Man-machine interaction-based phenotyping preprocedurally identifies patients with severe aortic stenosis, who will not recover from cardiac damage following transcatheter aortic valve replacement

Background

Severe aortic stenosis (AS) can lead to left heart dysfunction, pulmonary hypertension (PH), and eventually right heart failure. Clinical phenotypes therefore appear heterogeneous, depending on disease progression and comorbidities.

Purpose

This study therefore sought to improve diagnostic and prognostic resolution in patients undergoing transcatheter aortic valve replacement (TAVR) for severe AS by developing a man-machine interaction-based phenotyping approach.

Methods

Unsupervised agglomerative clustering was applied to preprocedural data from echocardiography and right heart catheterization from 366 consecutively enrolled patients undergoing TAVR for severe AS. Echocardiographic follow-up data, obtained on day 147±75.1 after TAVR, were available from 247 patients (67.5%).

Results

Cluster analysis revealed four distinct phenotypes, reflecting various extents of disease severity, and hence differing in mortality.

Patients from cluster 1 presented with preserved left ventricular ejection fraction (LVEF; 57.2±6.4%) and with normal mean pulmonary artery pressure (mPAP) levels (21.2±6.5 mmHg).

In contrast, patients in cluster 2 suffered from postcapillary PH (mPAP: 34.2±7.8 mmHg).

Left heart failure (LVEF: 42.4±15.7%), severe PH (mPAP: 46.9±8.5 mmHg), and right heart dysfunction (tricuspid annular plane systolic excursion [TAPSE]: 16.1±4.57 mm) characterized patients in cluster 3.

Patients from cluster 4 showed mild postcapillary PH (mPAP: 27.5±9.2 mmHg), yet dilatation of all heart chambers, biventricular dysfunction (LVEF: 47.3±12.2%, TAPSE: 16.8±4.5 mm), and a high prevalence of both mitral and tricuspid regurgitation (12.5% and 14.8%, respectively).

Correction of severe AS by TAVR significantly reduced the proportion of patients suffering from concurrent severe mitral regurgitation (from 9.29% to 3.64%, p-value: 0.0015). Moreover, pulmonary artery pressures were ameliorated (estimated systolic pulmonary artery pressure: from 47.2±15.8 mmHg to 43.3±15.1 mmHg, p-value: 0.0079). However, right heart dysfunction as well as the proportion of patients with severe tricuspid regurgitation remained unchanged. Clusters 3 and 4 with persistent right heart dysfunction ultimately displayed 2-year survival rates of 69.2% (95% CI: 56.6–84.7%) and 74.6% (95% CI: 65.9–84.4%), which were significantly lower compared to clusters 1 and 2 with little or no persistent cardiopulmonary impairment (88.3% [95% CI: 83.3–93.5%] and 85.5% [95% CI: 77.1–94.8%]).

Conclusion

This phenotyping approach preprocedurally identifies patients with severe AS, who will not recover from extra-aortic valve cardiac damage following TAVR and whose survival is therefore significantly reduced. Importantly, not the degree of PH at initial presentation, but the irreversibility of right heart dysfunction determines prognosis.

Funding Acknowledgement

Type of funding sources: None.

Real-time, large-depth holographic 3D head-up display: selected aspects

Today's state-of-the-art automotive head-up displays (HUD) possess single- or double layer focal planes that limit the observers' eye focus to these planes when crucial information is shown. Other visual 3D cues such as motion parallax also suffer from this limitation. The resulting viewing experience contradicts the natural way of viewing during driving or interaction, when alerts and hints should appear at the correct projection depth where real objects of interest are located. Here we present a real-time holographic HUD with continuous depth that supports the intuitive and natural way of viewing and interacting with virtual environments outside and inside the car. We demonstrate full-color, 3D real-time encoding within a field-of-view of 5^∘×3^∘.

Difference in patterns of prescribing antidepressants known for their weight-modulating and cardiovascular side effects for patients with obesity compared to patients with normal weight

BACKGROUND

Patients with depression and comorbid obesity may be more prone to weight modulating and cardiovascular side effects of selected antidepressants (AD). It is important to ascertain whether these AD prescriptions differ by patient weight status.

METHODS

Canadian Primary Care Sentinel Surveillance Network (CPCSSN) electronic medical records were used. Participants were adults with depression prescribed an AD in 2000-2016, with weight categories established before the first prescription. Logistic regression and mixed effects models were applied to examine associations between obesity and AD prescribing, adjusted for sex, age, and comorbidities. Machine learning algorithm random forest (RF) was used to evaluate the importance of weight in predicting prescribing patterns.

RESULTS

Of 26,571 participants, 72.4% were women, mean age was 38.9 years (standard deviation (SD)=14.2) and mean BMI 27.0 kg/m² (SD = 6.5); 9.5% had ≥ 1 comorbidity. Patients with obesity, compared to normal weight patients, were more likely to receive bupropion (adjusted odds ratio (aOR) 1.24, 95%CI: 1.09,1.42), fluoxetine (aOR 1.14, 95%CI: 0.97,1.34), and amitriptyline (aOR 1.13, 95%CI: 0.93,1.36), and less likely to receive mirtazapine (aOR 0.55, 95%CI: 0.44,0.68) and escitalopram (aOR 0.88, 95%CI: 0.80, 0.97). RF analysis showed that weight was among the most important predictors of prescribing patterns, equivalent to age and more important than sex.

CONCLUSIONS

AD prescribing patterns for patients with obesity appear to be different for selected AD types, including AD known for their weight-modulating and cardiovascular side effects. Longitudinal studies are needed to examine whether these prescribing patterns are associated with significant health outcomes.

