Reducing fracture incidence in children with osteogenesis imperfecta: contribution of orthotics to bisphosphonates treatment

PURPOSE

To determine whether there was a reduction in fracture incidence amongst children with OI who were treated with both bisphosphonates and orthoses.

OBJECTIVE

Was there an additional reduction in fracture incidence amongst children with Osteogenesis Imperfecta (OI) treated with both bisphosphonates and Hip-Knee-Ankle-Foot-Orthosis (HKAFO)?

MATERIALS AND METHODS

Of the 129 OI patients treated from 1990 to 2017, retrospective data from 48 patients who participated in the bisphosphonates-orthosis regime were analyzed including the incidence of fractures and modalities of fracture treatment.

RESULTS

Bisphosphonates usage was more frequent than bracing and there were more positive changes (smaller or equal number of fractures each year) than negative changes (more fractures each year); negative changes were scarce, explained by non-compliance with the use of bracing. Poisson regression models were significant for positive changes, whereas the interaction between them was borderline significant. The main finding is that the association between bisphosphonates usage and the number of positive changes was stronger among the patients who used braces more frequently and weaker among patients who used bracing less frequently.

CONCLUSIONS

Bracing of OI patients has an additive effect on bisphosphonate treatment in fracture prevention which should lead to the reconsideration of a hybrid approach to OI management.

Effects of interleukin-6 inhibition with ziltivekimab in patients at high risk of atherosclerotic events in Japan: results from the phase 2 RESCUE-2 trial

Introduction

In the US phase 2 RESCUE trial, ziltivekimab, a fully human monoclonal antibody against the ligand of the pro-inflammatory cytokine interleukin-6, was shown to reduce biomarkers of inflammation in patients with chronic kidney disease (CKD) and elevated levels of high-sensitivity C-reactive protein (hsCRP), a marker of inflammation and cardiac risk.1 Here, we present outcomes from the phase 2 RESCUE-2 trial of ziltivekimab in a patient population from Japan.

Purpose

To evaluate the efficacy and safety of ziltivekimab 15 mg and 30 mg compared with placebo in Japanese patients with non-dialysis-dependent CKD (NDD-CKD).

Methods

We conducted a randomized, double-blind, placebo-controlled trial in 36 patients aged ≥20 years with stage 3–5 NDD-CKD and hsCRP ≥2 mg/L. Patients were randomly assigned to receive subcutaneous ziltivekimab 15 mg (n=11) or 30 mg (n=12), or placebo (n=13) at weeks 0, 4 and 8. The primary endpoint was percentage change in hsCRP levels from baseline to end of treatment (EOT) (average of week 10 and week 12 values); secondary endpoints included percentage change from baseline to EOT in levels of fibrinogen, serum amyloid A (SAA), N-terminal pro B-type natriuretic peptide (NT-proBNP) and lipids. Analysis of endpoints was performed using Wilcoxon two-sample test; differences between treatment groups were calculated using the Hodges–Lehmann estimator.

Results

Baseline characteristics are shown in the Table. At EOT, median hsCRP levels were reduced by 96% and 93% in the ziltivekimab 15 mg and 30 mg groups, respectively, compared with 27% for placebo (both p<0.001 vs placebo). At both doses, ziltivekimab provided rapid and sustained suppression of hsCRP over the 12-week treatment period (Figure). Statistically significant reductions in levels of the inflammatory markers SAA (15 mg: 71%; 30 mg: 58%; placebo: 30%; both p<0.01 vs placebo) and fibrinogen (38%; 34%; 2%; both p<0.0001 vs placebo) were also observed. Ziltivekimab was well tolerated, did not result in persistent neutropenia or thrombocytopenia, and had minimal effect on liver enzyme levels. There was a non-significant increase in low-density lipoprotein levels and a neutral effect on high-density lipoprotein levels. There was a limited, but statistically significant (p<0.05 vs placebo) increase in triglycerides, whereby levels increased in some patients and decreased in others.

Conclusion

Ziltivekimab effectively reduced inflammatory biomarkers associated with atherosclerosis in patients from Japan with CKD and residual inflammatory risk as measured by hsCRP. A significant reduction of more than 90% in hsCRP levels for both doses of ziltivekimab was demonstrated, with a safety profile similar to placebo. Overall, the results of the RESCUE-2 trial in Japan are consistent with the efficacy and safety results of the US-based RESCUE trial.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was funded by Novo Nordisk A/S. Medical writing support was provided by Johanna Scheinost PhD, PharmaGenesis Oxford Central, Oxford, UK, with funding from Novo Nordisk A/S.

Sex differences in associations of comorbidities with incident cardiovascular disease: focus on absolute risk

Aim

To examine sex differences in associations of obesity, type-2 diabetes, hypertension, and atrial fibrillation (AF) with incident cardiovascular disease (CVD), focusing on absolute risk measures.

