Observation of Seven Astrophysical Tau Neutrino Candidates with IceCube

We report on a measurement of astrophysical tau neutrinos with 9.7 yr of IceCube data. Using convolutional neural networks trained on images derived from simulated events, seven candidate ν_{τ} events were found with visible energies ranging from roughly 20 TeV to 1 PeV and a median expected parent ν_{τ} energy of about 200 TeV. Considering backgrounds from astrophysical and atmospheric neutrinos, and muons from π^{±}/K^{±} decays in atmospheric air showers, we obtain a total estimated background of about 0.5 events, dominated by non-ν_{τ} astrophysical neutrinos. Thus, we rule out the absence of astrophysical ν_{τ} at the 5σ level. The measured astrophysical ν_{τ} flux is consistent with expectations based on previously published IceCube astrophysical neutrino flux measurements and neutrino oscillations.

Gene expression and copy number profiling of follicular lymphoma biopsies from patients treated with first-line rituximab without chemotherapy

The Nordic Lymphoma Study Group has performed two randomized clinical trials with chemotherapy-free first-line treatment (rituximab +/- interferon) in follicular lymphoma (FL), with 73% of patients alive and 38% without any need of chemotherapy after 10.6 years median follow-up. In order to identify predictive markers, that may also serve as therapeutic targets, gene expression- and copy number profiles were obtained from 97 FL patients using whole genome microarrays. Copy number alterations (CNAs) were identified, e.g. by GISTIC. Cox Lasso Regression and Lasso logistic regression were used to determine molecular features predictive of time to next therapy (TTNT). A few molecular changes were associated with TTNT (e.g. increased expression of INPP5B, gains in 12q23/q24), but were not significant after adjusting for multiple testing. Our findings suggest that there are no strong determinants of patient outcome with respect to GE data and CNAs in FL patients treated with a chemotherapy-free regimen (i.e. rituximab +/- interferon).

Identifying Early-Life Behavior to Predict Mothering Ability in Swine Utilizing NUtrack System

Early indicator traits for swine reproduction and longevity support economical selection decision-making. Activity is a key variable impacting a sow's herd life and productivity. Early-life activities could contribute to farrowing traits including gestation length (GL), number born alive (NBA), and number weaned (NW). Beginning at 20 weeks of age, 480 gilts were video recorded for 7 consecutive days and processed using the NUtrack system. Activity traits included angle rotated (radians), average speed (m/s), distance traveled (m), time spent eating (s), lying lateral (s), lying sternal (s), standing (s), and sitting (s). Final daily activity values were averaged across the period under cameras. Parity one data were collected for all gilts considered. Data were analyzed using linear regression models (R version 4.0.2). GL was significantly impacted by angle rotated (p = 0.03), average speed (p = 0.07), distance traveled (p = 0.05), time spent lying lateral (p = 0.003), and lying sternal (0.02). NBA was significantly impacted by time spent lying lateral (p = 0.01), lying sternal (p = 0.07), and time spent sitting (p = 0.08). NW was significantly impacted by time spent eating (p = 0.09), time spent lying lateral (p = 0.04), and time spent sitting (p = 0.007). This analysis suggests early-life gilt activities are associated with sow productivity traits of importance. Further examination of the link between behaviors compiled utilizing NUtrack and reproductive traits is necessitated to further isolate behavioral differences for potential use in selection decisions.

Observation of high-energy neutrinos from the Galactic plane

The origin of high-energy cosmic rays, atomic nuclei that continuously impact Earth's atmosphere, is unknown. Because of deflection by interstellar magnetic fields, cosmic rays produced within the Milky Way arrive at Earth from random directions. However, cosmic rays interact with matter near their sources and during propagation, which produces high-energy neutrinos. We searched for neutrino emission using machine learning techniques applied to 10 years of data from the IceCube Neutrino Observatory. By comparing diffuse emission models to a background-only hypothesis, we identified neutrino emission from the Galactic plane at the 4.5σ level of significance. The signal is consistent with diffuse emission of neutrinos from the Milky Way but could also arise from a population of unresolved point sources.

Combined regression score predicts outcome after neoadjuvant treatment of oesophageal cancer

BACKGROUND

Histopathologic regression following neoadjuvant treatment (NT) of oesophageal cancer is a prognostic factor of survival, but the nodal status is not considered. Here, a score combining both to improve prediction of survival after neoadjuvant therapy is developed.