Sub-phenotyping of patients with severe aortic stenosis undergoing transcatheter aortic valve replacement by unsupervised agglomerative clustering of echocardiographic and hemodynamic data

Background

Severe aortic stenosis (AS) can trigger a deleterious cascade of impairments including left heart dysfunction, pulmonary hypertension (PH), and eventually right heart failure. Clinical phenotypes therefore appear heterogeneous, depending on disease progression and comorbidities.

Purpose

This retrospective analysis aims to categorize patients with severe AS according to clinical presentation by applying unsupervised machine learning in combination with an artificial neural network (ANN).

Methods

Unsupervised agglomerative clustering was applied to pre-procedural data from echocardiography and right heart catheterization from 366 consecutively enrolled patients undergoing transcatheter aortic valve replacement (TAVR) for severe AS at two tertiary centers in Germany between 2014 and 2020. Association between cluster and 2-year all-cause mortality after TAVR was assessed, and an ANN was trained to open the avenue to prospectively predict cluster assignment in future patients.

Results

Cluster analysis revealed four distinct phenotypes, reflecting various extents of disease severity, and hence differing in mortality.

Patients from cluster 1, constituting the majority of cases and hereinafter referred to as reference, presented with regular cardiac function and without PH. Accordingly, estimated 2-year survival was 90.6% (95% CI: 85.8–95.6%).

Contrarily, patients from smallest cluster 3 displayed most extensive disease characteristics, i.e. left and right heart dysfunction together with combined pre- and postcapillary PH, and their 2-year mortality was increased (2-year survival: 77.3% (95% CI: 65.2–91.6%), HR for 2-year mortality: 2.6 (95% CI: 1.1–6.2); p-value: 0.025).

Clusters 2 and 4 comprised patients suffering from postcapillary PH. Whilst patients from cluster 2 showed similar survival as cluster 1 (2-year survival: 85.8% (95% CI: 76.9–95.6%)), patients from cluster 4 with right atrial enlargement and high prevalence of severe tricuspid regurgitation (TR) deceased more often (2-year survival: 74.9% (95% CI: 65.9–85.2%), HR for 2-year mortality: 2.8 (95% CI: 1.4–5.5); p-value: 0.004).

After randomly dividing the study population into derivation and validation cohorts, an ANN could precisely predict cluster assignment (accuracy: 83.5%), significantly outperforming the no information rate (46.8%; p-value: 2.26e-15). Importantly, patients from high-risk clusters 3 and 4 were detected with high sensitivity (100.0% and 85.2%, respectively) and specificity (95.9% and 95.1%, respectively).

Conclusion

Expanding the analytical armamentarium by machine learning technology aids in capturing complex clinical presentations as observed in patients with severe AS. Assigning patients to clusters can thus facilitate a more sophisticated risk stratification in future clinical practice. Addressing irreversibility of PH and persistence of severe TR after TAVR should obtain paramount priority in order to improve long-term survival.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Mark Lachmann receives funding from Technical University of Munich (Clinician Scientist Grant).

AB1110 QUANTUM BLUE® RAPID TDM ASSAY STANDARDIZATION HIGHLY CORRELATES WITH WHO INTERNATIONAL STANDARD FOR INFLIXIMAB

Background:

Therapeutic drug monitoring of RA patients under anti-TNF therapy is based on trough level determination of the drug. Rapid assays and multiple ELISAs are available that measure anti-TNF biologics. An international standard is required to improve comparability among different assays. Recently, WHO introduced a series of anti-TNF standards for etanercept, adalimumab and infliximab. This is the first step for achieving common standardisation of assays available on the market.

Objectives:

The aim of the study was to evaluate the correlation of the WHO standard with BÜHLMANN Quantum Blue® Infliximab standardization and to compare spiking recovery in three commercially available infliximab ELISAs and one infliximab rapid test.

Methods:

Calibration curves were generated with BÜHLMANN calibrators and with calibrators made from WHO international standard for infliximab (NIBSC 16/170). Twenty-six serum samples, covering a concentration range from 0.5 µg/mL to 19 µg/mL, were analyzed with both calibration curves and compared by Bland-Altman and Passing-Bablok analysis. Furthermore, recovery of six serum samples spiked with WHO international standard for infliximab was determined in Theradiag LISA TRACKER Infliximab (a), Grifols/Progenika Promonitor-IFX (b), Immundiagnostik IDKmonitor Infliximab drug level (c) and BÜHLMANN Quantum Blue® Infliximab (d). Spiking recovery experiments were performed according to Westgard 2008.

Results:

The sample values gained with BÜHLMANN calibrators showed an excellent correlation with values gained with the WHO international standard for infliximab as calibrator. Passing-Bablok regression analysis revealed a slope of 0.96 and correlation coefficient (R) of 0.99. Bland-Altman analysis revealed a mean difference in the obtained values of less than five percent. Regarding spiking recovery analysis, all tests exhibit an excellent mean recovery of 101% (85-114%; a), 99% (91-105%; b); 101% (95-107%; c) and 94% (88-100%, d).

Conclusion:

Current standardization of Quantum Blue® Infliximab rapid test correlates very well with the WHO international standard for infliximab (NIBSC 16/170). Spiking recovery was highly comparable for ELISAs and the Quantum Blue® Infliximab assay. This rapid test represents a unique and modern analytical method, for fast time-to-result and simplicity of usage in a more patient near medical environment.

References:

[1]Westgard, James. (2008). Basic Method Validation.

Disclosure of Interests:

None declared

Gender differences in patient and caregiver psychoeducation for schizophrenia

Objective:

The aim of this research is to detect gender-related differences in patients and caregivers regarding knowledge about schizophrenia and attitudes towards drugs as well as gender as predictor for changes in these variables during psychoeducation.