Methods and results

We included a total of 7994 individuals (mean age 49.1 years; 51.2% women) without prior CVD from the PREVEND (Prevention of Renal and Vascular End-stage Disease) cohort with a median follow-up of 12.5 years. Using Poisson regression, we calculated the increase in absolute as well as relative CVD risk associated with a comorbidity using incidence rate differences (IRD = IR_comorbidity−IR_{no-comorbidity}) and incidence rate ratios (IRR = IR_comorbidity/IR_{no-comorbidity}), respectively. Sex differences were presented as women-to-men differences (WMD = IRD_women−IRD_men) and women-to-men ratios (WMR = IRR_women/IRR_men). Absolute CVD risk was lower in women than in men (IR_women: 6.73 vs. IR_men: 14.58 per 1000 person-years). While increase in absolute CVD risk associated with prevalent hypertension was lower in women than in men [WMD: −6.12, 95% confidence interval: (−9.84 to −2.40), P = 0.001], increase in absolute CVD risk associated with prevalent obesity [WMD: −4.25 (−9.11 to 0.61), P = 0.087], type-2 diabetes [WMD: −1.04 (−14.36 to 12.29), P = 0.879] and AF [WMD: 18.39 (−39.65 to 76.43), P = 0.535] did not significantly differ between the sexes. Using relative risk measures, prevalent hypertension [WMR: 1.49%, 95% confidence interval: (1.12–1.99), P = 0.006], type-2 diabetes [WMR: 1.73 (1.09–2.73), P = 0.019], and AF [WMR: 2.53 (1.12–5.70), P = 0.025] were all associated with higher CVD risk in women than in men.

Conclusion

Increase in absolute risk of developing CVD is higher in hypertensive men than in hypertensive women, but no substantial sex-related differences were observed among individuals with obesity, type-2 diabetes and AF. On a relative risk scale, comorbidities, in general, confer a higher CVD risk in women than in men.

Nicotiana spp. for the Expression and Purification of Functional IgG3 Antibodies Directed Against the Staphylococcus aureus Alpha Toxin

Immunoglobulin subclass IgG1 is bound and neutralized effectively by Staphylococcus aureus protein A, allowing the bacterium to evade the host’s adaptive immune response. In contrast, the IgG3 subclass is not bound by protein A and can be used to treat S. aureus infections, including drug-resistant strains such as methicillin-resistant Staphylococcus aureus (MRSA). However, the yields of recombinant IgG3 are generally low because this subclass is prone to degradation, and recovery is hindered by the inability to use protein A as an affinity ligand for antibody purification. Here, we investigated plants (Nicotiana spp.) as an alternative to microbes and mammalian cell cultures for the production of an IgG3 antibody specific for the S. aureus alpha toxin. We targeted recombinant IgG3 to different subcellular compartments and tested different chromatography conditions to improve recovery and purification. Finally, we tested the antigen-binding capacity of the purified antibodies. The highest IgG3 levels in planta (>130 mg kg−1 wet biomass) were achieved by targeting the endoplasmic reticulum or apoplast. Although the purity of IgG3 exceeded 95% following protein G chromatography, product recovery requires further improvement. Importantly, the binding affinity of the purified antibodies was in the nanomolar range and thus comparable to previous studies using murine hybridoma cells as the production system.

Long-Term Effects of an Intensive Prevention Program After Acute Myocardial Infarction

Effective long-term prevention after myocardial infarction (MI) is crucial to reduce recurrent events. In this study the effects of a 12-months intensive prevention program (IPP), based on repetitive contacts between non-physician "prevention assistants" and patients, were evaluated. Patients after MI were randomly assigned to the IPP versus usual care (UC). Effects of IPP on risk factor control, clinical events and costs were investigated after 24 months. In a substudy efficacy of short reinterventions after more than 24 months ("Prevention Boosts") was analyzed. IPP was associated with a significantly better risk factor control compared to UC after 24 months and a trend towards less serious clinical events (12.5% vs 20.9%, log-rank p = 0.06). Economic analyses revealed that already after 24 months cost savings due to event reduction outweighted the costs of the prevention program (costs per patient 1,070 € in IPP vs 1,170 € in UC). Short reinterventions ("Prevention Boosts") more than 24 months after MI further improved risk factor control, such as LDL cholesterol and blood pressure lowering. In conclusion, IPP was associated with numerous beneficial effects on risk factor control, clinical events and costs. The study thereby demonstrates the efficacy of preventive long-term concepts after MI, based on repetitive contacts between non-physician coworkers and patients.

Quality of life in men and women with heart failure: association with outcome, and comparison between the Kansas City Cardiomyopathy Questionnaire and the EuroQol 5 dimensions questionnaire

Aims

We sought to analyse quality of life (QoL) measures derived from two questionnaires widely used in clinical trials, the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the EuroQoL 5 dimensions (EQ‐5D), and to compare their prognostic value in men and women with heart failure and reduced ejection fraction (HFrEF).

Methods and results

From the BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT‐CHF) we compared KCCQ and EQ‐5D at baseline and after 9 months in 1276 men and 373 women with new‐onset or worsening symptoms of HFrEF, who were sub‐optimally treated and in whom there was an anticipated up‐titration of guideline‐derived medical therapies. Women had significantly worse baseline QoL (median) as compared with men, both when assessed with KCCQ overall score (KCCQ‐OS, 44 vs. 53, P < 0.001) and EQ‐5D utility score (0.62 vs. 0.73, P < 0.001). QoL improved equally in women and men at follow‐up. All summary measures of QoL were independently associated with all‐cause mortality, with KCCQ‐OS showing the most remarkable association with mortality up to 1 year compared to the EQ‐5D scores (C‐statistic 0.650 for KCCQ‐OS vs. 0.633 and 0.599 for EQ‐5D utility score and EQ‐5D visual analogue scale, respectively). QoL was associated with all outcomes analysed, both in men and women (all P for interaction with sex >0.2).