METHODS

Seven hundred and fifteen patients with oesophageal squamous cell (SCC) or adenocarcinoma (AC) undergoing NT and esophagectomy were analysed. Histopathologic response was classified according to percentage of vital residual tumour cells (VRTC): complete response (CR) without VRTC, major response with <10% VRTC, minor response with >10% VRTC. Nodal stage was classified as ypN0 and ypN+. Kaplan-Meier and Cox regression were used for survival analysis.

RESULTS

Survival analysis identified three groups with significantly different mortality risks: (1) low-risk group for CR (ypT0N0) with 72% 5-year overall survival (5y-OS), (2) intermediate-risk group for minor/major responders and ypN0 with 59% 5y-OS, and (3) high-risk group for minor/major responders and ypN+ with 20% 5y-OS (p < 0.001). Median survival in AC and SCC cohorts were comparable (3.8 (CI 95%: 3.1, 5.3) vs. 4.6 years (CI 95%: 3.3, not reached), p = 0.3).

CONCLUSIONS

Histopathologic regression and nodal status should be combined for estimating AC and SCC prognosis. Poor survival in the high-risk group highlights need for adjuvant therapy.

Utilizing NUtrack to Access the Activity Levels in Pigs with Varying Degrees of Genetic Potential for Growth and Feed Intake

Feed cost accounts for over two-thirds of the variable cost of production. In order to reduce feed costs without sacrificing production numbers, feed efficiency must be improved. Calorie expenditure has been difficult to quantify in the past but is understood to impact residual feed intake (RFI) greatly. The objective of this work was to utilize an advanced computer vision system to evaluate activity levels across sex and sire groups with different expected breeding value combinations for growth and feed intake. A total of 199 pigs from four different sire groups (DNA Genetics Line 600) High Feed Intake/High Growth (HIHG), Low Feed Intake/High Growth (LIHG), High Feed Intake/Low Growth (HILG), and Low Feed Intake/Low Growth (LILG) were utilized at the UNL ENREC farm over 127 days. The NUtrack system allowed for individual monitoring of pigs in group housing to track daily activity traits. In total, HIHG pigs travelled less (p < 0.05; 139 vs. 150 km), spent more time lying (p < 0.05; 2421 vs. 2391 h), and less time eating (p < 0.05; 235 vs. 243 h) when compared to LILG pigs across time. The results suggest variation in activity occurs across the progeny of the sire groups selected to differentiate in growth and feed intake.

[Complementary or alternative medicine in oncology : Chances or risks?]

BACKGROUND

Approximately half of all cancer patients use complementary or alternative medicine.

AIM

The results of the German S3 guidelines on complementary oncology are presented and placed into the context of patient consultation.

MATERIAL AND METHODS

The core recommendations of the S3 guidelines are summarized including an overview of the evidence.

RESULTS

Selected methods of complementary medicine can be used with the aim of improving the quality of life and reducing side effects. Comprehensive data are available for physical activity with respect to survival, quality of life and supportive therapy. For most other methods the evidence is relatively low. Therefore, weighing up the benefits and risks more frequently resulted in negative recommendations in the guidelines, especially for methods based on substances. Exceptions to this are three micronutrients (vitamins B12, D and selenium), as even in the case of a well-balanced diet, deficiency symptoms are possible. Therefore, routine measurement of the blood levels of these micronutrients is recommended.

CONCLUSION

The questions from patients on what they can do by themselves should be answered respectfully and based on evidence. The benefits and risks of complementary methods must be carefully considered. To do this, regular questioning of patients on the interest in complementary methods is recommended. The decisive benefit of complementary medicine is the chance for patients to become active themselves. Therefore, all recommendations refer to the discussion with the patient, which do not formulate a therapy but are consultation recommendations: should be recommended instead of should be done.

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A supermassive black hole, obscured by cosmic dust, powers the nearby active galaxy NGC 1068. Neutrinos, which rarely interact with matter, could provide information on the galaxy’s active core. We searched for neutrino emission from astrophysical objects using data recorded with the IceCube neutrino detector between 2011 and 2020. The positions of 110 known gamma-ray sources were individually searched for neutrino detections above atmospheric and cosmic backgrounds. We found that NGC 1068 has an excess of 79 − 20 + 22 neutrinos at tera–electron volt energies, with a global significance of 4.2σ, which we interpret as associated with the active galaxy. The flux of high-energy neutrinos that we measured from NGC 1068 is more than an order of magnitude higher than the upper limit on emissions of tera–electron volt gamma rays from this source.

