General framework for ultrafast nonlinear photonics: unifying single and multi-envelope treatments [Invited]

Numerical modeling of ultrashort pulse propagation is important for designing and understanding the underlying dynamical processes in devices that take advantage of highly nonlinear interactions in dispersion-engineered optical waveguides. Once the spectral bandwidth reaches an octave or more, multiple types of nonlinear polarization terms can drive individual optical frequencies. This issue is particularly prominent in χ(2) devices where all harmonics of the input pulse are generated and there can be extensive spectral overlap between them. Single-envelope approaches to pulse propagation have been developed to address these complexities; this has led to a significant mismatch between the strategies used to analyze moderate-bandwidth devices (usually involving multi-envelope models) and those used to analyze octave-spanning devices (usually involving models with one envelope per waveguide mode). Here we unify the different strategies by developing a common framework, applicable to any optical bandwidth, that allows for a side-by-side comparison between single- and multi-envelope models. We include both χ(2) and χ(3) interactions in these models, with emphasis on χ(2) interactions. We show a detailed example based on recent supercontinuum generation experiments in a thin-film LiNbO3 on sapphire quasi-phase-matching waveguide. Our simulations of this device show good agreement between single- and multi-envelope models in terms of the frequency comb properties of the electric field, even for multi-octave-spanning spectra. Building on this finding, we explore how the multi-envelope approach can be used to develop reduced models that help build physical insights about new ultrafast photonics devices enabled by modern dispersion-engineered waveguides, and discuss practical considerations for the choice of such models. More broadly, we give guidelines on the pros and cons of the different modeling strategies in the context of device design, numerical efficiency, and accuracy of the simulations.

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

BACKGROUND

Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation.

METHODS

WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109.

FINDINGS

Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital.

INTERPRETATION

In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates.

FUNDING

European Society of Intensive Care Medicine, European Respiratory Society.

6-10-14 for Health - as an example of an interdisciplinary model of care for a patient with obesity

Issue

Overweight and obesity are public health challenges of growing importance in Poland. The fastest increase has been observed in children and adolescents. Some studies show that 22% of elementary school children are currently (2013) overweight or have obesity (IZZ), compared with no more than 15% in 1990 (WHO Europe, 2012).

Description of the problem

The “6-10-14 for Health” is the first comprehensive health programme implemented in Poland, focused on long-term health behaviour change both among children with obesity and their families. Screening tests are carried out at Gdańsk schools. Children who are diagnosed with excess body weight are invited to the second level of programme. Target groups are children in Gdansk, aged 6, 9-11 and 14 years, their parents and the school environment. Timeline: 2011-2021

Results

effects: Approximately 400-450 new patients join the programme every year. Programme participants receive annual care from an interdisciplinary team of specialists including a paediatrician, dietitian, specialist in physical activity and a psychologist. The effect of one year's participation in the programme is the reduction of excess body weight in 75% of participants. More then 2000 patients have complieted the Programme. The programme is accredited by the European Association for the Study of Obesity and is funded by the City of Gdańsk. changes: Further implementation of the Programme depends on providing funds from the City of Gdańsk. However, it seems that the 6-10-14 for Health is one of the city's health priorities. The challenge in the field of weight reduction programs is to provide care that will not lead to stigmatization of patients

Lessons

The work on designing the model has already resulted in creation of network of specialists from different backgrounds and allowed sharing different scopes, how to use limited resources for the benefit of children and adolescens.

Key messages

The proposed care model is fully possible to implement in the care system. So far, sharing knowledge and experience, the program has been implemented in several other local governments. In the era of the COVID19 pandemic, all activities aimed at the prevention and early treatment of obesity become even more important.

Effect of suramin on urinary excretion of diabetes-induced glomerular and tubular injury parameters in rats

Diabetes mellitus causes changes in metabolism of extracellular nucleotides acting through P2 receptors (P2Rs). This affects renal function and may lead to glomerular and tubular disturbances. We measured urinary excretion of nucleotides (ATP, ADP, AMP, UTP, UDP, UMP) in streptozotocin-induced diabetic rats (65 mg/kg, i.p., day 0) and the effects of P2Rs' blockade by suramin (10 mg/kg, i.p., days +7, +14) on glomerular P2×7R expression and urinary excretion of glomerular (albumin, nephrin) and tubular (KIM-1, NGAL) injury markers, electrolytes, and oxidative stress markers (TBARS, 8-OHdG). Concentrations of nucleotides, specific proteins, electrolytes, and oxidative stress markers in 24-h urine samples collected in metabolic cages at days -1, +6 and +20 were measured using ion-paired reversed-phase HPLC, immunoenzymatic and fluorometric methods, and flame photometry, respectively. Expression of KIM-1 and P2×7R was examined by immunohistochemistry or immunoblotting. Diabetes was associated with increased urinary excretion of ATP, ADP, UTP, UDP and glomerular P2×7R expression. Suramin attenuated P2×7R expression but did not affect urinary excretion of nucleotides. Urinary excretion of albumin, nephrin, NGAL, and 8-OHdG were increased in diabetic rats and were not affected by suramin. TBARS was higher in diabetic rats and suramin attenuated the excretion dynamics in this group. KIM-1 excretion was higher in diabetic rats and suramin further increased excretion of KIM-1 in both diabetic and non-diabetic rats. Furthermore, suramin attenuated the diabetes-induced natriuresis and kaliuresis. It is possible that suramin affects both glomerular and tubular functions in diabetic rats.

