. Mean age was 66±11 years, and 50 (56.2%) patients had a CS classified as Society for Cardiovascular Angiography and Interventions (SCAI) D or higher due to myocardial infarction. Median support time was 40 (IQR 24; 69) hours. Baseline characteristics are displayed in Table 1. Immediate haemostasis was more frequently achieved by MANTA® device compared to manual compression (p=0.034). Moreover, we observed significantly less overall (2 (6.5%) vs. 22 (37.9%), p=0.001) and minor bleedings (1 (3.2%) vs. 15 (25.9%), p=0.006) with the MANTA® device when compared to manual compression. Of note, there were no significant differences in vascular complications between the two groups (Table 2).

Conclusions

In patients requiring Impella® support and residing on ICU, the MANTA® device, compared to standard of care manual compression, seems to be a safe and effective option for access site management, especially with regards to the reduction of bleeding events. However, physicians should carefully assess the vascular anatomy and degree of calcification prior to deployment of the MANTA® device. Nevertheless, more prospective data is necessary for evaluating the optimal access closure among CS patients treated with a percutaneously implanted Impella® device.

Funding Acknowledgement

Type of funding sources: None. Table 1. Baseline demographicsTable 2. Outcomes

Effects of suspended coal particles on gill structure and oxygen consumption rates in a coral reef fish

Large quantities of coal are transported through tropical regions; however, little is known about the sub-lethal effects of coal contamination on tropical marine organisms, including fish. Here, we measured aerobic metabolism and gill morphology in a planktivorous coral reef damselfish, Acanthochromis polyacanthus to elucidate the sub-lethal effects of suspended coal particles over a range of coal concentrations and exposure durations. Differences in the standard oxygen consumption rates (M_O2) between control fish and fish exposed to coal particles (38 and 73 mg L^-1) were minimal and generally not dose dependent; however, the M_O2 of fish exposed to 38 mg coal L^-1 (21 days) and 73 mg coal L^-1 (31 days) were both significantly higher than the M_O2 of control fish. Chronic coal exposure (31 days) altered gill structure in the higher coal treatments (73 and 275 mg L^-1), with fish exposed to 275 mg L^-1 exhibiting significant reductions in gill mucous and thinning of lamellar and filament epithelium. These findings contribute to our limited understanding of the potential impacts of coal on tropical reef species; however, most of the observed effects occurred at high coal concentrations that are unlikely under most coal spill scenarios. Future studies should investigate other contamination scenarios such as the impacts of chronic exposures to lower concentrations of coal.

Maternal high-fat diet during lactation reprograms the dopaminergic circuitry in mice

The maternal perinatal environment modulates brain formation, and altered maternal nutrition has been linked to the development of metabolic and psychiatric disorders in the offspring. Here, we showed that maternal high-fat diet (HFD) feeding during lactation in mice elicits long-lasting changes in gene expression in the offspring's dopaminergic circuitry. This translated into silencing of dopaminergic midbrain neurons, reduced connectivity to their downstream targets, and reduced stimulus-evoked dopamine (DA) release in the striatum. Despite the attenuated activity of DA midbrain neurons, offspring from mothers exposed to HFD feeding exhibited a sexually dimorphic expression of DA-related phenotypes, i.e., hyperlocomotion in males and increased intake of palatable food and sucrose in females. These phenotypes arose from concomitantly increased spontaneous activity of D1 medium spiny neurons (MSNs) and profoundly decreased D2 MSN projections. Overall, we have unraveled a fundamental restructuring of dopaminergic circuitries upon time-restricted altered maternal nutrition to induce persistent behavioral changes in the offspring.

[PREVALENCE OF TOBACCO SMOKING AMONG MENTAL HEALTH INPATIENTS IN ISRAEL]

INTRODUCTION

Tobacco smoking is the worldwide leading preventable cause of morbidity [1]. The prevalence of current smoking among individuals with mental illnesses is more than twice as that of the general population [2]. Despite it being a primary cause of morbidity and mortality in Israel too, there is little information and research on the features of smoking among people with mental illnesses in Israel.

OBJECTIVES

To present an up-to-date estimation of the prevalence of smoking among hospitalized patients with mental illness in Israel and to compare the prevalence of comorbidities among smokers and non-smokers in this population.

METHODS

Analyzing data obtained from an electronic medical-records database, consisting of 4646 patients with mental illness, aged 18-90 years, who were hospitalized at Geha Mental Health Center during 2005-2013.