Methods:

Data sets of one randomised-controlled (study 1) and one naturalistic psychoeducation study (study 2) were reanalysed. Main outcome measures (knowledge about schizophrenia, drug attitude, confidence in medication) were assessed at baseline, post-intervention and 12 months after index discharge.

Results:

The reanalysed samples consisted in total of 1002 patients and 176 caregivers. In study 2, baseline knowledge was significantly better in male patients and female caregivers. All participants improved significantly their knowledge. The amount of knowledge gain did not differ between genders in either study or either group. Gender was not a major predictor of baseline knowledge or knowledge gain. Only in study 1 did gender significantly impact the knowledge gain from baseline to follow-up. Regarding improvement of drug attitude, females seemed to benefit significantly better from psychoeducation. In both studies, however, changes in drug attitudes respectively confidence in medication were best explained by lower corresponding baseline scores, not gender. Patients’ gender did not influence outcomes of their caregivers.

Conclusion:

Our findings suggest that psychoeducational programs might be better adapted to males in order to improve their drug attitude. Concerning knowledge, gender-related changes do not seem to be necessary.

[True thymic hyperplasia : Differential diagnosis of thymic mass lesions in neonates and children]

Reactive and neoplastic thymic pathologies are the main considerations in the case of masses in the anterior and middle part of the mediastinum, while neurogenic tumors are predominant in the posterior mediastinum (which are not dealt with here). In neonates and infants, the commonest pathologies in the anterior mediastinum comprise germ cell tumors (mainly teratomas), congenital thymic cysts and true thymic hyperplasia (TTH). In toddlers, teratomas, yolk sac tumors and cysts predominate. In children over 5 years of age, lymphomas are the commonest mass lesions whereas thymomas and thymic carcinomas are rare. In addition, inflammation-linked hyperplasia in myasthenia gravis and rebound thymic hyperplasia after chemotherapy must be considered. Although rare at all ages, sarcomas must be considered in the differential diagnosis from birth onwards and throughout adolescence. Based on the report of a rare case of recurrent TTH, the differential diagnosis of this benign but potentially life-threatening condition is discussed.

Does a brief, behavioural intervention, delivered by paediatricians or psychologists improve sleep problems for children with ADHD? Protocol for a cluster-randomised, translational trial

INTRODUCTION

Up to 70% of children with attention-deficit/hyperactivity disorder (ADHD) experience sleep problems. We have demonstrated the efficacy of a brief behavioural intervention for children with ADHD in a large randomised controlled trial (RCT) and now aim to examine whether this intervention is effective in real-life clinical settings when delivered by paediatricians or psychologists. We will also assess the cost-effectiveness of the intervention.

METHODS AND ANALYSIS

Children aged 5-12 years with ADHD (n=320) are being recruited for this translational cluster RCT through paediatrician practices in Victoria and Queensland, Australia. Children are eligible if they meet criteria for ADHD, have a moderate/severe sleep problem and meet American Academy of Sleep Medicine criteria for either chronic insomnia disorder or delayed sleep-wake phase disorder; or are experiencing sleep-related anxiety. Clinicians are randomly allocated at the level of the paediatrician to either receive the sleep training or not. The behavioural intervention comprises 2 consultations covering sleep hygiene and standardised behavioural strategies. The primary outcome is change in the proportion of children with moderate/severe sleep problems from moderate/severe to no/mild by parent report at 3 months postintervention. Secondary outcomes include a range of child (eg, sleep severity, ADHD symptoms, quality of life, behaviour, working memory, executive functioning, learning, academic achievement) and primary caregiver (mental health, parenting, work attendance) measures. Analyses will address clustering at the level of the paediatrician using linear mixed effect models adjusting for potential a priori confounding variables.

ETHICS AND DISSEMINATION

Ethics approval has been granted. Findings will determine whether the benefits of an efficacy trial can be realised more broadly at the population level and will inform the development of clinical guidelines for managing sleep problems in this population. We will seek to publish in leading international paediatric journals, present at major conferences and through established clinician networks.

TRIAL REGISTRATION NUMBER

ISRCTN50834814, Pre-results.

Health-Related Behaviour Among Children of Childhood Cancer Survivors in Germany

Purpose: Childhood cancer survivors fear that previous therapy could not only impair their own but also their children's health. We examined whether health-related behaviour in children of childhood cancer survivors differs from the general population. Methods: Our first nationwide survey wave (2013-2014) surveyed offspring health in 396 German childhood cancer survivors known to have a child of their own. Answers about health behaviour were analysed using descriptive statistics. Data were collected for 418 offspring and 394 could be integrated for matched-pair analyses with data from the German general population (KIGGS, n=17 641). Results: Teeth-cleaning routine, body-mass-index or subjective body image evaluation by parents were no different from children in the general population. Parents who included a cancer survivor smoked less in the presence of their children (p=0.01). During pregnancy, mothers in cancer survivor parent pairs abstained from drinking alcohol more often (p=0.01) and smoked less (p=0.05). While the calculated effect sizes (Phi) were generally low (0.135-0.247), children from cancer survivors played less outdoors than peers did (p=0.01). Boys participated in sports outside a club more often (p=0.05) and watched less TV on weekdays (p=0.01) and girls spent more time on the computer during weekdays than peers did (p=0.01). Conclusions: This study provides the first data for health-related behaviour in cancer survivors' offspring and sheds light on differences to parenting in the general population. Multivariate analyses in a larger study population are needed to relate these differences to fear issues in cancer survivors.