Conclusion

Amongst patients with HFrEF, women reported significantly worse QoL than men. QoL was independently associated with subsequent outcome, similarly in men and women. The KCCQ in general, and the KCCQ‐OS in particular, showed the strongest independent association with outcome.

Long-term effects of an intensive prevention program (IPP) after acute myocardial infarction – the IPP Follow-up and Prevention Boost Trial

Background

The effects of an intensive prevention program (IPP) for 12 months following 3-week rehabilitation after myocardial infarction (MI) have been proven by the randomized IPP trial. The present study investigates if the effects of IPP persist one year after termination of the program and if a reintervention after &gt;24 months (“prevention boost”) is effective.

Methods

In the IPP trial patients were recruited during hospitalization for acute MI and randomly assigned to IPP versus usual care (UC) one month after discharge (after 3-week rehabilitation). IPP was coordinated by non-physician prevention assistants and included intensive group education sessions, telephone calls, telemetric and clinical control of risk factors. Primary study endpoint was the IPP Prevention Score, a sum score evaluating six major risk factors. The score ranges from 0 to 15 points, with a score of 15 points indicating best risk factor control.

In the present study the effects of IPP were investigated after 24 months – one year after termination of the program. Thereafter, patients of the IPP study arm with at least one insufficiently controlled risk factor were randomly assigned to a 2-months reintervention (“prevention boost”) vs. no reintervention.

Results

At long-term follow-up after 24 months, 129 patients of the IPP study arm were compared to 136 patients of the UC study arm. IPP was associated with a significantly better risk factor control compared to UC at 24 months (IPP Prevention Score 10.9±2.3 points in the IPP group vs. 9.4±2.3 points in the UC group, p&lt;0.01). However, in the IPP group a decrease of risk factor control was observed at the 24-months visit compared to the 12-months visit at the end of the prevention program (IPP Prevention Score 10.9±2.3 points at 24 months vs. 11.6±2.2 points at 12 months, p&lt;0.05, Figure 1).

A 2-months reintervention (“prevention boost”) was effective to improve risk factor control during long-term course: IPP Prevention Score increased from 10.5±2.1 points to 10.7±1.9 points in the reintervention group, while it decreased from 10.5±2.1 points to 9.7±2.1 points in the group without reintervention (p&lt;0.05 between the groups, Figure 1).

Conclusions

IPP was associated with a better risk factor control compared to UC during 24 months; however, a deterioration of risk factors after termination of IPP suggests that even a 12-months prevention program is not long enough. The effects of a short reintervention after &gt;24 months (“prevention boost”) indicate the need for prevention concepts that are based on repetitive personal contacts during long-term course after coronary events.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Stiftung Bremer Herzen (Bremen Heart Foundation)

Living with a left ventricular assist device: psychological burden and coping: protocol for a cross-sectional and longitudinal qualitative study

INTRODUCTION

Due to technological progress and persistent shortage of donor hearts, left ventricular assist devices (LVADs) have become established in the treatment of advanced heart failure. Accordingly, more patients live with LVADs for prolonged periods. Related research focused primarily on clinical issues and little is known about psychosocial aspects of living with an LVAD. This study aims to explore psychological burden and coping following LVAD implantation.

METHODS AND ANALYSIS

An exploratory qualitative study with cross-sectional and longitudinal elements will be carried out. At least 18 patients with LVAD who have the device implanted from a few weeks to more than 3 years will be interviewed in the cross-sectional component using an interview guide. A subsample of patients who live with the LVAD for up to 3 months when recruited will be interviewed two additional times in the following year. The cross-sectional interviews will be analysed using an inductive qualitative content analysis to describe psychological burden, coping resources and behaviour from the patient's perspective. Based on the findings, the longitudinal interviews will be analysed with a deductive content analysis to explore psychological adjustment during the first year after implantation. The findings will provide a deeper understanding of the complex and specific situation of patients with LVAD and of psychological adjustment to living with a life-sustaining implant. This can help clinicians in considering individual aspects to promote patient outcomes and is the basis for further research on healthcare interventions or technical solutions to reduce burden and for developing rehabilitation measures to promote psychosocial outcomes.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the ethics committee of the School of Medicine and Health Sciences at the University of Oldenburg (2019-023). Study findings will be disseminated at national and international conferences and through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register (DRKS00016883).

The validity of self-rated psychotic symptoms in depressed inpatients

Background

Self-ratings of psychotic experiences might be biased by depressive symptoms.

Method

Data from a large naturalistic multicentre trial on depressed inpatients (n = 488) who were assessed on a biweekly basis until discharge were analyzed. Self-rated psychotic symptoms as assessed with the 90-Item Symptom Checklist (SCL-90) were correlated with the SCL-90 total score, the SCL-90 depression score, the Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale 21 item (HAMD-21) total score, the Montgomery Åsberg Depression Rating Scale (MADRS) total score and the clinician-rated paranoid-hallucinatory score of the Association for Methodology and Documentation in Psychiatry (AMDP) scale.

Results

At discharge the SCL-90 psychosis score correlated highest with the SCL-90 depression score (0.78, P<0.001) and with the BDI total score (0.64, P<0.001). Moderate correlations were found for the MADRS (0.34, P<0.001), HAMD (0.37, P<0.001) and AMDP depression score (0.33, P<0.001). Only a weak correlation was found between the SCL-90 psychosis score and the AMDP paranoid-hallucinatory syndrome score (0.15, P<0.001). Linear regression showed that change in self-rated psychotic symptoms over the treatment course was best explained by a change in the SCL-90 depression score (P<0.001). The change in clinician-rated AMDP paranoid-hallucinatory score had lesser influence (P = 0.02).