RESULTS

The smoking rate among hospitalized patients with mental illness was significantly higher than the general population (51.3% versus 19.7%, respectively). The smoking rate among male hospitalized patients with mental illness was higher than that of the females (58.2% versus 42.7%, respectively), however, the difference between men and women is smaller compared to this difference in the general population. Smoking rates were highest among those with personality disorder (65.1%), bipolar disorder (58.8%) and schizophrenia (53.81%). The prevalence of comorbid substance use (alcohol or drug abuse) among hospitalized patients with mental illness was found to be higher in the smokers group than in the non-smokers group (37.4% versus 4.6%, respectively, p<0.0001).

CONCLUSIONS

The prevalence of smoking among hospitalized patients with mental illness in Israel is 2.74 times that of the general population in 2013, in line with the reported worldwide rate. In addition, among hospitalized patients with mental illness the prevalence of comorbid substance use (alcohol or drug abuse) was higher among the smokers than among the non-smokers.

Impact of Covid-19 infection in high-risk coronary patients

Background

Methods

Results

Conclusions

Value of regular endosonography and [18F]fluorodeoxyglucose PET-CT after surgery for gastro-oesophageal junction, stomach or pancreatic cancer

BACKGROUND

Most patients undergo follow-up after surgery for cancers of the gastro-oesophageal junction, stomach or pancreas, but data to support which modalities to use and the frequency of investigation are limited.

METHODS

Patients in the EUFURO study were randomized to either visits to the outpatient clinic at 3, 6, 9, 12, 18, and 24 months after surgery (standard), or to the addition of [18F]fluorodeoxyglucose (FDG) PET-CT and endoscopic ultrasonography (EUS) with guided fine-needle aspiration biopsy to clinical assessments (intervention). Data from the intervention arm were used to analyse the diagnostic performance of endosonography or [18F]FDG PET-CT in detecting recurrences.

RESULTS

During the scheduled follow-up, 42 of 89 patients developed recurrence; PET-CT and EUS in combination detected 38 of these recurrences. EUS detected 23 of the 42 patients with recurrent disease during follow-up and correctly diagnosed 17 of 19 locoregional recurrences. EUS was able to detect isolated locoregional recurrence in 11 of 13 patients. In five patients, EUS was false-positive for isolated locoregional recurrence owing to missed distant metastases. PET-CT detected locoregional recurrence in only 12 of 19 patients, and isolated locoregional recurrence in only 7 of 13. False-positive PET-CT results in 23 patients led to a total of 44 futile procedures.

CONCLUSION

Accuracy in detecting recurrences by concomitant use of PET-CT and EUS was high (90 per cent). PET-CT had moderate to high sensitivity for overall recurrence detection, but low specificity. EUS was superior to PET-CT in the detection of locoregional and isolated locoregional recurrences.

Cyclizing Painkillers: Development of Backbone-Cyclic TAPS Analogs

Painkillers are commonly used medications. Native peptide painkillers suffer from various pharmacological disadvantages, while small molecule painkillers like morphine are highly addictive. We present a general approach aimed to use backbone-cyclization to develop a peptidomimetic painkiller. Backbone-cyclization was applied to transform the linear peptide Tyr-Arg-Phe-Sar (TAPS) into an active backbone-cyclic peptide with improved drug properties. We designed and synthesized a focused backbone-cyclic TAPS library with conformational diversity, in which the members of the library have the generic name TAPS c(n-m) where n and m represent the lengths of the alkyl chains on the nitrogens of Gly and Arg, respectively. We used a combined screening approach to evaluate the pharmacological properties and the potency of the TAPS c(n-m) library. We focused on an in vivo active compound, TAPS c(2-6), which is metabolically stable and has the potential to become a peripheral painkiller being a full μ opioid receptor functional agonist. To prepare a large quantity of TAPS c(2-6), we optimized the conditions of the on-resin reductive alkylation step to increase the efficiency of its SPPS. NMR was used to determine the solution conformation of the peptide lead TAPS c(2-6).

P2Y12 inhibition by clopidogrel increases adverse clinical outcomes in patients undergoing transcatheter aortic valve replacement

Introduction

Current recommendations support short-term dual antiplatelet therapy (DAPT) for patients undergoing transcatheter aortic valve replacement (TAVR) despite no relevant study exploring the extent of platelet inhibition by clopidogrel.

Purpose

To assess whether P2Y12 inhibition by clopidogrel as evaluated by vasodilator-stimulated phosphoprotein flow cytometry test (VASP-FCT) impacts 1-year clinical outcomes in patients undergoing TAVR.