Centrality Dependence of the Charged-Particle Multiplicity Density at Midrapidity in Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

The pseudorapidity density of charged particles, dN_{ch}/dη, at midrapidity in Pb-Pb collisions has been measured at a center-of-mass energy per nucleon pair of sqrt[s_{NN}]=5.02  TeV. For the 5% most central collisions, we measure a value of 1943±54. The rise in dN_{ch}/dη as a function of sqrt[s_{NN}] is steeper than that observed in proton-proton collisions and follows the trend established by measurements at lower energy. The increase of dN_{ch}/dη as a function of the average number of participant nucleons, ⟨N_{part}⟩, calculated in a Glauber model, is compared with the previous measurement at sqrt[s_{NN}]=2.76  TeV. A constant factor of about 1.2 describes the increase in dN_{ch}/dη from sqrt[s_{NN}]=2.76 to 5.02 TeV for all centrality classes, within the measured range of 0%-80% centrality. The results are also compared to models based on different mechanisms for particle production in nuclear collisions.

Measurement of an Excess in the Yield of J/ψ at Very Low p_{T} in Pb-Pb Collisions at sqrt[s]_{NN}=2.76 TeV

We report on the first measurement of an excess in the yield of J/ψ at very low transverse momentum (p_{T}<0.3  GeV/c) in peripheral hadronic Pb-Pb collisions at sqrt[s_{NN}]=2.76  TeV, performed by ALICE at the CERN LHC. Remarkably, the measured nuclear modification factor of J/ψ in the rapidity range 2.5<y<4 reaches about 7 (2) in the p_{T} range 0-0.3  GeV/c in the 70%-90% (50%-70%) centrality class. The J/ψ production cross section associated with the observed excess is obtained under the hypothesis that coherent photoproduction of J/ψ is the underlying physics mechanism. If confirmed, the observation of J/ψ coherent photoproduction in Pb-Pb collisions at impact parameters smaller than twice the nuclear radius opens new theoretical and experimental challenges and opportunities. In particular, coherent photoproduction accompanying hadronic collisions may provide insight into the dynamics of photoproduction and nuclear reactions, as well as become a novel probe of the quark-gluon plasma.

Production of K[Formula: see text](892)[Formula: see text] and [Formula: see text](1020) in p-Pb collisions at [Formula: see text] = 5.02 TeV

The production of K[Formula: see text](892)[Formula: see text] and [Formula: see text](1020) mesons has been measured in p-Pb collisions at [Formula: see text][Formula: see text] 5.02 TeV. K[Formula: see text] and [Formula: see text] are reconstructed via their decay into charged hadrons with the ALICE detector in the rapidity range [Formula: see text]. The transverse momentum spectra, measured as a function of the multiplicity, have a p[Formula: see text] range from 0 to 15 GeV/c for K[Formula: see text] and from 0.3 to 21 GeV/c for [Formula: see text]. Integrated yields, mean transverse momenta and particle ratios are reported and compared with results in pp collisions at [Formula: see text][Formula: see text] 7 TeV and Pb-Pb collisions at [Formula: see text][Formula: see text] 2.76 TeV. In Pb-Pb and p-Pb collisions, K[Formula: see text] and [Formula: see text] probe the hadronic phase of the system and contribute to the study of particle formation mechanisms by comparison with other identified hadrons. For this purpose, the mean transverse momenta and the differential proton-to-[Formula: see text] ratio are discussed as a function of the multiplicity of the event. The short-lived K[Formula: see text] is measured to investigate re-scattering effects, believed to be related to the size of the system and to the lifetime of the hadronic phase.

Inclusive quarkonium production at forward rapidity in pp collisions at [Formula: see text]TeV

We report on the inclusive production cross sections of [Formula: see text], [Formula: see text], [Formula: see text](1S), [Formula: see text](2S) and [Formula: see text](3S), measured at forward rapidity with the ALICE detector in [Formula: see text] collisions at a center-of-mass energy [Formula: see text] TeV. The analysis is based on data collected at the LHC and corresponds to an integrated luminosity of 1.23 pb[Formula: see text]. Quarkonia are reconstructed in the dimuon-decay channel. The differential production cross sections are measured as a function of the transverse momentum [Formula: see text] and rapidity y, over the [Formula: see text] ranges [Formula: see text] GeV/c for [Formula: see text], [Formula: see text] GeV/c for all other resonances, and for [Formula: see text]. The cross sections, integrated over [Formula: see text] and y, and assuming unpolarized quarkonia, are [Formula: see text] [Formula: see text]b, [Formula: see text] [Formula: see text]b, [Formula: see text] nb, [Formula: see text] nb and [Formula: see text] nb, where the first uncertainty is statistical and the second one is systematic. These values agree, within at most [Formula: see text], with measurements performed by the LHCb collaboration in the same rapidity range.

Multiplicity and transverse momentum evolution of charge-dependent correlations in pp, p-Pb, and Pb-Pb collisions at the LHC

We report on two-particle charge-dependent correlations in pp, p-Pb, and Pb-Pb collisions as a function of the pseudorapidity and azimuthal angle difference, [Formula: see text] and [Formula: see text] respectively. These correlations are studied using the balance function that probes the charge creation time and the development of collectivity in the produced system. The dependence of the balance function on the event multiplicity as well as on the trigger and associated particle transverse momentum ([Formula: see text]) in pp, p-Pb, and Pb-Pb collisions at [Formula: see text] 7, 5.02, and 2.76 TeV, respectively, are presented. In the low transverse momentum region, for [Formula: see text] GeV/c, the balance function becomes narrower in both [Formula: see text] and [Formula: see text] directions in all three systems for events with higher multiplicity. The experimental findings favor models that either incorporate some collective behavior (e.g. AMPT) or different mechanisms that lead to effects that resemble collective behavior (e.g. PYTHIA8 with color reconnection). For higher values of transverse momenta the balance function becomes even narrower but exhibits no multiplicity dependence, indicating that the observed narrowing with increasing multiplicity at low [Formula: see text] is a feature of bulk particle production.