Conclusions

In depressed patients self-rated psychotic symptoms correlate poorly with clinician-rated psychotic symptoms. Caution is warranted when interpreting results from epidemiological surveys using self-rated psychotic symptom questionnaires as indicators of psychotic symptoms. Depressive symptoms which are highly prevalent in the general population might influence such self-ratings.

Does depression explain poor effort on Symptom Validity Tests (SVT)?

Background and aims

Valid assessments require sufficient effort from the part of the testee. Motivation may be compromised, particularly in psychiatric conditions. We examined associations between response bias on free recall and self-reported symptoms in depressed and PTSD patients.

Participants and methods

This is a cross-sectional study. Patients had depression (n = 48), or PTSD or other anxiety disorders (n = 37). A control group (n = 47%) had chronic pain disorder, fibromyalgia or chronic fatigue. The Green Word Memory Test (GWMT) was administered to all subjects. The Structured Inventory of Malingered. Symptomatology (SIMS), and the Beck Depression Inventory (BDI-II) were administered in subsamples. Study outcome was self-reported depressive symptoms in Symptom Validity Test (SVT) negative cases.

Results

Average age of the participants was 45.1 years (SD 9.5), 48.5% were female. GWMT was positive in 52.3% of all cases, GWMT and SIMS were positive in 33.8%, and GWMT and SIMS were negative in 37.7%. No significant group effects on GWMT were found. Average BDI-II scores were 32.8 (SD 13.9) for depressed patients, 28.3 (15.5) for those with anxiety disorders, and 27.6 (14.1) for controls (P = 0.43). Seventy-eight percent of depressed GWMT negative cases reported at least moderate depressive symptoms (BDI-II > 18), and 44.4% severe symptoms (BDI-II > 29). Approximately half of the GWMT negative cases with anxiety disorders and controls scored BDI-II > 18.

Conclusions

Non credible test performance is prevalent in disability claimants with affective, mood disorders. However, depressive symptoms per se do not explain poor effort on cognitive tasks.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Identifying optimal doses of heart failure medications in men compared with women: a prospective, observational, cohort study

BACKGROUND

Guideline-recommended doses of angiotensin-converting-enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs), and β blockers are similar for men and women with heart failure with reduced ejection fraction (HFrEF), even though there are known sex differences in pharmacokinetics of these drugs. We hypothesised that there might be sex differences in the optimal dose of ACE inhibitors or ARBs and β blockers in patients with HFrEF.

METHODS

We did a post-hoc analysis of BIOSTAT-CHF, a prospective study in 11 European countries of patients with heart failure in whom initiation and up-titration of ACE inhibitors or ARBs and β blockers was encouraged by protocol. We included only patients with left ventricular ejection fraction less than 40%, and excluded those who died within the first 3 months. Primary outcome was a composite of time to all-cause mortality or hospitalisation for heart failure. Findings were validated in ASIAN-HF, an independent cohort of 3539 men and 961 women with HFrEF.

FINDINGS

Among 1308 men and 402 women with HFrEF from BIOSTAT-CHF, women were older (74 [12] years vs 70 [12] years, p<0·0001) and had lower bodyweights (72 [16] kg vs 85 [18] kg, p<0·0001) and heights (162 [7] cm vs 174 [8] cm, p<0·0001) than did men, although body-mass index did not differ significantly. A similar number of men and women reached guideline-recommended target doses of ACE inhibitors or ARBs (99 [25%] vs 304 [23%], p=0·61) and β blockers (57 [14%] vs 168 [13%], p=0·54). In men, the lowest hazards of death or hospitalisation for heart failure occurred at 100% of the recommended dose of ACE inhibitors or ARBs and β blockers, but women showed approximately 30% lower risk at only 50% of the recommended doses, with no further decrease in risk at higher dose levels. These sex differences were still present after adjusting for clinical covariates, including age and body surface area. In the ASIAN-HF registry, similar patterns were observed for both ACE inhibitors or ARBs and β blockers, with women having approximately 30% lower risk at 50% of the recommended doses, with no further benefit at higher dose levels.

INTERPRETATION

This study suggests that women with HFrEF might need lower doses of ACE inhibitors or ARBs and β blockers than men, and brings into question what the true optimal medical therapy is for women versus men.

FUNDING

European Commission.

Internal Versus External Electrical Cardioversion of Atrial Arrhythmia in Patients With Implantable Cardioverter-Defibrillator: A Randomized Clinical Trial

BACKGROUND

Atrial arrhythmias are common in patients with implantable cardioverter-defibrillator (ICD). External shocks and internal cardioversion through commanded ICD shock for electrical cardioversion are used for rhythm-control. However, there is a paucity of data on efficacy of external versus internal cardioversion and on the risk of lead and device malfunction. We hypothesized that external cardioversion is noninferior to internal cardioversion for safety, and superior for successful restoration of sinus rhythm.

METHODS

Consecutive patients with ICD undergoing elective cardioversion for atrial arrhythmias at 13 centers were randomized in 1:1 fashion to either internal or external cardioversion. The primary safety end point was a composite of surrogate events of lead or device malfunction. Conversion of atrial arrhythmia to sinus rhythm was the primary efficacy end point. Myocardial damage was studied by measuring troponin release in both groups.