Functional outcomes and quality of life during long-term follow-up after acute pulmonary embolism: analysis of the prospective multicentre FOCUS study

Background

It is unclear to which extent persistence of symptoms and/or residual haemodynamic impairment clinical course of pulmonary embolism are associated with worse quality of life (QoL).

Aims

To study the correlation between symptoms and haemodynamic impairment with QoL during the first year after acute pulmonary embolism (PE).

Methods

The Follow-Up after acute pulmonary embolism (FOCUS) study prospectively enrolled and followed consecutive adult patients diagnosed with acute symptomatic objectively diagnosed PE. In the present analysis, we considered patients who completed the Pulmonary Embolism QoL (PEmb-QoL) Questionnaire at predefined visits 3 and 12 months after acute PE. The PEmb-QoL score ranges from 0% (best QoL) to 100% (worst QoL). We evaluated at these two time points the correlation between persisting symptoms (group: symptoms), elevation of natriuretic peptides or residual right ventricular dysfunction (group: RVD), or their combination (group: symptoms + RVD) and QoL.

Results

A total of 617 patients were included; their median age was 62 years, 44% were women; 8% had active cancer, and 21% previous venous thromboembolism. At 3 months, patients with neither symptoms nor RVD (n=302) had the highest quality of life (median score 18%, 25th–75th percentile: 8%–34%), followed by those without symptoms but with RVD (n=255; median score 19%, 25th–75th percentile: 7%–34%), and by those with symptoms only (n=131; median PEmb-QoL 31%, 25th–75th percentile: 18%–49%). Patients with both symptoms and RVD (n=170) had the worst quality of life (median score 38%, 25th–75th percentile: 19%–53%); Figure 1A. At 12 months, we found an overall improvement of PEmb-QoL score. The degree of this QoL improvement varied across groups, being largest for patients who recovered from having symptoms + RVD at 3 months to normalization of at least one at 12 months. The change in QoL from 3 to 12 months was smaller both in patients who had neither symptoms nor RVD and in patients who had no recovery in either symptoms or RVD; Figure 1B.

Conclusions

Persistent symptoms after PE, especially in patients with elevated biomarkers or residual echocardiographic dysfunction, were the main drivers of QoL at 3 months as well as of the course of QoL over time.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): University Medical Center of the Johannes Gutenberg University, Mainz, Germany; German Federal Ministry of Education and Research

Higher responsiveness to rosuvastatin in polygenic versus monogenic hypercholesterolaemia: a propensity score analysis

Background

The underlying monogenic defect in familial hypercholesterolemia (FH) can be detected in ∼40% of cases. The majority of mutation-negative patients have a polygenic cause of high LDL-cholesterol (LDL-C) due to having inherited a greater than average number of common LDL-C raising single nucleotide polymorphisms (SNPs).

Purpose

We sought to investigate, whether the monogenic or polygenic defect in FH is associated with the response to rosuvastatin.

Methods

Individuals with a clinical diagnosis of FH were tested for mutations in LDLR and APOB genes. A previously established LDL-C-specific polygenic risk score (PRS) was used to examine the possibility of polygenic hypercholesterolemia in mutation negative patients. The propensity score analysis was performed to evaluate the variables associated with the response to rosuvastatin. The type of hypercholesterolemia (polygenic or monogenic) and following variables: age, gender, LDL-baseline, statin intolerance, ezetimibe use, rosuvastatin dose, diabetes and cardiovascular disease (CVD), were examined to minimize the bias of this observational study.

Results

LDLR/APOB mutation was found in 47 (42%) patients, whereas polygenic hypercholesterolemia was diagnosed in 65 (58%) of patients. Mean age was comparable in both groups (54±13 vs 51±13, p=0.134). CVD was diagnosed in ≈26% of individuals in both cohorts (p=0.343). There was no difference in the distribution of CV risk factors, such as arterial hypertension, smoking, diabetes, body mass index and in rate of statin intolerance. Monogenic subjects had higher baseline LDL-C compared to polygenic (Table 1). Adjusted model showed a lower percentage of change in LDL-C after rosuvastatin treatment in monogenic vs. polygenic subjects (46% vs 55%, p<0.001) (Figure 1). The probability of achieving LDL-C targets in monogenic FH was lower than in polygenic subjects (0.075 vs. 0.245, p=0.004). Polygenic patients were more likely to achieve LDL-C goals, compared to mutation-positive patients (OR 3.28; 95% CI:1.23–8.72).