Implementing public health and social measures: an integral part of the health emergency management cycle

Public health and social measures (PHSM) have been utilized as a tool to reduce the infection rates and disease burden throughout the COVID-19 pandemic and continue to play an important role even with vaccination campaigns well underway in preventing severe disease. In order to systematically track, analyze and report qualitative and quantitative data o PHSM implementation across the European Region and assist countries in the COVID-19 response, the COVID-19 Incident Management Support team at the WHO Regional Office for Europe developed PHSM Severity Index and PHSM Dashboard. The PHSM Severity Index captures the types, severity and timing of PHSMs implemented by a country across six main indicators. By providing standardized data on PHSM implementation, the PHSM Severity Index can support and inform the development of policy at country and regional levels. PHSM data, severity methodology and policy tools developed throughout the COVID-19 pandemic should be adapted to provide a foundation for preparedness for future large-scale health emergencies. In addition, discerning the epidemiological impact of specific PHSM and their combinations currently is a priority for policy-makers and can guide countries’ transition strategies. Analysing the impact of PHSM on COVID-19 transmission is of critical importance, especially as variants of concern bring new waves of COVID-19 cases and may challenge countries’ vaccination and response strategies. Reference PHSM in Response to COVID-19 (who.int)

Supporting decision making on public health and social measures in response to COVID-19- The PHSM calibration tool

 

Public health and social measures (PHSM) are preventative measures taken by individuals, communities and government institutions at national and local levels to prevent and reduce transmission of an infectious disease - in this instance SARS-CoV-2. The decision to introduce, adapt or lift PHSM should be based primarily on a situational assessment of the intensity of transmission of SARS-CoV-2 and the capacity of the health system to respond to subsequent increases in hospital admissions, but must also consider the effects these measures may have on the general welfare of society and individuals. The WHO Regional Office for Europe developed an online public health and social measures (PHSM) calibration tool to assist Member States in decision-making relating to PHSM implementation during the COVID-19 pandemic. The tool, designed to be used primarily by policy-makers in national and local government authorities, provides guidance based on a situational-level assessment framework that is determined by the level of community transmission and the overall capacity of health systems and public health services within a country or region to respond. By using a combination of country-reported and user-input data, the tool automatically generates a situational assessment and corresponding PHSM guidance for users, summarized in a downloadable report.

Reference

https://phsm.euro.who.int/calibrationTool

Search for Unstable Sterile Neutrinos with the IceCube Neutrino Observatory

We present a search for an unstable sterile neutrino by looking for a resonant signal in eight years of atmospheric ν_{μ} data collected from 2011 to 2019 at the IceCube Neutrino Observatory. Both the (stable) three-neutrino and the 3+1 sterile neutrino models are disfavored relative to the unstable sterile neutrino model, though with p values of 2.8% and 0.81%, respectively, we do not observe evidence for 3+1 neutrinos with neutrino decay. The best-fit parameters for the sterile neutrino with decay model from this study are Δm_{41}^{2}=6.7_{-2.5}^{+3.9}  eV^{2}, sin^{2}2θ_{24}=0.33_{-0.17}^{+0.20}, and g^{2}=2.5π±1.5π, where g is the decay-mediating coupling. The preferred regions of the 3+1+decay model from short-baseline oscillation searches are excluded at 90% C.L.

P11.15.B First multicentric real-life experience with the combination of lomustine and temozolomide in newly diagnosedMGMT promoter methylatedIDH wildtype glioblastoma

Background

The CeTeG/NOA-09 trial assessed in a randomized phase 3 setting, whether combined treatment of lomustine together with temozolomide was superior to temozolomide treatment alone in newly diagnosed MGMT (O(6)-methylguanine-DNA-methyltransferase) promoter methylated glioblastoma patients. Survival was significantly improved from 31.4 months with temozolomide alone to 48.1 months with the combination of lomustine plus temozolomide. In view of this encouraging data - suggesting this combination could have a significant impact on the survival of newly diagnosed glioblastoma patients - we were curious to assess safety and efficacy of this regimen under real-life conditions.