RESULTS

N=230 patients were randomized. Shock efficacy was 93% in the external cardioversion group and 65% in the internal cardioversion group (P<0.001). Clinically relevant adverse events caused by external or internal cardioversion were not observed. Three cases of pre-existing silent lead malfunction were unmasked by internal shock, resulting in lead failure. Troponin release did not differ between groups.

CONCLUSIONS

This is the first randomized trial on external vs internal cardioversion in patients with ICDs. External cardioversion was superior for the restoration of sinus rhythm. The unmasking of silent lead malfunction in the internal cardioversion group suggests that an internal shock attempt may be reasonable in selected ICD patients presenting for electrical cardioversion.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT03247738.

Microscopic origin of highly enhanced current carrying capabilities of thin NdFeAs(O,F) films

Fe-based superconductors present a large variety of compounds whose physical properties strongly depend on the crystal structure and chemical composition. Among them, the so-called 1111 compounds show the highest critical temperature T _c in the bulk form. Here we demonstrate the realization of excellent superconducting properties in NdFeAs(O_1-x F _x ). We systematically investigated the correlation between the microstructure at the nanoscale and superconductivity in an epitaxial 22 nm NdFeAs(O_1-x F _x ) thin film on a MgO single crystalline substrate (T _c = 44.7 K). Atomic resolution analysis of the microstructure by transmission electron microscopy and atom probe tomography identified several defects and other inhomogeneities at the nanoscale that can act as extrinsic pinning centers. X-Ray diffraction and transmission electron microscopy displayed a broad variation of the a-axis lattice parameter either due to a partially strained layer at the interface to the substrate, high local strain at dislocation arrays, mosaicity, or due to composition variation within the film. The electrical transport properties are substantially affected by intrinsic pinning and a matching field corresponding to the film thickness and associated with the Bean-Livingston surface barrier of the surfaces. The thin film showed a self-field critical current density J _c(4.2 K) of ∼7.6 MA cm^-2 and a record pinning force density of F _p ≈ 1 TN m^-3 near 35 T for H‖ab at 4.2 K. These investigations highlight the role of the microstructure in fine-tuning and possibly functionalizing the superconductivity of Fe-based superconductors.

Plasma levels of the oxyphytosterol 7α-hydroxycampesterol are associated with cardiovascular events

BACKGROUND AND AIMS

There are safety issues regarding plant sterol ester-enriched functional food. Oxidized plant sterols, also called oxyphytosterols, are supposed to contribute to plant sterol atherogenicity. This study aimed to analyze associations of plasma oxyphytosterol levels with cardiovascular events.

METHODS

Plasma cholesterol was measured by gas chromatography-flame ionization detection. Plasma campesterol and sitosterol and their 7-oxygenated metabolites were analyzed by gas chromatography-mass selective detection.

RESULTS

In 376 patients admitted for elective coronary angiography, who were not on lipid-lowering drugs, 82 cardiovascular events occurred during a follow-up period of 4.2 ± 1.8 years. Patients with cardiovascular events had significantly higher 7α-hydroxycampesterol plasma levels (median, 0.46; [interquartile range (IQR) 0.22-0.81] nmol/L vs. median, 0.25 [IQR, 0.17-0.61] nmol/L; p = 0.003) and 7α-hydroxycampesterol-to-cholesterol ratios (median 0.08 [IQR, 0.04-0.14] nmol/mmol vs. median, 0.05 [IQR 0.03-0.11] nmol/mmol; p = 0.005) than controls without such events. Patients above the median were characterized by higher cumulative event rates in Kaplan-Meier-analysis (Logrank-test p = 0.084 and p = 0.025) for absolute and cholesterol corrected 7α-hydroxycampesterol, respectively. After adjustment for influencing factors and related lipids, the hazard ratios per one standard deviation of the log-transformed variables (HR) were 1.19 [95% confidence interval (CI), 0.95-1.48], p = 0.132 for 7α-hydroxycampesterol and HR, 1.18 [95% CI, 0.94-1.48], p = 0.154 for 7α-hydroxycampesterol-to-cholesterol ratio. None of the other investigated oxyphytosterols showed an association with cardiovascular events.

CONCLUSIONS

In patients not on lipid-lowering drugs, absolute plasma levels of 7α-hydroxycampesterol and their ratios to cholesterol are associated with cardiovascular events. Further research is required to elucidate the role of OPS in cardiovascular diseases.

Direct Frequency-Comb-Driven Raman Transitions in the Terahertz Range

We demonstrate the use of a femtosecond frequency comb to coherently drive stimulated Raman transitions between terahertz-spaced atomic energy levels. More specifically, we address the 3d ^{2}D_{3/2} and 3d ^{2}D_{5/2} fine structure levels of a single trapped ^{40}Ca^{+} ion and spectroscopically resolve the transition frequency to be ν_{D}=1,819,599,021,534±8  Hz. The achieved accuracy is nearly a factor of five better than the previous best Raman spectroscopy, and is currently limited by the stability of our atomic clock reference. Furthermore, the population dynamics of frequency-comb-driven Raman transitions can be fully predicted from the spectral properties of the frequency comb, and Rabi oscillations with a contrast of 99.3(6)% and millisecond coherence time have been achieved. Importantly, the technique can be easily generalized to transitions in the sub-kHz to tens of THz range and should be applicable for driving, e.g., spin-resolved rovibrational transitions in molecules and hyperfine transitions in highly charged ions.