Conclusion

Our findings indicate an essentially higher responsiveness to rosuvastatin in patients with a polygenic cause, as compared to those carrying monogenic mutations.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): 1. Polish Ministry of Science and Higher Education European Regional Development Fund under the Programme Innovative Economy 2007–2013 (POIG.01.01.02-22-079/09). 2. British Heart Foundation (PG 08/008). 3. The National Institute for Health Research, University College London Hospitals, Biomedical Research Centre. 4. The Foundation Leducq Transatlantic Networks of Excellence Program grant (no. 14 CVD03)

Quality of life 3 and 12 months after acute pulmonary embolism: analysis of 617 patients from the prospective multicentre FOCUS study

Background

Few data are available on the long-term course and predictors of quality of life (QoL) after acute pulmonary embolism (PE).

Aims

To evaluate the kinetics and determinants of QoL at 3 and 12 months after acute PE.

Methods

The Follow-Up after acute pulmonary embolism (FOCUS) study prospectively followed consecutive adult patients with objectively diagnosed PE. For this analysis, we considered patients who completed the Pulmonary Embolism QoL (PEmb-QoL) Questionnaire at two predefined visits 3 and 12 months after PE. PEmb-QoL, studied as total score and in its six dimensions, ranges from 0% (best QoL) to 100% (worst QoL). We studied the course of PEmb-QoL and the impact of baseline characteristics using multivariable linear regression.

Results

In 617 included patients (44% women, median age 62 years), overall QoL improved from 3 to 12 months, with a decrease of the mean PEmb-QoL score from 25.3% to 21.5% (p-value <0.001). Intra-individual correlation between PEmb-QoL score at 3 and 12 months was high; Figure A. The improvement was consistent across all PEmb-QoL dimensions; Figure B. Female sex, cardiopulmonary diseases, and higher body mass index were the main factors associated with a worse QoL; Table. Age and smoking affected QoL only at 12 months. The improvement in QoL was faster in patients without cardiopulmonary diseases (−4.2%; 95% CI: −5.2% to −3.1%), without previous VTE (−4.3%; −5.5% to −3.2%), and in non-smokers (−4.2%; −5.3% to −3.1%).

Conclusions

In a large cohort of patients with pulmonary embolism, we quantified the improvement of QoL between 3 and 12 months after diagnosis. We identified factors independently associated with lower QoL and slower recovery of QoL that may reflect special patient needs. These estimates may facilitate the planning and interpretation of clinical trials with QoL as a study outcome.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): University Medical Center of the Johannes Gutenberg University, Mainz, Germany; German Federal Ministry of Education and Research

Long-course preoperative chemoradiation versus 5 × 5 Gy and consolidation chemotherapy for clinical T4 and fixed clinical T3 rectal cancer: long-term results of the randomized Polish II study

BACKGROUND

This trial evaluated whether preoperative short-course radiotherapy and consolidation chemotherapy (CCT) were superior to chemoradiation in rectal cancers with clinical (c)T4 or fixed cT3. Previously, we reported early results showing no differences in the radical surgery rate (primary end point). In the short-course/CCT group, we observed lower acute toxicity of preoperative treatment and better overall survival (OS). We updated results to determine whether the benefit in OS was sustained and to evaluate late complications.

PATIENTS AND METHODS

Patients with cT4 or fixed cT3 rectal cancer were randomized either to preoperative 5 × 5 Gy and three cycles of FOLFOX4 or to chemoradiation (50.4 Gy with bolus 5-Fu, leucovorin and oxaliplatin).

RESULTS

Patients (N = 515) were eligible for analysis, 261 in the short-course/CCT group and 254 in the chemoradiation group. The median follow-up was 7.0 years. The difference in OS was insignificant [hazard ratio (HR) 0.90; 95% confidence interval (CI) 0.70-1.15; P = 0.38). However, the difference in early OS favouring short-course/CCT previously reported was observed again, being 9% at 3 years (95% CI 0.5% to 17%). This difference disappeared later; at 8 years OS was 49% in both groups. There was no difference in disease-free survival (HR 0.95; 95% CI 0.75-1.19; P = 0.65) at 8 years 43% versus 41% in the short-course/CCT group versus the chemoradiation group, respectively. The corresponding values for cumulative incidences of local failure and distant metastases did not differ and were HR = 1.08, 95% CI 0.70-1.23, P = 0.60, 35% versus 32% and HR = 1.10, 95% CI 0.68-1.23, P = 0.54, 36% versus 34%, respectively. The rate of late complications was similar (P = 0.66), grade 3+ being 11% versus 9% in the short-course/CCT group versus the chemoradiation group, respectively.

CONCLUSION

The superiority of preoperative short-course/CCT over chemoradiation was not demonstrated.

CLINICAL TRIAL NUMBER

The trial is registered as ClinicalTrials.gov number NCT00833131.

Accuracy of real-time shear wave elastography in the assessment of normal small intestine mucosa in dogs

The aim of the study was to assess the physiological stiffness of the normal canine jejunal mucosa based on shear wave elastography. The study was carried out on 60 dogs. In all the animals studied, the abdominal ultrasound was carried out using the SuperSonic Imagine Aixplorer system. The site of the jejunal elastography was determined using standard ultrasonography and all the measurements were carried out thrice. The stiffness of the area examined was determined during each measurement. Mean values were calculated based on the results obtained. The normal stiffness of the jejunal mucosa ranged from 1.305 kPa to 9.319 kPa (mean 5.31 ± 2.04 kPa). Based on our findings, we determined the range of normal values of the jejunal mucosal stiffness in healthy dogs. In addition, shear wave elastography was found to be safe and easy to perform. Moreover, it did not require anaesthesia or patient immobilisation for long periods.