Measurement of pion, kaon and proton production in proton-proton collisions at [Formula: see text] TeV

The measurement of primary [Formula: see text], [Formula: see text], [Formula: see text] and [Formula: see text] production at mid-rapidity ([Formula: see text] 0.5) in proton-proton collisions at [Formula: see text][Formula: see text] 7 TeV performed with a large ion collider experiment at the large hadron collider (LHC) is reported. Particle identification is performed using the specific ionisation energy-loss and time-of-flight information, the ring-imaging Cherenkov technique and the kink-topology identification of weak decays of charged kaons. Transverse momentum spectra are measured from 0.1 up to 3 GeV/[Formula: see text] for pions, from 0.2 up to 6 GeV/[Formula: see text] for kaons and from 0.3 up to 6 GeV/[Formula: see text] for protons. The measured spectra and particle ratios are compared with quantum chromodynamics-inspired models, tuned to reproduce also the earlier measurements performed at the LHC. Furthermore, the integrated particle yields and ratios as well as the average transverse momenta are compared with results at lower collision energies.

Production of [Formula: see text] and [Formula: see text] in proton-proton collisions at [Formula: see text] 7 TeV

The production of the strange and double-strange baryon resonances ([Formula: see text], [Formula: see text]) has been measured at mid-rapidity ([Formula: see text][Formula: see text]) in proton-proton collisions at [Formula: see text] [Formula: see text] 7 TeV with the ALICE detector at the LHC. Transverse momentum spectra for inelastic collisions are compared to QCD-inspired models, which in general underpredict the data. A search for the [Formula: see text] pentaquark, decaying in the [Formula: see text] channel, has been carried out but no evidence is seen.

Exclusive J/ψ photoproduction off protons in ultraperipheral p-Pb collisions at √(s(NN))=5.02 TeV

We present the first measurement at the LHC of exclusive J/ψ photoproduction off protons, in ultraperipheral proton-lead collisions at sqrt[s_{NN}]=5.02  TeV. Events are selected with a dimuon pair produced either in the rapidity interval, in the laboratory frame, 2.5<y<4 (p-Pb) or -3.6<y<-2.6 (Pb-p), and no other particles observed in the ALICE acceptance. The measured cross sections σ(γ+p→J/ψ+p) are 33.2±2.2(stat)±3.2(syst)±0.7(theor)  nb in p-Pb and 284±36(stat)_{-32}^{+27}(syst)±26(theor)  nb in Pb-p collisions. We measure this process up to about 700 GeV in the γp center of mass, which is a factor of two larger than the highest energy studied at HERA. The data are consistent with a power law dependence of the J/ψ photoproduction cross section in γp energies from about 20 to 700 GeV, or equivalently, from Bjorken x scaling variable between ∼2×10^{-2} and ∼2×10^{-5}, thus indicating no significant change in the gluon density behavior of the proton between HERA and LHC energies.

Measurement of prompt D-meson production in p-Pb collisions at √(s(NN))=5.02 TeV

The p_{T}-differential production cross sections of the prompt charmed mesons D^{0}, D^{+}, D^{*+}, and D_{s}^{+} and their charge conjugate in the rapidity interval -0.96<y_{cms}<0.04 were measured in p-Pb collisions at a center-of-mass energy sqrt[s_{NN}]=5.02  TeV with the ALICE detector at the LHC. The nuclear modification factor R_{pPb}, quantifying the D-meson yield in p-Pb collisions relative to the yield in pp collisions scaled by the number of binary nucleon-nucleon collisions, is compatible within the 15%-20% uncertainties with unity in the transverse momentum interval 1<p_{T}<24  GeV/c. No significant difference among the R_{pPb} of the four D-meson species is observed. The results are described within uncertainties by theoretical calculations that include initial-state effects. The measurement adds experimental evidence that the modification of the momentum spectrum of D mesons observed in Pb-Pb collisions with respect to pp collisions is due to strong final-state effects induced by hot partonic matter.

Quantification of diastolic dysfunction via the age dependence of diastolic function - impact of insulin resistance with and without type 2 diabetes

BACKGROUND

The alarming prevalence of heart failure with preserved ejection fraction requires quantification of diastolic dysfunction (DDF). Myocardial diastolic velocity E' implies that age is the most important determinant. We tested the hypothesis that age allows for quantification of DDF and assessment of the structural and metabolic determinants in patients with and without type 2 diabetes (D).

METHODS

This prospective, cross-sectional study assessed cardiovascular, metabolic and ultrasound data in 409 consecutive patients (Diabetes Center, Bogenhausen-Munich) between 20 and 90 years without known cardiac disease and either with (n=204) or without D but with common prevalence of cardiovascular risk factors, including a subgroup of healthy individuals (H, n=94).

RESULTS

In H, E' related to age as: E'norm=-0.163∗years+19.69 (R(2)=0.77, p<0.0001). According to this 1% reduction by annual physiologic aging, DDF was quantitated as E'-E' norm. Compared to nondiabetics, D patients were older, had greater BMI, lower E', more cardiovascular risk and greater DDF. In nondiabetics, grading of DDF by E-E'norm correlated with grading by filling pressure E/E'. Determinants of DDF by multivariate analysis included pulse wave velocity, diastolic blood pressure and the triglyceride/HDL ratio (a marker of insulin resistance) in nondiabetics and in D the same risk factors in reverse sequence and heart rate. Neither left atrial size nor left ventricular mass had significant impact.