Effects of an intensive long-term prevention programme after myocardial infarction - a randomized trial

BACKGROUND

Long-term risk factor control after myocardial infarction (MI) is currently inadequate and there is an unmet need for effective secondary prevention programmes.

DESIGN AND METHODS

It was the aim of the study to compare a 12-month intensive prevention programme (IPP), coordinated by prevention assistants and including education sessions, telephone visits and telemetric risk factor control, with usual care after MI. Three hundred and ten patients were randomized to IPP vs. usual care one month after hospital discharge for MI in two German heart centres. Primary study endpoint was the IPP Prevention Score (0-15 points) quantifying global risk factor control.

RESULTS

Global risk factor control was strongly improved directly after MI before the beginning of the randomized study (30% increase IPP Prevention Score). During the 12-month course of the randomized trial the IPP Prevention Score was improved by a further 14.3% in the IPP group ( p < 0.001), while it decreased by 11.8% in the usual care group ( p < 0.001). IPP significantly reduced smoking, low-density lipoprotein cholesterol, systolic blood pressure and physical inactivity compared with usual care ( p < 0.05). Step counters with online documentation were used by the majority of patients (80%). Quality of life was significantly improved by IPP ( p < 0.05). The composite endpoint of adverse clinical events was slightly lower in the IPP group during 12 months (13.8% vs. 18.9%, p = 0.25).

CONCLUSIONS

A novel intensive prevention programme after MI, coordinated by prevention assistants and using personal teachings and telemetric strategies for 12 months, was significantly superior to usual care in providing sustainable risk factor control and better quality of life.

Controlling the Local Electronic Properties of Si(553)-Au through Hydrogen Doping

We propose a quantitative and reversible method for tuning the charge localization of Au-stabilized stepped Si surfaces by site-specific hydrogenation. This is demonstrated for Si(553)-Au as a model system by combining density functional theory simulations and reflectance anisotropy spectroscopy experiments. We find that controlled H passivation is a two-step process: step-edge adsorption drives excess charge into the conducting metal chain "reservoir" and renders it insulating, while surplus H recovers metallic behavior. Our approach illustrates a route towards microscopic manipulation of the local surface charge distribution and establishes a reversible switch of site-specific chemical reactivity and magnetic properties on vicinal surfaces.

Preliminary report: Surgical outcomes following genitoplasty in children with moderate to severe genital atypia

INTRODUCTION

Prior studies of outcomes following genitoplasty have reported high rates of surgical complications among children with atypical genitalia. Few studies have prospectively assessed outcomes after contemporary surgical approaches.

OBJECTIVE

The current study reported the occurrence of early postoperative complications and of cosmetic outcomes (as rated by surgeons and parents) at 12 months following contemporary genitoplasty procedures in children born with atypical genitalia.

STUDY DESIGN

This 11-site, prospective study included children aged ≤2 years, with Prader 3-5 or Quigley 3-6 external genitalia, with no prior genitoplasty and non-urogenital malformations at the time of enrollment. Genital appearance was rated on a 4-point Likert scale. Paired t-tests evaluated differences in cosmesis ratings.

RESULTS

Out of 27 children, 10 were 46,XY patients with the following diagnoses: gonadal dysgenesis, PAIS or testosterone biosynthetic defect, severe hypospadias and microphallus, who were reared male. Sixteen 46,XX congenital adrenal hyperplasia patients were reared female and one child with sex chromosome mosaicism was reared male. Eleven children had masculinizing genitoplasty for penoscrotal or perineal hypospadias (one-stage, three; two-stage, eight). Among one-stage surgeries, one child had meatal stenosis (minor) and one developed both urinary retention (minor) and urethrocutaneous fistula (major) (Summary Figure). Among two-stage surgeries, three children developed a major complication: penoscrotal fistula, glans dehiscence or urethral dehiscence. Among 16 children who had feminizing genitoplasty, vaginoplasty was performed in all, clitoroplasty in nine, external genitoplasty in 13, urethroplasty in four, perineoplasty in five, and total urogenital sinus mobilization in two. Two children had minor complications: one had a UTI, and one had both a mucosal skin tag and vaginal mucosal polyp. Two additional children developed a major complication: vaginal stenosis. Cosmesis scores revealed sustained improvements from 6 months post-genitoplasty, as previously reported, with all scores reported as good or satisfied.

DISCUSSION

In these preliminary data from a multi-site, observational study, parents and surgeons were equally satisfied with the cosmetic outcomes 12 months after genitoplasty. A small number of patients had major complications in both feminizing and masculinizing surgeries; two-stage hypospadias repair had the most major complications. Long-term follow-up of patients at post-puberty will provide a better assessment of outcomes in this population.

CONCLUSION

In this cohort of children with moderate to severe atypical genitalia, preliminary data on both surgical and cosmetic outcomes were presented. Findings from this study, and from following these children in long-term studies, will help guide practitioners in their discussions with families about surgical management.

Cholesterol Absorption and Synthesis in Vegetarians and Omnivores

SCOPE

Vegetarian diets are considered health-promoting; however, a plasma cholesterol lowering effect is not always observed. We investigate the link between vegetarian-diet-induced alterations in cholesterol metabolism.