Development of a reactor for the in situ monitoring of 2D materials growth on liquid metal catalysts, using synchrotron x-ray scattering, Raman spectroscopy, and optical microscopy

Liquid metal catalysts (LMCats) (e.g., molten copper) can provide a new mass-production method for two-dimensional materials (2DMs) (e.g., graphene) with significantly higher quality and speed and lower energy and material consumption. To reach such technological excellence, the physicochemical properties of LMCats and the growth mechanisms of 2DMs on LMCats should be investigated. Here, we report the development of a chemical vapor deposition (CVD) reactor which allows the investigation of ongoing chemical reactions on the surface of a molten metal at elevated temperatures and under reactive conditions. The surface of the molten metal is monitored simultaneously using synchrotron x-ray scattering, Raman spectroscopy, and optical microscopy, thereby providing complementary information about the atomic structure and chemical state of the surface. To enable in situ characterization on a molten substrate at high temperatures (e.g., ∼1370 K for copper), the optical and x-ray windows need to be protected from the evaporating LMCat, reaction products, and intense heat. This has been achieved by creating specific gas-flow patterns inside the reactor. The optimized design of the reactor has been achieved using multiphysics COMSOL simulations, which take into account the heat transfer, fluid dynamics, and transport of LMCat vapor inside the reactor. The setup has been successfully tested and is currently used to investigate the CVD growth of graphene on the surface of molten copper under pressures ranging from medium vacuum up to atmospheric pressure.

Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery

BACKGROUND

Perioperative fluid management is a crucial element of perioperative care and has been studied extensively recently; however, 'the right amount' remains uncertain. One concept in perioperative fluid handling is goal-directed fluid therapy (GDFT), wherein fluid administration targets various continuously measured haemodynamic variables with the aim of optimizing oxygen delivery. Another recently raised concept is that perioperative restrictive fluid therapy (RFT) may be beneficial and at least as effective as GDFT, with lower cost and less resource utilization.

OBJECTIVES

To investigate whether RFT may be more beneficial than GDFT for adults undergoing major non-cardiac surgery.

SEARCH METHODS

We searched the following electronic databases on 11 October 2019: Cochrane Central Register of Controlled Trials, in the Cochrane Libary; MEDLINE; and Embase. Additionally, we performed a targeted search in Google Scholar and searched trial registries (World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov) for ongoing and unpublished trials. We scanned the reference lists and citations of included trials and any relevant systematic reviews identified.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing perioperative RFT versus GDFT for adults (aged ≥ 18 years) undergoing major non-cardiac surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references for eligibility, extracted data, and assessed risk of bias. We resolved discrepancies by discussion and consulted a third review author if necessary. When necessary, we contacted trial authors to request additional information. We presented pooled estimates for dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs), and for continuous outcomes as mean differences (MDs) with standard deviations (SDs). We used Review Manager 5 software to perform the meta-analyses. We used a fixed-effect model if we considered heterogeneity as not important; otherwise, we used a random-effects model. We used Poisson regression models to compare the average number of complications per person.

MAIN RESULTS

From 6396 citations, we included six studies with a total of 562 participants. Five studies were performed in participants undergoing abdominal surgery (including one study in participants undergoing cytoreductive abdominal surgery with hyperthermic intraperitoneal chemotherapy (HIPEC)), and one study was performed in participants undergoing orthopaedic surgery. In all studies, surgeries were elective. In five studies, crystalloids were used for basal infusion and colloids for boluses, and in one study, colloid was used for both basal infusion and boluses. Five studies reported the ASA (American Society of Anesthesiologists) status of participants. Most participants were ASA II (60.4%), 22.7% were ASA I, and only 16.9% were ASA III. No study participants were ASA IV. For the GDFT group, oesophageal doppler monitoring was used in three studies, uncalibrated invasive arterial pressure analysis systems in two studies, and a non-invasive arterial pressure monitoring system in one study. In all studies, GDFT optimization was conducted only intraoperatively. Only one study was at low risk of bias in all domains. The other five studies were at unclear or high risk of bias in one to three domains. RFT may have no effect on the rate of major complications compared to GDFT, but the evidence is very uncertain (RR 1.61, 95% CI 0.78 to 3.34; 484 participants; 5 studies; very low-certainty evidence). RFT may increase the risk of all-cause mortality compared to GDFT, but the evidence on this is also very uncertain (RD 0.03, 95% CI 0.00 to 0.06; 544 participants; 6 studies; very low-certainty evidence). In a post-hoc analysis using a Peto odds ratio (OR) or a Poisson regression model, the odds of all-cause mortality were 4.81 times greater with the use of RFT compared to GDFT, but the evidence again is very uncertain (Peto OR 4.81, 95% CI 1.38 to 16.84; 544 participants; 6 studies; very low-certainty evidence). Nevertheless, sensitivity analysis shows that exclusion of a study in which the final volume of fluid received intraoperatively was higher in the RFT group than in the GDFT group revealed no differences in mortality. Based on analysis of secondary outcomes, such as length of hospital stay (464 participants; 5 studies; very low-certainty evidence), surgery-related complications (364 participants; 4 studies; very low-certainty evidence), non-surgery-related complications (74 participants; 1 study; very low-certainty evidence), renal failure (410 participants; 4 studies; very low-certainty evidence), and quality of surgical recovery (74 participants; 1 study; very low-certainty evidence), GDFT may have no effect on the risk of these outcomes compared to RFT, but the evidence is very uncertain. Included studies provided no data on administration of vasopressors or inotropes to correct haemodynamic instability nor on cost of treatment.