Material and Methods

We collected clinical and radiographic data from adult newly diagnosed MGMT promoter methylated IDH (isocitrate dehydrogenase) wildtype glioblastoma patients treated at five neuro-oncology centers in Germany. As a requirement for inclusion, first-line treatment with lomustine plus temozolomide had to be performed for at least six weeks (one course). The available radiographic data was independently reviewed by an experienced board-certified neuro-radiologist.

Results

In total, 70 patients were included. Median progression-free survival of the full cohort was 14.4 months and median overall survival was 36.0 months. Patients who received TTFields (Tumor Treating Fields) treatment for eight weeks or longer together with the combination of lomustine plus temozolomide (n=22, 31%) had a prolonged progression-free survival compared to those patients who received TTFields treatment less than eight weeks or did not receive treatment with TTFields (n=48, 69%) (21.5 months versus 11.2 months; HR: 2.118, 95% CI: 1.245-3.605; p=0.0105). In a multivariable Cox regression analysis the use of TTFields for eight weeks or longer together with the combination of lomustine plus temozolomide as well as the application of at least five courses of CeTeG therapy emerged as independent prognostic factors for progression-free survival and overall survival. Pseudoprogression occurred in n=16 (33%) of the patients. We observed no treatment related deaths and high-grade hematotoxicity in n=31 (44%) of the patients.

Conclusion

The results from this multicentric trial that investigated newly diagnosed MGMT promoter methylated IDH wildtype glioblastoma under real-life conditions indicate toxicity and survival estimates comparable to the CeTeG/NOA-09 trial. The use of TTFields for at least eight weeks in combination with this regimen was independently associated with extended progression-free and overall survival.

OS06.5.A Investigating safety and efficacy of TTFields prior and concomitant to radiotherapy in newly diagnosed glioblastoma - the PriCoTTF phase I/II trial

Background

The EF-14 phase III trial demonstrated improved survival for patients with newly diagnosed glioblastoma (nGBM) when TTFields therapy was added to adjuvant temozolomide chemotherapy. TTFields at 200 kHz are applied to the tumor utilizing arrays on the patients’ scalp. In preclinical studies, a synergistic inhibiting effect on glioblastoma cell proliferation was found for the combination of TTFields and radiotherapy. Based on these findings, we conduct the phase I/II PriCoTTF trial in adult nGBM patients to investigate the safety and efficacy of TTFields therapy initiated prior and concomitant to radiochemotherapy.

Material and Methods

Per study protocol, TTFields therapy is initiated following surgery and completed wound healing. Continuing throughout radiochemotherapy and adjuvant chemotherapy, TTFields therapy is used for approximately 9 months in total with TTFields rechallenge allowed at recurrence. Radiotherapy is conducted with arrays applied on the patients’ scalp. A total recruitment of 33 patients was sought, with 20 patients in arm A receiving normo-fractionated radiotherapy, and 13 elderly patients in arm B receiving hypo-fractionated radiotherapy. Safety and tolerance are the study’s primary endpoint, analyzed by a selection of pre-specified treatment-limiting toxicities (TLTs).

Results

A total of 33 patients have been enrolled. Patients' characteristics were mostly typical for glioblastoma, except for a rather low fraction of patients with gross total resection (GTR, 22.5%). The distribution of adverse events of common toxicity criteria (CTC) grade 3 or higher was comparable to that of established glioblastoma trials. Notably, skin toxicity of CTC grade 3 or higher was quite uncommon (n=2, 6%). As no patient developed TLTs, the study's primary endpoint was met. Median TTFields treatment duration was 8.4 months. Overall survival data was not mature enough (event rate 48%) to allow for a definite conclusion. Notably, on multivariable Cox regression, the number of days with TTFields adherence of more than 23 hours was independently associated with overall survival (HR 0.96, 95% confidence interval 0.93 - 0.99, p=0.008).

Conclusion

The PriCoTTF trial met its primary endpoint indicating that combined TTFields and radiotherapy is safe and well tolerated. High-grade skin toxicity was quite uncommon and the patients with high TTFields adherence seem to perform particularly well. An extended follow-up is required to provide first estimates regarding putative efficacy. At that point in time, the reduced overall TTFields duration and fraction of patients with GTR need to be factored in.