CONCLUSIONS

The physiological impact of age on myocardial function consists of a 1% annual reduction in E' and enables precise quantification of diastolic dysfunction thereby unmasking the importance of metabolic risk for DDF.

[Prevalence of the metabolic syndrome and its risk factors: results of a large work-site health assessment]

BACKGROUND

Facing the demographic change, cardiovascular risk factors have been assessed within an occupational checkup to establish health programs.

PATIENTS AND METHODS

From 2006 to 2007, anthropometric and blood parameters of 27 359 employees of a large company of the German automobile industry were collected aiming to determine the prevalence of metabolic syndrome (by NCEP ATP III) and its risk factors. Data from 3048 employees (fasting state) were analyzed (age: ∅ 39,4 ± 10,3 years, 81.4% males).

RESULTS

The most common risk factors were hypertension ≥ 130/85 mmHg (men [m]: 74,4%, 95%-confidence interval [CI] 73-76%, women [w]: 47,1%, 95%-CI 43-51%), elevated triglycerides (≥ 150 mg/dl; m: 32,8%, 95%-CI 31-35%, w: 13,8%, 95%-CI 11-17%) and waist-circumferences (> 102 cm for men: 15,1%, 95%-CI 14-17%; > 88 cm for women: 16,9%, 95%-CI 14-20%). The prevalence of metabolic syndrome (≥ 3 risk factors) was 11,7% (95%-CI 12-15%; m: 12,7%, 95%-CI 11-14%, w: 7,4%, 95%-CI 6-10%) increasing with physical inactivity and rising age up to 20%. The prevalence of hypertension in young (< 20 years) and elder men (≥ 50 years) was similarly high (79,1%, 95%-CI 70-86% vs. 79,9%, 95%-CI 75-82%).

CONCLUSION

The prevalence of metabolic syndrome in this sample is rather low, but 75% of the men and nearly 50% of the women had hypertension. Health programs should focus on this risk factor in particular.

Measurement of quarkonium production at forward rapidity in [Formula: see text] collisions at [Formula: see text]TeV

The inclusive production cross sections at forward rapidity of [Formula: see text], [Formula: see text], [Formula: see text](1S) and [Formula: see text](2S) are measured in [Formula: see text] collisions at [Formula: see text] with the ALICE detector at the LHC. The analysis is based on a data sample corresponding to an integrated luminosity of 1.35 pb[Formula: see text]. Quarkonia are reconstructed in the dimuon-decay channel and the signal yields are evaluated by fitting the [Formula: see text] invariant mass distributions. The differential production cross sections are measured as a function of the transverse momentum [Formula: see text] and rapidity [Formula: see text], over the ranges [Formula: see text] GeV/c for [Formula: see text], [Formula: see text] GeV/c for all other resonances and for [Formula: see text]. The measured cross sections integrated over [Formula: see text] and [Formula: see text], and assuming unpolarized quarkonia, are: [Formula: see text] [Formula: see text]b, [Formula: see text] [Formula: see text]b, [Formula: see text] nb and [Formula: see text] nb, where the first uncertainty is statistical and the second one is systematic. The results are compared to measurements performed by other LHC experiments and to theoretical models.

Energy dependence of the transverse momentum distributions of charged particles in pp collisions measured by ALICE

Differential cross sections of charged particles in inelastic pp collisions as a function of p_T have been measured at [Formula: see text] at the LHC. The p_T spectra are compared to NLO-pQCD calculations. Though the differential cross section for an individual [Formula: see text] cannot be described by NLO-pQCD, the relative increase of cross section with [Formula: see text] is in agreement with NLO-pQCD. Based on these measurements and observations, procedures are discussed to construct pp reference spectra at [Formula: see text] up to p_T=50 GeV/c as required for the calculation of the nuclear modification factor in nucleus-nucleus and proton-nucleus collisions.

Directed flow of charged particles at midrapidity relative to the spectator plane in Pb-Pb collisions at √(s(NN))=2.76 TeV

The directed flow of charged particles at midrapidity is measured in Pb-Pb collisions at √(s(NN))=2.76 TeV relative to the collision symmetry plane defined by the spectator nucleons. A negative slope of the rapidity-odd directed flow component with approximately 3 times smaller magnitude than found at the highest RHIC energy is observed. This suggests a smaller longitudinal tilt of the initial system and disfavors the strong fireball rotation predicted for the LHC energies. The rapidity-even directed flow component is measured for the first time with spectators and found to be independent of pseudorapidity with a sign change at transverse momenta p(T) between 1.2 and 1.7  GeV/c. Combined with the observation of a vanishing rapidity-even p(T) shift along the spectator deflection this is strong evidence for dipolelike initial density fluctuations in the overlap zone of the nuclei. Similar trends in the rapidity-even directed flow and the estimate from two-particle correlations at midrapidity, which is larger by about a factor of 40, indicate a weak correlation between fluctuating participant and spectator symmetry planes. These observations open new possibilities for investigation of the initial conditions in heavy-ion collisions with spectator nucleons.