AUTHORS' CONCLUSIONS

Based on very low-certainty evidence, we are uncertain whether RFT is inferior to GDFT in selected populations of adults undergoing major non-cardiac surgery. The evidence is based mainly on data from studies on abdominal surgery in a low-risk population. The evidence does not address higher-risk populations or other surgery types. Larger, higher-quality RCTs including a wider spectrum of surgery types and a wider spectrum of patient groups, including high-risk populations, are needed to determine effects of the intervention.

P4347Automated echocardiographic quantification of left ventricular ejection fraction without volume measurements using a machine learning algorithm mimicking a human expert

Background

Echocardiographic quantification of left ventricular (LV) ejection fraction (EF) relies on either manual or automated identification of endocardial boundaries followed by standard calculation of model-based end-systolic and end-diastolic LV volumes. Recent developments in artificial intelligence resulted in computer algorithms that allow near automated detection of endocardial boundaries and measurement of LV volumes and function. However, boundary identification is still prone to errors limiting accuracy in certain patients. We hypothesized that a fully automated machine learning algorithm could be developed, which circumvents border detection and instead estimates the degree of ventricular contraction, similar to a human expert trained on tens of thousands of images.

Purpose

This study was designed to test the feasibility and accuracy of this approach.

Methods

Machine learning algorithm was developed and trained on a database of >50,000 echocardiographic studies, including multiple apical 2- and 4-chamber views, to automatically estimate LVEF (AutoEF, BayLabs). Testing was performed on an independent group of 99 unselected patients, whose automated EF values were compared to reference values obtained by averaging measurements by 3 experts using conventional volume-based technique. Inter-technique agreement was assessed using linear regression and Bland-Altman analysis of bias and limits of agreement (LOA). Consistency was assessed by mean absolute deviation (MAD) among automated estimates based on different combinations of apical views. Finally, sensitivity and specificity of detecting of EF≤35% was calculated. These metrics were compared side-by-side against the same reference standard to those obtained from conventional EF measurements by clinical readers.

Results

Automated estimation of LVEF was feasible in all 99 patients. AutoEF values showed high consistency (MAD=2.9%) and excellent agreement with the reference values: r=0.95, bias=1.0%, LOA=±11.8%, with sensitivity 0.90 and specificity 0.92 for detection of EF≤35%. This was similar to clinicians' measurements: r=0.94, bias=1.4%, LOA=±13.4%,sensitivity 0.93, specificity 0.87.

Conclusions

Machine learning algorithm for volume-independent LVEF estimation is highly feasible and similar in accuracy to conventional volume-based measurements, when compared to reference values provided by an expert panel.

Acknowledgement/Funding

Bay Labs, Inc.

[Epidemiology of childhood cancer, a single-center study (1985-2016)]

Cancer is the second leading cause of death among children aged 5 to 14, after accidents. We conducted a study on the epidemiology of childhood cancer in the university pediatric oncology department of the CHU-CHR in Liège, Belgium. We studied a cohort of 662 patients between the ages of 0 and 17 whose malignancy diagnosis was made between 1985 and 2016. The analyzes were performed retrospectively using medical files. The number of new cases, the proportion of different cancers, sex ratio, age at diagnosis and survival at 5 and 10 years were the epidemiological factors studied.We have been able to show an increase in the number of new diagnoses per year. More than 40 % of childhood cancers occur before the age of five. The most common neoplasias are leukemias, tumors of the central nervous system and lymphomas. This distribution is influenced by age. All malignant tumours combined, we observed a slightly larger proportion of affected boys than girls. Overall survival at 5 years reaches 80.2 %. However, it varies according to the type of tumour from 59.3 % for malignant soft tissue tumors up to 100 % for hepatoblastomas.