Methods

Patients were included in a prospective registry between February 2010 and May 2019. VASP-FCT was assessed 24h after the procedure. Responder to clopidogrel was defined by a platelet reactivity index ≤50%.

Results

Of 640 patients who underwent TAVR with preprocedural clopidogrel therapy, we enrolled 491 patients for whom VASP data were available. Responders were identified in 22% (n=110) of patients and low responders were 78% (n=381) of patients. Low body mass index, active cancer, and clopidogrel on admission were found to be independent predictors of responder. Mean transaortic pressure gradient was lower in the responder group at 1-month post-TAVR (9.9±4.4 mmHg vs. 11.2±5.8 mmHg, p=0.03) but was similar at 1-year (11.5±6.2 mmHg vs. 11.9±7.4 mmHg, p=0.74). By multivariate Cox regression analysis, patients responding to clopidogrel (hazard ratio [HR]: 2.19; 95% confidence interval [CI]: 1.04 to 3.64; p=0.04), prior PCI (HR: 2.12; 95% CI: 1.07 to 4.37; p=0.03), and mean transaortic pressure gradient at baseline (HR: 0.07; 95% CI: 0.01 to 0.70; p=0.02) were identified as independent predictors of 1-year adverse clinical outcomes, including all-cause death, myocardial infarction, stroke, and heart failure hospitalization.

Conclusions

Appropriate P2Y12 inhibition by clopidogrel is a major determinant of adverse clinical events after TAVR. In sum, the present data challenges the need of DAPT as a standard therapy during TAVR.

Figure 1

Funding Acknowledgement

Type of funding source: None

Residual inflammation is a major determinant of myocardial recovery and cardiovascular outcome in takotsubo patients

Background

Recent insights have emphasized the importance of myocardial and systemic inflammation in Takotsubo Syndrome (TTS).

Objective

In a large registry of unselected patients, we sought to evaluate whether residual high inflammatory response (RHIR) could impact cardiovascular outcome after TTS.

Methods

Patients with TTS were retrospectively included between 2008 and 2018 in three general hospitals. 385 patients with TTS were split into three subgroups, according to tertiles of C-reactive protein (CRP) levels at discharge (CRP&lt;5.2 mg/l, CRP range 5.2 to 19 mg/l, and CRP&gt;19 mg/L). The primary endpoint was the impact of RHIR, defined as CRP&gt;19 mg/L at discharge, on cardiac death or hospitalization for heart failure.

Results

Follow-up was obtained in 382 patients (99%) after a median of 747 days. RHIR patients were more likely to have a history of cancer or a physical trigger. Left ventricular ejection fraction (LVEF) at admission and at discharge were comparable between groups. By contrast, RHIR was associated with lower LVEF at follow-up (61.7 vs. 60.7 vs. 57.9%; p=0.004) and increased cardiac late mortality (0% vs. 0% vs. 10%; p=0.001). By multivariate Cox regression analysis, RHIR was an independent predictor of cardiac death or hospitalization for heart failure (hazard ratio: 1.97; 95% confidence interval: 1.11 to 3.49; p=0.02).

Conclusions

RHIR was associated with impaired LVEF recovery and was evidenced as an independent factor of cardiovascular events. All together these findings underline RHIR patients as a high-risk subgroup, to target in future clinical trials with specific therapies to attenuate RHIR.

Main results

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): GERCA (Groupe pour l'Enseignement, la prévention et la Recherche Cardiovasculaire en Alsace)

Predictive impact of PVL assessments on clinical outcomes in patients undergoing TAVR

Introduction

Paravalvular leakage (PVL) following transcatheter aortic valve replacement (TAVR) is associated with greater mortality. In clinical practice, determining PVL severity after TAVR remains challenging and often requires multiparametric assessment.

Purpose

This study sought to evaluate the respective value of various modalities of PVL assessments, including transthoracic echocardiography (TTE), cine-angiography, aortic regurgitation index (ARI), and closure time with adenosine diphosphate (CT-ADP), in the prediction of adverse clinical outcomes.

Methods

We included 1044 patients from our prospective TAVR registry between February 2010 and May 2019. Major adverse cardiac and cerebrovascular events (MACCE) was defined as a composite of all-cause death, myocardial infarction, stroke, and heart failure hospitalization within 1-year. Established cutoff values of ARI (&lt;25) and CT-ADP (&gt;180 sec) were used to assess the presence of PVL after TAVR.