METHODS AND RESULTS

We study male and female omnivores, lacto-ovo vegetarians, lacto vegetarians, and vegans. Cholesterol intake, absorption, and fecal sterol excretion are measured as well as plasma concentrations of cholesterol and noncholesterol sterols. These serve as markers for cholesterol absorption, synthesis, and catabolism. The biliary cholesterol secretion rate is estimated. Flux data are related to body weight. Individual vegetarian diet groups are statistically compared to the omnivore group. Lacto vegetarians absorb 44% less dietary cholesterol, synthesized 22% more cholesterol, and show no differences in plasma total and LDL cholesterol. Vegan subjects absorb 90% less dietary cholesterol, synthesized 35% more cholesterol, and have a similar plasma total cholesterol, but a 13% lower plasma LDL cholesterol. No diet-related differences in biliary cholesterol secretion and absorption are observed. Total cholesterol absorption is lower only in vegans. Total cholesterol input is similar under all vegetarian diets.

CONCLUSIONS

Unaltered biliary cholesterol secretion and higher cholesterol synthesis blunt the lowered dietary cholesterol intake in vegetarians. LDL cholesterol is significantly lower only in vegans.

A typical diffusion monitored by flow cytometry: slow diffusion of small molecules in polyelectrolyte multilayers

An innovative approach has been developed to measure small molecule diffusion in polyelectrolyte multilayers (PEMs) assembled on colloidal particles by means of flow cytometry (FACS). FACS allows changes in fluorescence emission as a function of time to be recorded per particle in a colloidal dispersion. Dithionite, S₂O₄^2-, diffusion in PEMs composed of polyallylamine hydrochloride (PAH) and poly styrene sulfonate (PSS) assembled on silica particles has been studied by recording the quenching of (7-nitrobenz-2-oxa-1,3-diazol-4yl)amino (NBD) labelled PAH layers by FACS. NBD is reduced when it encounters dithionite, and is therefore no longer fluorescent. The decay in fluorescence will be used to follow the kinetics of dithionite diffusion. The fluorescence decay curves show slow diffusion that does not follow classical Fickean law. However, by assuming that the diffusion coefficient is time dependent and follows an inverse power law in an atypical diffusion case, it was possible to obtain an excellent fit for the decay curves.

Single-cell analysis by ICP-MS/MS as a fast tool for cellular bioavailability studies of arsenite

A fast and reliable single-cell ICP-MS/MS method is presented to determine the bioavailability of metal species as well as sulfur and phosphorus as internal control after re-suspension of cells in water.

Electrical cardioversion of patients with implanted pacemaker or cardioverter-defibrillator: results of a survey of german centers and systematic review of the literature

AIMS

A relevant number of patients presenting for electrical cardioversion carry a pacemaker (PM) or ICD. Case reports suggest a potential hazard of external cardioversion/defibrillation. The incidence of shock related device complications is unknown. No guidelines or recommendations by international medical societies for a cardioversion protocol of cardiovascular implantable electronic device (CIED) patients exist. We conducted a nationwide survey to gather real-world clinical data on the current clinical approach towards these patients during electrical cardioversion and to estimate the incidence of shock-related complications.

METHODS AND RESULTS

Ninety hospitals with > 380 ECV in 2014 were identified from mandatory hospital quality reports and 60 were randomly selected. All centers were provided with a standardized questionnaire on the general proceedings and complications during electrical cardioversion of pacemaker, ICD and CRT patients (CIED patients). Thirty-two centers (53%) participated in the survey. In total, 16,554 ECV were reported (534 ± 314 per center). Biphasic cardioversion with a first shock energy of ≥ 150 J via adhesive patches in antero-posterior orientation was preferred by most centers (78%). Eleven percent (n = 1809) of pts were reported to carry a PM/ICD. The ECV protocol was heterogeneous among centers. Complications associated with electrical cardioversion were reported in 11/1809 patients (0.6%), all were transitory elevations of pacing thresholds.

CONCLUSIONS

In this nationwide snapshot survey of cardioversion procedures in Germany, approximately 11% of patients presenting for elective electrical cardioversion were pacemaker or ICD carriers. Cardioversion protocols in these patients are heterogeneous throughout centers and mostly not in accordance with recommendation of the German Cardiac Society. Complications associated with external electrical cardioversion are rare. Controlled trials and large registries are necessary to provide evidence for future recommendations.

Influence of hydrostatic pressure on intracoronary indices of stenosis severity in vivo

BACKGROUND

An influence of hydrostatic pressure on intracoronary indices of stenosis severity in vitro was recently reported. We sought to analyze the influence of hydrostatic pressure, caused by the height difference between the distal and proximal pressure sensor after guidewire positioning in the interrogated vessel, on intracoronary pressure measurements in vivo.

METHODS AND RESULTS

In 30 coronary stenoses, intracoronary pressure measurements were performed in supine, left, and right lateral patient position. Height differences between the distal and proximal pressure sensor were measured by blinded observers. Measurement results of the position with the highest ("high") and lowest height difference ("low") were compared. In group "high", all measured indices were higher: mean difference of fractional flow reserve (FFR) 0.045 (SD 0.033, 95% CI 0.033-0.057, p < 0.0001), of instantaneous wave-free ratio (iFR) 0.043 (SD 0.04, 95% CI 0.029-0.057, p < 0.0001), and of resting Pd/Pa 0.037 (SD 0.034, 95% CI 0.025-0.049, p < 0.0001). Addition of the physically expectable hydrostatic pressure to the distal coronary pressures of the control group abolished the differences: corrected ∆FFR - 0.006 (SD 0.027, 95% CI - 0.015 to 0.004, p = 0.26), corrected ∆Pd/Pa - 0.008 (SD 0.03, 95% CI - 0.019 to 0.003, p = 0.18). Adjustment for hydrostatic pressure of FFR values in a standard supine position increased all values in anterior vessels and decreased all values in posterior vessels. The mean changes of FFR due to adjustment were: LAD - 0.048 (SD 0.016), CX 0.02 (SD 0.009), RCA 0.02 (SD 0.021). Dichotomous severity classification changed in 12.9% of stenoses.