Transcriptomic profile of cell cycle progression genes in human ovarian granulosa cells

The ovarian granulosa cells (GCs) that form the structure of follicle undergo substantial modification during the various stages of human folliculogenesis. These modifications include morphological changes, accompanied by differential expression of genes, encoding proteins which are mainly involved in cell growth, proliferation and differentiation. Recent data bring a new insight into the aspects of GCs' stem-like specificity and plasticity, enabling their prolonged proliferation and differentiation into other cell types. This manuscript focuses attention on emerging alterations during GC cell cycle - a series of biochemical and biophysical changes within the cell. Human GCs were collected from follicles of women set to undergo intracytoplasmic sperm injection procedure, as a part of remnant follicular fluid. The cells were primarily cultured for 30 days. Throughout this time, we observed the prominent change in cell morphology from epithelial-like to fibroblast-like, suggesting differentiation to other cell types. Additionally, at days 1, 7, 15 and 30, the RNA was isolated for molecular assays. Using Affymetrix® Human Genome U219 Array, we found 2579 human transcripts that were differentially expressed in GCs. From these genes, we extracted 582 Gene Ontology Biological Process (GO BP) Terms and 45 KEGG pathways, among which we investigated transcripts belonging to four GO BPs associated with cell proliferation: "cell cycle phase transition", "G1/S phase transition", G2/M phase transition" and "cell cycle checkpoint". Microarray results were validated by RT-qPCR. Increased expression of all the genes studied indicated that increase in GC proliferation during long-term in vitro culture is orchestrated by the up-regulation of genes related to cell cycle control. Furthermore, observed changes in cell morphology may be regulated by a presented set of genes, leading to the induction of pathways specific for stemness plasticity and transdifferentiation in vitro.

Human Wharton's jelly mesenchymal stem cells: properties, isolation and clinical applications

Human Wharton’s jelly mesenchymal stem cells (WJ-MSCs) exhibit CD29, CD79 and CD105 markers, characteristic for mesenchymal cell lines. Under the influence of the appropriate factors, WJ-MSCs can be dedifferentiated to osteoblasts, chondrocytes, adipocytes, myocytes, cardiomyocytes, glial cells and dopaminergic neurons. Wharton’s jelly (WJ) is one of the potential sources of mesenchymal stem cells (MSCs) - obtaining these cells does not raise moral or ethical objections, because the umbilical cord (UC) is a regular waste material. The expression of the OCT-4 and Nanog proteins, which are characteristic for WJ-MSCs may indicate that these cells have retained some embryonic character. The collected data suggests that WJMSCs show increased division and telomerase activity compared to bone marrow MSCs (BM-MSCs). The published results showed no human leucocyte antigen (HLA) class II expression, with the possibility of HLA class I modification by WJ-MSCs, allowing for the transplantation of these cells both within the same and other species - which allows the use of human cells in animal models. The results of selected studies indicate that WJ-MSCs can be an essential element of regenerative medicine of the 21st century.

The p75 neurotrophin receptor in cells of oral mucosal epithelium

The p75 neurotrophin receptor (p75NTR) can play different roles in cells. This protein can on the one hand act in the regulation of cell growth and survival, while being an apoptosis inducing factor in different contexts. p75NTR regulates cell cycle not only in nerve cells but also in epithelial oral mucosal cells. In the former, neurotrophin-p75NTR signaling affects cell growth and survival. Recent studies showed that p75NTR is expressed in basal cells of oral mucosal epithelium and can be used as one of the markers of epithelial stem/progenitor cells. This role of p75NTR can be utilised in aspects such as tissue engineering and gene therapy. One of the examples of clinical use of cultivated oral mucosal cells is ocular surface reconstruction. p75NTR can be a significant marker of stem cells in studies of epithelial tissues, especially when the cells will exhibit other specific markers, such as CK13, CK14 and PCNA..

Enzyme linked receptor protein signaling pathway is one of the ontology groups that are highly up-regulated in porcine oocytes before in vitro maturation

Before being able to fully participate in the processes associated with its function as a female gamete, the oocyte needs to undergo a range of changes to achieve its mature form. These morphological, biochemical and metabolomic processes are induced by the somatic tissues surrounding the oocyte, through the expression of specific transcription and growth factors. The maturation of the oocyte is highly important for the proceedings that lead to successful fertilization, early embryonic development and implantation. Domestic pigs were used as models for our study, with the cumulus-oocyte complexes obtained from the ovaries that were recovered at slaughter. After shedding of the cumulus, oocytes were assessed with BCB test, with the viable ones chosen to undergo in vitro maturation. With the use of expression microarrays, we analyzed gene expression before and after IVM and detected major changes in both genes that were proven to be associated with oocyte maturation before (FOS, VEGFA, CHRDL1, TGFBR3, FST, INSR, ID1, TXNIP, SMAD4, MAP3K1, EIF2AK3 and KIT) and genes not previously linked with reproduction associated processes (MYO1E, PHIP, KLF10 and SHOC2). All the genes were briefly described, with consideration of possible involvement of the newly discovered elements of the transcriptome in the process of oocyte maturation.