Results

Moderate to severe PVL occurred in 14.2% and 5.2% of patients as measured by TTE and angiography. The rate of patients with ARI &lt;25 and CT-ADP &gt;180 sec were 36.5% and 24.9%, respectively. Among the four modalities, PVL evaluated by angiography predicted poorer clinical outcomes (Log rank test; p=0.001), whereas TTE, ARI &lt;25, and CT-ADP &gt;180 sec were not associated with 1-year MACCE. By multivariate Cox regression analysis, moderate to severe PVL by angiography was an independent predictor of 1-year MACCE (hazard ratio: 1.96; 95% confidence interval: 1.22–3.00; p=0.007).

Conclusions

Paravalvular leakage measured by angiography was evidenced as the most meaningful modality in the prediction of adverse clinical outcomes. Future multicenter studies are warranted to ensure these findings in the current TAVR era.

Figure 1

Funding Acknowledgement

Type of funding source: None

FRI0203 A SINGLE-CENTER INVESTIGATION ON THE PREVALENCE OF MALIGNANCIES IN PATIENTS WITH POLYMYALGIA RHEUMATICA AND GIANT CELL ARTERITIS BY WAY OF 18F-FDG PET/CT: A PROSPECTIVE COHORT STUDY

Background:

Several chronic inflammatory diseases are associated with a higher risk of cancer.[1] Whether, this is the case in Polymyalgia Rheumatica (PMR) and Giant Cell Arteritis (GCA) is still a matter of debate.

Objectives:

To identify the prevalence of newly diagnosed cancers in patients with PMR and GCA by means of 18F-FDG PET/CT. Moreover, to compare the characteristics of the patients with and without cancer.

Methods:

Eighty consecutive patients with newly diagnosed PMR/GCA were studied. Diagnosis of PMR/GCA was confirmed by a 40-weeks follow up. A unilateral temporal artery biopsy (TAB) was also performed at the time of diagnosis. All included patients underwent an 18F-FDG PET/CT before, or in case of GCA, within 3 days of initiation of high dose oral glucocorticoid (40-75mg). All cancer-suspicious 18F-FDG-PET/CT findings were assessed thoroughly and malignant diseases were confirmed by histology. Total PMR and GCA scores were defined as the sum of a 4-point visual grading scale in each articular/periarticular site as well as arterial segment.

Results:

Of the 80 patients, 64 (83.1%) were diagnosed with pure PMR, 10 (13.0%) with concomitant GCA with PMR and 3 (3.9%) with pure GCA. Three patients were diagnosed with rheumatoid arthritis during follow up and excluded from the study. Five types of cancer in 4 (5.2%;95% CI:1.4-12.8%) patients were found. Two patients had breast cancer, one patient had adenocarcinoma of colon and one patient had adenocarcinoma of colon together with skin cancer. Besides, 4 (5.2%;95% CI:1.4-12.8%) patients had Monoclonal Gammopathy of Unknown Significance (MGUS). Age and C-reactive protein were significantly higher among those with solid cancers (p:0.049) and MGUS (p:0.017), respectively (Table1).

Table 1.

Characteristics of the patients with and without solid cancer ae well as MGUS

VariablesCancer –,n=73Cancer +,n=4P-valueMGUS -, n =73MGUS +,n =4P-valueAge, mean±SD71.4±7.879.7±7.50.04971.9±8.070.2±9.20.79Gender, n(%)Female46(59.7%)3(3.9%)0.9947(61.0%)2(2.6%)0.62Constitutional symptoms, n(%)70(90.9%)4(5.2%)0.9970(90.9%)4(5.2%)0.99Shoulder girdle symptoms, n(%)68(88.3%)4(5.2%)0.9968(88.3%)4(5.2%)0.99Hip girdle symptoms, n(%)65(84.4%)3(3.9%)0.4064(83.1%)4(5.2%)0.99Cranial symptoms, n(%)19(24.7%)0(0%)0.5717(22.1%)2(2.6%)0.25Patients pain VAS75(50-85)62.5(50-75)0.5372.5(50 -80)87.5(77.5-95)0.07Patients global VAS80(60-90)62.5(50-75)0.3780(60-90)89.5(79.5-95)0.23Physician global VAS30(25-40)24.5(20-29)0.1530(22.5-40)37.5(32.5-45)0.17Erythrocyte sedimentation rate, mm[2-20]54(38-79)62.5(37.5-76)0.9354(38-77.5)57.5(39 -73.5)0.94C-reactive protein, mg/L[<6.0]37(17-64)34(17.0-76)0.8033(17-60)98(68 -115)0.017TAB positive7(9.1%)0(0%)0.997(9.1%)0(0%)0.99Total PMR score14(10-17)12(5-15)0.3914(10-17)13(6-15.5)0.64Total GCA score0(0-0)0(0-0.5)0.890(0-0)0(0-0)0.34Clinical diagnosis, n(%)0.990.53 Pure PMR60(77.9%)4(5.2%)61(79.2%)3(3.9%) Pure GCA3(3.9%)0(0%)3(3.9%)0(0%) Concomitant PMR and GCA10(13.0%)0(0%)9(11.7%)1(1.3%)