K(S)0 and Λ production in Pb-Pb collisions at √(s(NN))=2.76 TeV

The ALICE measurement of K(S)(0) and Λ production at midrapidity in Pb-Pb collisions at √(s(NN))=2.76 TeV is presented. The transverse momentum (p(T)) spectra are shown for several collision centrality intervals and in the p(T) range from 0.4 GeV/c (0.6 GeV/c for Λ) to 12 GeV/c. The p(T) dependence of the Λ/K(S)(0) ratios exhibits maxima in the vicinity of 3 GeV/c, and the positions of the maxima shift towards higher p(T) with increasing collision centrality. The magnitude of these maxima increases by almost a factor of three between most peripheral and most central Pb-Pb collisions. This baryon excess at intermediate p(T) is not observed in pp interactions at √s=0.9 TeV and at √s=7 TeV. Qualitatively, the baryon enhancement in heavy-ion collisions is expected from radial flow. However, the measured p(T) spectra above 2 GeV/c progressively decouple from hydrodynamical-model calculations. For higher values of p(T), models that incorporate the influence of the medium on the fragmentation and hadronization processes describe qualitatively the p(T) dependence of the Λ/K(S)(0) ratio.

[Time-dependent confounding in the estimation of treatment effects in randomised trials with multimodal therapies--an illustration of the problem of time-dependent confounding by causal graphs]

Biased effect estimates induced by unconsidered confounding variables are a known problem in observational studies. Selection bias, resulting from non-random sampling of study participants, is widely recognised as a problem in case-control and cross-sectional studies. In contrast, possible bias in randomised controlled trials (RCTs) is mostly ignored. This paper illustrates, by applying directed acyclic graphs (DAGs), possible bias in the effect estimates of first-line therapy, caused by subsequent changes in therapy (time-dependent confounding). Possible selection bias, induced by not only random loss to follow-up, will be explained as well using DAGs. Underlying assumptions of standard methods usually used to analyse RCTs (like intention-to-treat, per-protocol) are shown and it is explained why effect estimates may be biased in RCTs, if only these conventional methods are used. Adequate statistical methods (causal inference models as marginal structural models and structural nested models) exist. Higher documentary efforts, however, are necessary, because any changes in medication, loss to follow-up as well as reasons for such changes need to be documented in detail as required by these advanced statistical methods. Nevertheless, causal inference models should become standard along side the currently applied standard methods, especially in studies with high non-compliance due to changes in therapy and substantial loss to follow-up. Possible bias cannot be excluded if similar results are obtained from both methods. However, study results should be interpreted with caution if they differ between both approaches.

Charmonium and e+e- pair photoproduction at mid-rapidity in ultra-peripheral Pb-Pb collisions at [Formula: see text]

The ALICE Collaboration at the LHC has measured the J/ψ and ψ' photoproduction at mid-rapidity in ultra-peripheral Pb-Pb collisions at [Formula: see text]. The charmonium is identified via its leptonic decay for events where the hadronic activity is required to be minimal. The analysis is based on an event sample corresponding to an integrated luminosity of about 23 μb-1. The cross section for coherent and incoherent J/ψ production in the rapidity interval -0.9 Collapse

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J/ψ elliptic flow in Pb-Pb collisions at √(s(NN))=2.76 TeV

We report on the first measurement of inclusive J/ψ elliptic flow v2 in heavy-ion collisions at the LHC. The measurement is performed with the ALICE detector in Pb-Pb collisions at √(s(NN))=2.76 TeV in the rapidity range 2.5<y<4.0. The dependence of the J/ψ v2 on the collision centrality and on the J/ψ transverse momentum is studied in the range 0≤p(T)<10 GeV/c. For semicentral Pb-Pb collisions at √(s(NN))=2.76 TeV, an indication of nonzero v2 is observed with a largest measured value of v2=0.116±0.046(stat)±0.029(syst) for J/ψ in the transverse momentum range 2≤p(T)<4 GeV/c. The elliptic flow measurement complements the previously reported ALICE results on the inclusive J/ψ nuclear modification factor and favors the scenario of a significant fraction of J/ψ production from charm quarks in a deconfined partonic phase.

Somatic copy number changes in DPYD are associated with lower risk of recurrence in triple-negative breast cancers

BACKGROUND

Genomic rearrangements at the fragile site FRA1E may disrupt the dihydropyrimidine dehydrogenase gene (DPYD) which is involved in 5-fluorouracil (5-FU) catabolism. In triple-negative breast cancer (TNBC), a subtype of breast cancer frequently deficient in DNA repair, we have investigated the susceptibility to acquire copy number variations (CNVs) in DPYD and evaluated their impact on standard adjuvant treatment.

METHODS

DPYD CNVs were analysed in 106 TNBC tumour specimens using multiplex ligation-dependent probe amplification (MLPA) analysis. Dihydropyrimidine dehydrogenase (DPD) expression was determined by immunohistochemistry in 146 tumour tissues.

RESULTS

In TNBC, we detected 43 (41%) tumour specimens with genomic deletions and/or duplications within DPYD which were associated with higher histological grade (P=0.006) and with rearrangements in the DNA repair gene BRCA1 (P=0.007). Immunohistochemical analysis revealed low, moderate and high DPD expression in 64%, 29% and 7% of all TNBCs, and in 40%, 53% and 7% of TNBCs with DPYD CNVs, respectively. Irrespective of DPD protein levels, the presence of CNVs was significantly related to longer time to progression in patients who had received 5-FU- and/or anthracycline-based polychemotherapy (hazard ratio=0.26 (95% CI: 0.07-0.91), log-rank P=0.023; adjusted for tumour stage: P=0.037).

CONCLUSION

Genomic rearrangements in DPYD, rather than aberrant DPD protein levels, reflect a distinct tumour profile associated with prolonged time to progression upon first-line chemotherapy in TNBC.

Transferring innovative freehand SPECT to the operating room: first experiences with sentinel lymph node biopsy in malignant melanoma

PURPOSE

The purpose of this study was to report on the first experiences with freehand single-photon emission-computed tomography (freehand SPECT) in sentinel lymph node biopsy (SLNB) in patients with malignant melanoma. Freehand SPECT is a novel imaging modality combining gamma probes, surgical navigation systems, and emission tomography algorithms, designed to overcome some of the limitations of conventional gamma probes.