Genes involved in regulation of cellular metabolic processes, signaling and adhesion are the markers of porcine buccal pouch mucosal cells long-term primary cultured in vitro

Extraordinary abilities for continuous proliferation and differentiation, associated with constant renewal triggered by stimulation from the mastication process, together with the relative lack of aesthetic complications associated with post-surgery healing, have highlighted buccal pouch mucosa as a potential source of explants that could be used in transplantation and tissue engineering. Additionally, this tissue plays a major role in the oral drug delivery process, which brings special interest to its molecular properties in the context of new drug development. There is therefore a need to analyse the exact mechanisms of oral mucosa functioning, especially when it comes to the processes that are associated with the potential clinical applications. In this study we analysed a complete transcriptome of long-term in vitro cultures of porcine buccal pouch oral mucosa cells. Using a microarray approach, we focused on genes associated with cellular metabolic processes, signalling and adhesion, from 4 gene ontology groups: "Positive regulation of cellular component movement", "Positive regulation of cellular process", "Positive regulation of intracellular signal transduction" and "Single organism cell adhesion". Nineteen genes (CCL8, CXCL2, PLK2, DUSP5, PTGS2, LIF, CCL2, ATP1B1, REL, ITGB3, SCARB1, UGCG, PDPN, LYN, ETS1, FCER1G, TGFB1, RFC4, LMO2) with fold changes higher than |2| and p value Extraordinary abilities for continuous proliferation and differentiation, associated with constant renewal triggered by stimulation from the mastication process, together with the relative lack of aesthetic complications associated with post-surgery healing, have highlighted buccal pouch mucosa as a potential source of explants that could be used in transplantation and tissue engineering. Additionally, this tissue plays a major role in the oral drug delivery process, which brings special interest to its molecular properties in the context of new drug development. There is therefore a need to analyse the exact mechanisms of oral mucosa functioning, especially when it comes to the processes that are associated with the potential clinical applications. In this study we analysed a complete transcriptome of long-term in vitro cultures of porcine buccal pouch oral mucosa cells. Using a microarray approach, we focused on genes associated with cellular metabolic processes, signalling and adhesion, from 4 gene ontology groups: "Positive regulation of cellular component movement", "Positive regulation of cellular process", "Positive regulation of intracellular signal transduction" and "Single organism cell adhesion". Nineteen genes (CCL8, CXCL2, PLK2, DUSP5, PTGS2, LIF, CCL2, ATP1B1, REL, ITGB3, SCARB1, UGCG, PDPN, LYN, ETS1, FCER1G, TGFB1, RFC4, LMO2) with fold changes higher than |2| and p value less than 0.05 were identified, described in context and analysed. While the study needs much further validation to become applicable in a clinical environment, it yields valuable information about the transcriptomic basis of oral mucosal cell functioning in vitro, that might serve as a reference for further research, aiming to apply this knowledge in clinical situations.0.05 were identified, described in context and analysed. While the study needs much further validation to become applicable in a clinical environment, it yields valuable information about the transcriptomic basis of oral mucosal cell functioning in vitro, that might serve as a reference for further research, aiming to apply this knowledge in clinical situations.

Balance between epithelial and stromal marker expression and distribution in primary culture model of porcine endometrium during real-time cell proliferation

The similarity between humans and pigs, when it comes to tissue morphology, makes Sus scrofa not only a good research model, but also a potential source of cells for tissue engineering. Cell samples obtained from the pig donor, could be influenced in vitro, in order to become a source of tissue material for xenotransplantation, reconstructive and regenerative medicine. Significant amounts of data point to especially major similarities in pig and human reproductive systems. Because of that, particular scientific focus is centered on research concerning porcine COCs, theca and granulosa cells in primary cultures. One of the aspects of the reproductive process, that is still largely undiscovered, is the interaction between preimplantation blastocyst and maternal uterine tissues. In this study, we used molecular analysis techniques, such as RT-qPCR and immunocytochemistry, to analyze the expression and distribution of cytokeratin 18 and panCytokeratins 8, 18 and 19 and vimentin in porcine luminal endometrial epithelial cells, coupled with analysis of their behavior in RTCA. The results have confirmed the presence of epithelial, as well as stromal cell markers in the cells, varying in levels at different stages of culture. They have also given insight into the modes of proliferation and differentiation of studied cells in in vitro culture, as well as providing additional proof for the possible mesenchymal transdifferentiation of epithelial cells.

Role of macrophages in the pathogenesis of atherosclerosis and aortocoronary graft disease

Atherosclerosis and disease of graft implanted to bypass occluded coronary or peripheral arteries are similar processes. Patency of implanted grafts is of paramount importance in respect to long-term outcomes. Although few cell types participate in atherosclerotic plaque formation, macrophages play a crucial role. In this article we review the fate of monocytes that infiltrate vessel wall following endothelium damage, and then undergo transformation to macrophages (identified as CD68 positive cells) and eventually lead to severe stenosis of vessel. Opposing biological activity of two subpopulations of macrophages and their impact on plaque instability and its calcification is also presented. At the end of this paper, a possible clinical significance of pre-existing, CD68 positive cell infiltration of vessel wall, applied as aortocoronary grafts, is discussed.

Once-daily long-acting beta₂-agonists/inhaled corticosteroids combined inhalers versus inhaled long-acting muscarinic antagonists for people with chronic obstructive pulmonary disease

BACKGROUND

Three classes of inhaler medication are used to manage chronic obstructive pulmonary disease (COPD): long-acting beta₂-agonists (LABA); long-acting muscarinic antagonists (LAMA); and inhaled corticosteroids (ICS). To encourage patient adherence, two classes of medication are often combined in a single medication device; it seems that once-daily dosing offers greatest convenience to patients and may markedly influence adherence.