VAS: Visual analogue scale

Conclusion:

The prevalence of cancers in this cohort was higher, compared to the 1-year prevalence of all cancer sites of 1.2% among age-, gender- and region-matched background population in 2016. Occult malignancies are important and relatively prevalent findings in newly diagnosed PMR/GCA patients.

References:

[1]Hemminki K, et al. Cancer risk in hospitalized rheumatoid arthritis patients. Rheumatology (Oxford) 2008;47:698-701.

Disclosure of Interests:

None declared

Phase-Amplitude Markers of Synchrony and Noise: A Resting-State and TMS-EEG Study of Schizophrenia

The electroencephalogram (EEG) of schizophrenia patients is known to exhibit a reduction of signal-to-noise ratio and of phase locking, as well as a facilitation of excitability, in response to a variety of external stimuli. Here, we demonstrate these effects in transcranial magnetic stimulation (TMS)-evoked potentials and in the resting-state EEG. To ensure veracity, we used 3 weekly sessions and analyzed both resting-state and TMS-EEG data. For the TMS responses, our analysis verifies known results. For the resting state, we introduce the methodology of mean-normalized variation to the EEG analysis (quartile-based coefficient of variation), which allows for a comparison of narrow-band EEG amplitude fluctuations to narrow-band Gaussian noise. This reveals that amplitude fluctuations in the delta, alpha, and beta bands of healthy controls are different from those in schizophrenia patients, on time scales of tens of seconds. We conclude that the EEG-measured cortical activity patterns of schizophrenia patients are more similar to noise, both in alpha- and beta-resting state and in TMS responses. Our results suggest that the ability of neuronal populations to form stable, locally, and temporally correlated activity is reduced in schizophrenia, a conclusion, that is, in accord with previous experiments on TMS-EEG and on resting-state EEG.

[Common femoral artery bailout stenting with covered stent graft due to TAVR vascular complication: Clinical long term follow-up]

BACKGROUND

Vascular complications are frequent in the context of transcatheter aortic valve replacement and may require the implantation of a covered stent graft in the common femforal artery. However, common femoral artery is considered to be at high risk of stent fracture or occlusion due to high mobility of the hip joint.

PATIENTS AND METHODS

We analyzed medical records of patients with transcatheter aortic valve replacement related vascular complications between 2015 and 2018, treated with commom femoral artery transluminal angioplasty or surgery. Vascular complications or suspect symptoms were followed up by phone calls.

RESULTS

Among 552 patients, 43 patients were included. Twelve (11.6 %) were managed by prolonged balloon inflation, 5 (11.6 %) by first line surgery and 26 (60.4 %) by the implantation of a covered stent graft. Among the latter group, the covered stent graft was efficient in 24 patients (92.3 %). The median follow-up was 430 days [3-1499]. The first-line surgery group had a higher risk of red blood cell transfusion and all causes mortality. At follow-up, no patient had suspicious symptoms of vascular covered stent complication. Four patients (9.3 %) had US-doppler or CT vascular imaging at follow-up, showing no evidence of stent fracture or occlusion.

CONCLUSION

In our study, the implantation of a covered stent graft in the common femoral artery was an efficient and safe strategy for the management of transcatheter aortic valve replacement related vascular complications.

Vitamin D Supplementation in Chronic Schizophrenia Patients Treated with Clozapine: A Randomized, Double-Blind, Placebo-controlled Clinical Trial

BACKGROUND

While accumulating evidence suggests that vitamin D deficiency may be involved in the risk to develop schizophrenia and its outcome, there are no studies on vitamin D supplementation in this context. We sought to assess the effect of vitamin D supplementation on psychiatric, cognitive and metabolic parameters in chronic clozapine-treated schizophrenia patients.