CONCLUSIONS

The study demonstrates a relevant influence of hydrostatic pressure on intracoronary indices of stenosis severity in vivo, caused by the height differences between distal and proximal pressure sensor.

Effects of arsenolipids on in vitro blood-brain barrier model

Arsenic-containing hydrocarbons (AsHCs), a subgroup of arsenolipids (AsLs) occurring in fish and edible algae, possess a substantial neurotoxic potential in fully differentiated human brain cells. Previous in vivo studies indicating that AsHCs cross the blood-brain barrier of the fruit fly Drosophila melanogaster raised the question whether AsLs could also cross the vertebrate blood-brain barrier (BBB). In the present study, we investigated the impact of several representatives of AsLs (AsHC 332, AsHC 360, AsHC 444, and two arsenic-containing fatty acids, AsFA 362 and AsFA 388) as well as of their metabolites (thio/oxo-dimethylpropionic acid, dimethylarsinic acid) on porcine brain capillary endothelial cells (PBCECs, in vitro model for the blood-brain barrier). AsHCs exerted the strongest cytotoxic effects of all investigated arsenicals as they were up to fivefold more potent than the toxic reference species arsenite (iAs^III). In our in vitro BBB-model, we observed a slight transfer of AsHC 332 across the BBB after 6 h at concentrations that do not affect the barrier integrity. Furthermore, incubation with AsHCs for 72 h led to a disruption of the barrier at sub-cytotoxic concentrations. The subsequent immunocytochemical staining of three tight junction proteins revealed a significant impact on the cell membrane. Because AsHCs enhance the permeability of the in vitro blood-brain barrier, a similar behavior in an in vivo system cannot be excluded. Consequently, AsHCs might facilitate the transfer of accompanying foodborne toxicants into the brain.

Observation of the spin Nernst effect

The observation of the spin Hall effect triggered intense research on pure spin current transport. With the spin Hall effect, the spin Seebeck effect and the spin Peltier effect already observed, our picture of pure spin current transport is almost complete. The only missing piece is the spin Nernst (-Ettingshausen) effect, which so far has been discussed only on theoretical grounds. Here, we report the observation of the spin Nernst effect. By applying a longitudinal temperature gradient, we generate a pure transverse spin current in a Pt thin film. For readout, we exploit the magnetization-orientation-dependent spin transfer to an adjacent yttrium iron garnet layer, converting the spin Nernst current in Pt into a controlled change of the longitudinal and transverse thermopower voltage. Our experiments show that the spin Nernst and the spin Hall effect in Pt are of comparable magnitude, but differ in sign, as corroborated by first-principles calculations.

Ectoine can enhance structural changes in DNA in vitro

Strand breaks and conformational changes of DNA have consequences for the physiological role of DNA. The natural protecting molecule ectoine is beneficial to entire bacterial cells and biomolecules such as proteins by mitigating detrimental effects of environmental stresses. It was postulated that ectoine-like molecules bind to negatively charged spheres that mimic DNA surfaces. We investigated the effect of ectoine on DNA and whether ectoine is able to protect DNA from damages caused by ultraviolet radiation (UV-A). In order to determine different isoforms of DNA, agarose gel electrophoresis and atomic force microscopy experiments were carried out with plasmid pUC19 DNA. Our quantitative results revealed that a prolonged incubation of DNA with ectoine leads to an increase in transitions from supercoiled (undamaged) to open circular (single-strand break) conformation at pH 6.6. The effect is pH dependent and no significant changes were observed at physiological pH of 7.5. After UV-A irradiation in ectoine solution, changes in DNA conformation were even more pronounced and this effect was pH dependent. We hypothesize that ectoine is attracted to the negatively charge surface of DNA at lower pH and therefore fails to act as a stabilizing agent for DNA in our in vitro experiments.

An axis-specific rotational rainbow in the direct scatter of formaldehyde from Au(111) and its influence on trapping probability

The conversion of translational to rotational motion often plays a major role in the trapping of small molecules at surfaces, a crucial first step for a wide variety chemical processes that occur at gas-surface interfaces. However, to date most quantum-state resolved surface scattering experiments have been performed on diatomic molecules, and little detailed information is available about how the structure of nonlinear polyatomic molecules influences the mechanisms for energy exchange with surfaces. In the current work, we employ a new rotationally resolved 1 + 1' resonance-enhanced multiphoton ionization (REMPI) scheme to measure the rotational distribution in formaldehyde molecules directly scattered from the Au(111) surface at incidence kinetic energies in the range 0.3-1.2 eV. The results indicate a pronounced propensity to excite a-axis rotation (twirling) rather than b- or c-axis rotation (tumbling or cartwheeling), and are consistent with a rotational rainbow scattering model. Classical trajectory calculations suggest that the effect arises-to zeroth order-from the three-dimensional shape of the molecule (steric effects). Analysis suggests that the high degree of rotational excitation has a substantial influence on the trapping probability of formaldehyde at incidence translational energies above 0.5 eV.