OBJECTIVES

To compare a once-daily combination of inhaled corticosteroid and long-acting beta₂-agonist inhalers (ICS/LABA) versus inhaled long-acting muscarinic antagonists alone (LAMA) for people with chronic obstructive pulmonary disease (COPD).

SEARCH METHODS

We performed an electronic search of the Specialised Register of the Cochrane Airways Group (14 May 2018), ClinicalTrials.gov (14 May 2018), and the World Health Organization International Clinical Trials Registry Platform (20 September 2017), then a search of other resources, including reference lists of included studies and manufacturers' trial registers (10 October 2017). Two pairs of review authors screened and scrutinised selected articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing once-daily administered ICS/LABA and LAMA in adults with COPD.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias in each study. We analysed dichotomous data as random-effects odds ratios (ORs) and continuous data as mean differences (MDs), both with 95% confidence intervals (95% CIs), using Review Manager 5.

MAIN RESULTS

We included two studies with 880 participants. We identified one ongoing trial with planned recruitment of 80 participants. Included studies enrolled participants with both partially reversible and non-reversible COPD and baseline mean per cent predicted (%pred) forced expiratory volume in one second (FEV₁) of 43.4 to 49.6. Both studies lasted 12 weeks. Both studies used the same combination of inhaled ICS/LABA (fluticasone furoate and vilanterol 100/25 mcg once daily; FF/VI) versus LAMA (18 mcg tiotropium; TIO). They were published as full articles, and neither study was at low risk of bias in all domains.Compared to the TIO arm, results for pooled primary outcomes for the FF/VI arm were as follows: mortality: OR 0.20, 95% CI 0.02 to 1.73, 880 participants (deaths reported only in the TIO arm), very low-quality evidence; COPD exacerbation (requiring short-burst oral corticosteroids or antibiotics, or both): OR 0.72, 95% Cl 0.35 to 1.50, 880 participants, very low-quality evidence; pneumonia: reported in both studies only during treatment with FF/VI: OR 6.12, 95% Cl 0.73 to 51.24, 880 participants, very low-quality evidence; and total serious adverse events: OR 0.96, 95% Cl 0.50 to 1.83, 880 participants, very low-quality evidence. None of the pneumonias were fatal. Compared to the TIO arm, we found no statistically significant difference for pooled secondary outcomes, including St George's Respiratory Questionnaire (SGRQ) mean total score change; hospital admissions (all-cause); disease-specific adverse events; mean weekly rescue medication use (results available from only one of the studies); and mean weekly percentage of rescue-free days for FF/VI. We found no statistically significant differences between ICS/LABA and LAMA for improvement in symptoms measured by the COPD Assessment Test (CAT score) nor for FEV₁ (change from baseline trough in 24-hour weighted mean on treatment day 84). Many pooled estimates lacked precision. Data for other endpoints such as exacerbations leading to intubation and physical activity measures were not available in included trials.

AUTHORS' CONCLUSIONS

Based on analysis of primary and secondary outcomes, we are uncertain whether once-daily ICS/LABA, combined in one inhaler, has a different efficacy or adverse effect profile compared to LAMA for treatment of people with COPD. However, the current review is based on only two trials with the main focus on primary outcomes other than those considered in this review. The short follow-up period and the very low quality of evidence limit our confidence in the result and increase uncertainty. Further trials of longer duration are needed. Current evidence is not strong enough to demonstrate important differences between inhalers in terms of effects, nor to establish that once-daily fluticasone/vilanterol 100/25 mcg and tiotropium 18 mcg are equivalent.

Gender and age-related variability of macrophage representation in the internal thoracic artery wall: does it matter?

Some recent reports suggested that elderly and female patients did not benefit from implantation of the second internal thoracic artery (ITA) during coronary artery bypass surgery (CABG). Macrophages, among other cells, were described to be involved in both atherosclerosis and aortocoronary grafts failure. The aim of the study was to examine the age and gender association with different distribution of CD68+ cells within the layers of ITA wall. This study involved 158 consecutive patients (95 male and 63 female), with the mean age of 64.5±9.5 years, who underwent elective CABG procedures. During surgery, the surplus distal segments of ITA were harvested for immunohistochemical analysis. The number and distribution of CD68+ cells was calculated and plotted against the age and gender of the study participants. CD68+ cells were present in all of the harvested ITA fragments (median 44), more in women (55) than in men (42) (p less than 0.001). However, this difference was of statistical significance exclusively in the tunica intima. Approximately 70% of macrophages were found in the tunica adventitia. The total number of CD68+ cells the in arterial wall as well as in the tunica intima and adventitia correlated positively with the age of patients (r=0.544, r=501 and r=0.462, respectively). The lack of significant advantages of the use of two thoracic arteries, in elderly patients and women, might have resulted from the larger population of CD68+ cells in their walls, especially the tunica intima. However, this result from immunohistochemical analysis needs validation in long-term clinical research on a larger cohort of patients.