METHODS

In this study 20 patients with malignant melanoma underwent conventional planar scintigraphy prior to surgery. In the operating room, the number and location of separable SLNs were detected first by a pre-incisional scan with freehand SPECT to render a 3D-image of the target site and afterwards by a scan with a conventional gamma probe. After SLNB another scan was performed to document the removal of all targeted SLNs.

RESULTS

Planar scintigraphy identified 40 SLNs in 26 nodal basins. Pre-incisional freehand SPECT mapped 38 of these nodes as well as one additional node in one patient (95.0% node based sensitivity). The results of freehand SPECT were identical to those of planar scintigraphy in 25 basins, while it missed one basin (96.2% basin based sensitivity). In comparison, the gamma probe failed to detect 7 nodes in 4 basins (82.5% node based sensitivity and 84.6% basin based sensitivity). After resection freehand SPECT detected 9 remaining radioactive spots, two of whichwere resected as they matched the position of SLNs detected on preoperative planar scintigraphy.

CONCLUSIONS

Freehand SPECT provides a real-time, intraoperative 3D-image of the radioactive labelled SLNs, facilitating their detection and resection.

D meson elliptic flow in noncentral Pb-Pb collisions at sqrt[sNN]=2.76 Tev

Azimuthally anisotropic distributions of D0, D+, and D*+ mesons were studied in the central rapidity region (|y|<0.8) in Pb-Pb collisions at a center-of-mass energy sqrt[sNN]=2.76  TeV per nucleon-nucleon collision, with the ALICE detector at the LHC. The second Fourier coefficient v2 (commonly denoted elliptic flow) was measured in the centrality class 30%-50% as a function of the D meson transverse momentum pT, in the range 2-16  GeV/c. The measured v2 of D mesons is comparable in magnitude to that of light-flavor hadrons. It is positive in the range 2<pT<6  GeV/c with 5.7σ significance, based on the combination of statistical and systematic uncertainties.

Motional coherence of fermions immersed in a Bose gas

We prepare a superposition of two motional states by addressing lithium atoms immersed in a Bose-Einstein condensate of sodium with a species-selective potential. The evolution of the superposition state is characterized by the populations of the constituent states as well as their coherence. The latter we extract employing a novel scheme analogous to the spin-echo technique. Comparing the results directly to measurements on freely evolving fermions allows us to isolate the decoherence effects induced by the bath. In our system, the decoherence time is close to the maximal possible value since the decoherence is dominated by population relaxation processes. The measured data are in good agreement with a theoretical model based on Fermi's golden rule.

Plasma oxytocin and vasopressin do not predict neuropeptide concentrations in human cerebrospinal fluid

The involvement of the neuropeptides oxytocin (OXT) and vasopressin (AVP) in human socio-emotional behaviours is attracting increasing attention. There is ample evidence for elevated plasma levels upon a wide variety of social and emotional stimuli and scenarios, ranging from romantic love via marital distress up to psychopathology, with cause versus consequence being largely unclear. The present study examined whether plasma levels of both OXT and AVP are reflective of central neuropeptide levels, as assumed to impact upon socio-emotional behaviours. Concomitant plasma and cerebrospinal fluid (CSF) samples were taken from 41 non-neurological and nonpsychiatric patients under basal conditions. Although OXT and AVP levels in the CSF exceeded those in plasma, there was no correlation between both compartments, clearly suggesting that plasma OXT and AVP do not predict central neuropeptide concentrations. Thus, the validity of plasma OXT and AVP as potential biomarkers of human behaviour needs further clarification.

Oxidative stress after a carbohydrate meal contributes to the deterioration of diastolic cardiac function in nonhypertensive insulin-treated patients with moderately well controlled type 2 diabetes

The prevalence and prognostic importance of diastolic dysfunction in type 2 diabetes has only recently been appreciated. We tested the hypothesis that in insulin treated type 2 diabetes (D), carbohydrate consumption induces oxidative stress resulting in further impairment of diastolic function beyond structural myocardial stiffness. The effects of a pure carbohydrate breakfast (48 g) on oxidative stress and cardiac function were studied in the fasting and postmeal states in subjects without hypertension or overt cardiac disease (moderately well controlled D, n=21 and controls without D, n=20). Studied variables included systolic and early diastolic (E') myocardial velocities, traditional metabolic and hemodynamic parameters, serum nitrotyrosine, and sVCAM-1. In D compared to control subjects, the postmeal increase (∆) in glucose (1.44±2.78 vs. 0.11±0.72 mmol/l, p=0.04) and ∆nitrotyrosine (0.34±0.37 vs. -0.23±0.47 nM/l, p<0.001) were significantly higher. sVCAM-1 was higher in fasting and postmeal (p=0.02). E' was significantly lower in postmeal (7.3±1.3 vs. 9.6±1.3 cm/s, p<0.001) and fasting (p<0.001) whereas the rate pressure product was significantly higher (9 420±1 118 vs. 7 705±1 871 mm Hg/min, p<0.001). Multivariable regression models of the pooled data demonstrated that independent predictors for postmeal E' were ∆nitrotyrosine and septal thickness (R² 0.466) and for fasting E' age, ∆nitrotyrosine, and septal thickness (R² 0.400). In insulin requiring type 2 diabetes, carbohydrate consumption may induce oxidative stress that is associated with worsening diastolic function, indicating that this metabolic factor is an important determinant of diastolic dysfunction in the diabetic heart beyond the increase in structural myocardial stiffness.