METHODS

This eight-week, randomized, double-blind, placebo-controlled clinical trial, recruited schizophrenia patients who had been maintained on clozapine treatment for at least 18weeks and had low levels of vitamin D (<75nmol/l) and total PANSS scores >70 (to ascertain the presence of residual symptoms). Patients were randomly allocated to either weekly oral drops of vitamin D (14,000IU) or placebo and subsequently assessed at two-week intervals for psychosis severity, mood, cognition and metabolic profile.

RESULTS

Twenty four patients were randomly assigned to vitamin D (aged 39.4±9.6years, 75% males) and the other 23 patients to the placebo arm (aged 42.5±11.2years, 60.9% males). After eight weeks, the vitamin D group exhibited a significant increase in vitamin D levels (31.4 vs -0.4nmol/l, p<0.0001). There was no significant effect of vitamin D on psychotic, depressive or metabolic parameters. However, in the vitamin D group, there was a trend towards improved cognition (effect size=0.17, significance lost following Bonferroni correction).

CONCLUSIONS

Vitamin D supplementation was associated with a trend towards improved cognition, but did not affect psychosis, mood or metabolic status. It is possible that the robust decrease in the PANSS scores in both groups may have obscured an effect of vitamin D supplementation.

Endothelial immunogenicity – A matter of matrix microarchitecture

The endothelium is a highly specialized active interface between blood and the underlying tissues, maintaining vascular tone, thrombo-resistance and selective permeability to cells and proteins. It is also an important regulator of inflammatory diseases, and endothelial-leukocyte interactions often herald complex diseases with an inflammatory component.Yet, the exact mechanisms promoting immune activation of endothelial cells (EC) are incompletely understood. Knowledge is accumulating that the immediate environment defines the cellular phenotype, whereby matrix composition and spatial formation (three- versus two-dimensional) seem to act as pivotal mediators. Here we summarize current findings denoting a key role of matrix environment in regulating endothelial immunogenicity. The immune response to three-dimensional matrix-embedded EC stands in stark contrast to the response engendered by injection of these same cells in their free state. Matrix-embedding confers a quiescent endothelial state with reduced expression levels of chemokines, adhesion, costimulatory, and major histocompatibility complex II molecules. Compared to EC grown on two-dimensional tissue culture plates, cytokine-stimulation of matrixembedded EC results in significantly reduced adhesion of natural killer cells and proliferation of co-cultivated allogeneicT cells. On the contrary, matrix-embedded EC induce an immune-inhibitory phenotype of dendritic cells and T regulatory cells to a greater extent than non-embedded EC. As vascular diseases are associated with profound changes in basement membrane composition and overall tissue architecture, our results indicate that the immediate environment of EC might play a pivotal role in initiating and regulating of different vascular diseases. Cell-matrix interconnections appear to govern endothelial immunogenicity and interactions between EC and immune cells.

Decreased serum L-arginine and L-citrulline levels in major depression

RATIONALE

It has been suggested that endothelial dysfunction caused by a decreased endothelial production of nitric oxide (NO) may contribute to the consistently observed increased risk of developing cardiovascular disease (CVD) in physically healthy patients suffering from major depression (MD). NO is a gas synthesized from Larginine (a conditionally essential amino acid) and oxygen by endothelial nitric oxide synthase (eNOS). The end products of NO production include both NO and L-citrulline. NO is rapidly reduced to the anions nitrite and nitrate, classically referred to as NO metabolites. Their measurement has been used as a surrogate measurement for endothelial NO production. We and others have shown decreased levels of NO metabolites in the serum of MD patients. The mechanism of this decreased production of NO by the endothelium has not yet been elucidated.

OBJECTIVES

The purpose of this study is to assess serum levels of L-arginine and L-citrulline in patients with MD.

METHODS

Levels of L-arginine and L-citrulline were measured in 35 unmedicated physically healthy MD patients and 36 healthy controls (HCs).

RESULTS

L-arginine and L-citrulline concentrations were significantly lower in MD patients than in healthy controls (L-arginine, 73.54 + 21.53 μmol/L and 84.89 + 25.16, p = 0.04 μmol/L and L-citrulline 31.58 + 6.05 μmol/L and 35.19 + 6.85 μmol/L, p = 0.03, respectively).

CONCLUSIONS

The decrease in L-arginine levels in MD patients is a possible explanation for the decrease in NO metabolites in MD patients and therefore may contribute, through endothelial dysfunction, to the increased CV risk associated with MD.

The health technology assessment of the compulsory accident insurance scheme of hand transplantation in Switzerland

Recently the decision-making committee of the compulsory Swiss accident insurance scheme needed to make a basic decision as to whether to fund hand transplantation under that scheme or not. A Health Technology Assessment was commissioned to inform decision-making and gain experience with applicability of the method. The following were main findings from various domains. Compared with prosthesis fitting, the outcome of hand transplantation is satisfactory for function and sensibility. Complications due to immunosuppression are frequent, sometimes severe and potentially life-shortening. The direct medical costs over the entire life span calculated for a 35-year-old unilaterally amputated base case patient were CHF 528,600 (EUR 438,500) higher than for a prosthesis. There are challenging ethical, legal and organizational issues. The committee decided not to reimburse hand transplantation for ethical reasons. The Health Technology Assessment has been shown to be a useful tool for decision-making in the context of Swiss accident insurance.

LEVEL OF EVIDENCE

IV.

Community IntraVenous Antibiotic Study (CIVAS): protocol for an evaluation of patient preferences for and cost-effectiveness of community intravenous antibiotic services

INTRODUCTION

Outpatient parenteral antimicrobial therapy (OPAT) is used to treat a wide range of infections, and is common practice in countries such as the USA and Australia. In the UK, national guidelines (standards of care) for OPAT services have been developed to act as a benchmark for clinical monitoring and quality. However, the availability of OPAT services in the UK is still patchy and until quite recently was available only in specialist centres. Over time, National Health Service (NHS) Trusts have developed OPAT services in response to local needs, which has resulted in different service configurations and models of care. However, there has been no robust examination comparing the cost-effectiveness of each service type, or any systematic examination of patient preferences for services on which to base any business case decision.

METHODS AND ANALYSIS

The study will use a mixed methods approach, to evaluate patient preferences for and the cost-effectiveness of OPAT service models. The study includes seven NHS Trusts located in four counties. There are five inter-related work packages: a systematic review of the published research on the safety, efficacy and cost-effectiveness of intravenous antibiotic delivery services; a qualitative study to explore existing OPAT services and perceived barriers to future development; an economic model to estimate the comparative value of four different community intravenous antibiotic services; a discrete choice experiment to assess patient preferences for services, and an expert panel to agree which service models may constitute the optimal service model(s) of community intravenous antibiotics delivery.

ETHICS AND DISSEMINATION

The study has been approved by the NRES Committee, South West-Frenchay using the Proportionate Review Service (ref 13/SW/0060). The results of the study will be disseminated at national and international conferences, and in international journals.

[THE PSYCHIATRIC DIAGNOSIS GUIDE - DSM-5 - INNOVATIONS AND CRITICISM]

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association (APA) as a guide for diagnosing psychiatric diseases and enables the alignment of psychiatric diagnoses with those of the psychologists, the social workers, the nursing staff and other mental health professionals. In addition, it helps bring cohesion to research, public health policy, education, the field of insurance and compensation and the legal system. After 14 years of hard work, the updated version of the DSM, the DSM-5, was published on May 2013. The current review aims to update the readers on the essence of the DSM and the methods of psychiatric diagnosing and to present the main changes in the field, as expressed in the 5th edition of the guide. In addition to details of those changes we included discussions of the criticisms brought against them. We hope that the review will contribute to broadening the readers' knowledge, broaden exposure and familiarity with the psychiatric lingo and to strengthening the professional ties between psychiatrists and professionals in other, tangential, medical fields.

Kinetic Theory for a Dilute Gas of Particles with Spin

The kinetic theory of particles with spin previously developed for a LORENTzian gas is extended to the case of a pure gas. In part A the transport (BOLTZMANN) equation for the one particle distribution operator is stated and discussed (conservation laws, Η-theorem). A magnetic field acting on the magnetic moment of the particles is incorporated throughout. In part B the pertaining linearized collision operator and certain bracket expressions linked with this operator are considered. Part C deals with the expansion of the distribution operator and of the linearized transport equation with respect to a complete set of composite irreducible tensors built from the components of particle velocity and spin. Thus, the distribution operator is replaced by a set of tensors depending only on time and space-coordinates. The physical meaning of these tensors (expansion coefficients) is invoked. They obey a set of coupled first-order differential equations (transport-relaxation equations) . The reciprocity relations for the relaxation matrices are stated. Finally a detailed discussion of angular momentum conservation is given.

Verallgemeinerte Boltzmann-Gleichung für mehratomige Gase

A generalized quantum mechanical Boltzmann equation is derived for the one particle distribution operator of a dilute gas consisting of molecules with arbitrary internal degrees of freedom. The effect of an external, time-independent potential on the scattering process is taken into account. The collision term of the transport equation contains the two-particle scattering operator T and its adjoint in a bilinear way and is non-local. The conservation equations for number of particles, energy, momentum and angular momentum as well as the H-theorem are deduced from the transport equation. One obtains the correct equilibrium distribution operator even in the presence of an external field (e. g. for particles with spin in a homogeneous magnetic field). Some special cases of the generalized Boltzmann equation are discussed treating position and momentum of a particle as classical variables but characterizing the internal state of a molecule by quantum mechanical observables. Using the local part of the collision term only and considering molecules with degenerate, but sufficiently separated internal energy levels one arrives at the Waldmann-Snider equation, which in turn comprises the Waldmann equation for particles with spin and the Wang Chang-Uhlenbeck equation. Special attention is drawn to the case of particles with spin in a magnetic field. Finally, for particles with spin, the local conservation equation for angular momentum, i.e. the Barnett effect (magnetization by rotation) and the antisymmetric part of the pressure tensor are derived from the generalized Boltzmann equation with non-local collision term.

Notizen: The Effect Reciprocal to Flow Birefringence in Cases

Flow birefringence in molecular gases is due to a collisional alignment (tensor polarization) of the rotational angular momentum of the molecules in the presence of a gradient of the flow velocity. The reciprocal phenomenon is an anisotropy of the velocity distribution caused by an externally maintained tensor polarization. The kinetic theory of this new effect is presented and methods for its experimental detection are indicated.

Monte Carlo Simulation of the Director Field of a Nematic Liquid Crystal with Three Elastic Coefficients

In this article, a Monte Carlo simulation is presented, which generates the equilibrium director field of a nematic liquid crystal under the influence of an external field and fixed boundary conditions. The liquid crystal is characterized by a set of directors on a spatially fixed lattice. The simulation is based on an expression for the Frank free energy with three elastic coefficients. The chosen discretisation conserves the nematic symmetry, which means n and - n are equivalent. The results for several Frederiks geometries with homogeneous and spatially modulated external fields are shown, as well as an investigation of a capillary with homeotropic boundary conditions. Further we compare our method with the Lebwohl-Lasher model and introduce an extension of the latter which distinguishes between splay-, twist-and bend-configurations.

Dynamic Ginzburg-Landau Theory for the Liquid-Solid Phase Transition

The anisotropy of the probability distribution function for the unit vector joining two nearest neighbour atoms is characterized by tensorial order parameters. For cubic symmetry, the most relevant tensor is of rank 4. Starting from an ansatz for the dependence of the (specific) internal energy, volume and entropy; the entropy production is calculated which is caused by a temporial change of the 4-th rank anisotropy tensor. A constitutive law which guarantees that the entropy production is positive leads to a nonlinear relaxation equation. It shows the features typical for a dynamic Ginzburg-Landau theory. The linearized version of the relaxation equation contains an effective relaxation time and a correlation length which exhibit a temperature dependence typical for a mean field theory. For a special case where the anisotropy tensor can be characterized by a scalar order parameter, the nonlinear relaxation equation is studied in some detail. Its stationary and spatially homogeneous solutions are zero and nonzero values for the order parameter depending on whether the temperature T is larger or smaller than the transition temperature. The unordered phase corresponds to a liquid state, the ordered phase to a simple or body centered cubic crystal. The phase transition is of 1st order. There exist also metastable states.

Kinetic Theory of Flow Birefringence in Dilute Gases of Symmetric Top Molecules

Flow birefringence in dilute gases of symmetric top molecules is treated within the framework of the kinetic theory based on the Waldmann-Snider equation. A microscopic expression is derived for the characteristic flow birefringence coefficient. Its magnitude is related to the magnetic-field-induced change of the viscosity.

Derivation and Application of an Algorithm for the Numerical Calculation of the Local Orientation of Nematic Liquid Crystals

Starting from a relaxation equation for the alignment tensor, an algorithm is derived which allows the numerical calculation of the dynamic and static behavior of the director field n with the correct nematic symmetry property, where n and - n are equivalent. As a first application, a two-dimensional problem is treated where the typical nematic defects with half-integer winding numbers only occur when the algorithm with the correct nematic symmetry property is used. Furthermore, the method is applied to the static and dynamic behavior of a Frederiks cell with strong and weak anchoring.