P11.14.A Systematic review of phase III trials in newly diagnosed glioblastoma 2005-2021

Background

Despite a plethora of studies since the EORTC/NCIC trial in 2005, glioblastoma (GBM) prognosis remains poor. We here identify and compare glioblastoma phase III trials in terms of efficacy and baseline characteristics in an attempt to summarize the experience of the past 16 years.

Methods

A systematic literature search using PubMed and ClinicalTrials.gov was conducted to provide an overview of clinically relevant GBM phase III trials (years 2005-2021) of adult patients younger than 70 years of age. Search results were screened according to predefined inclusion criteria and either excluded or included in further analysis on study design, baseline characteristics, and survival results.

Results

Eleven trials from the literature and clinical trial database fulfilled the search criteria. Among these trials, a total of three GBM phase III trials reported overall survival (OS) benefit, including the EORTC/NCIC study (NCT00006353), EF-14 (NCT00916409) and CeTeG/NOA09 (NCT01149109). All three studies demonstrate similar hazard ratios, which translate into risk reduction of about 40%. Furthermore, low toxicity profile and mostly preserved quality of life were attributed to the treatments tested. Looking at the study designs, eight out of eleven trials were open label randomized trials, including all of the positive ones, and only three negative trials employed treatment blinding and a placebo control. Canonical baseline characteristics (extent of resection, age, gender, MGMT promoter methylation status) did not significantly differ between positive and negative trials. IDH mutation status was analyzed in only two trials, each showing a small percentage of IDH-mutant tumors only.

Conclusion

This analysis on GBM phase III trials conducted between 2005 and 2021 revealed that the majority of trials did not show a significant improvement in overall survival. CeTeG/NOA-09 and EF-14 are the only two studies with positive overall survival outcome since the EORTC/NCIC trial in 2005.

P17.04.B Combination of Trofosfamide and Etoposide in Recurrent Glioma

Background

Disease relapse almost inevitably occurs in patients with adult-type diffuse glioma. Standard of care treatment options at tumor relapse are still not well defined. Frequently used drugs for adult-type diffuse glioma recurrence include lomustine (CCNU) and bevacizumab. Few studies indicate that the combination of trofosfamide/etoposide, given their high lipid solubility with good blood-brain barrier penetrance, may be feasible in pediatric glioblastoma patients. In this retrospective analysis, we determined tolerability and feasibility of combined trofosfamide/etoposide treatment at disease recurrence of patients with adult-type diffuse glioma.

Material and Methods

We collected clinicopathological data from adult patients with adult-type diffuse glioma treated with the combination of trofosfamide/etoposide at the Division of Clinical Neurooncology at the University Hospital Essen. Only those patients were considered eligible who received trofosfamide/etoposide treatment for more than four weeks (one course). Trofosfamide (100mg/m2/day) and Etoposide (25mg/m2/day) was administered orally in a “one week on, one week off” scheme. A cohort of patients receiving empiric treatment at the investigators’ discretion balanced for tumor entity and canonical prognostic factors (number of previous treatments, MGMT promoter methylation, IDH mutation status, KPS, age, extent of resection) served as control. We collected toxicity data as it pertained to CTCAE (Common Terminology Criteria for Adverse Events, version 5.0) and survival data to explore putative efficacy.

Results

A total of 33 patients were eligible for this analysis. In the IDH wild-type glioblastoma (n=18) subgroup, median progression-free survival (3.8 months versus 2.9 months, HR: 2.09, 95% CI: 1.010-4.312, p=0.0227; PFS-6: 39% versus 6%) and median overall survival (10.4 months versus 5.7 months, HR: 3.05, 95% CI: 1.393-6.655, p=0.0008) were significantly prolonged as compared to the control cohort. In a multivariable Cox regression analysis, treatment with trofosfamide/etoposide emerged as statistically significant prognostic marker regarding progression-free survival and overall survival. We observed high-grade adverse events (CTCAE grade≥III ) in 21 (64%) of all recurrent glioma patients with hematotoxicity comprising most adverse events (n=18, 86%). Lymphopenia was by far the most observed hematotoxic adverse event (n=13, 62%). Among non-hematologic high-grade adverse events was transaminase elevation (n=3, 14%).

Conclusion

This study provides first indication that the combination of trofosfamide/etoposide is safe in patients with adult-type diffuse gliomas and may be associated with prolonged survival in adult patients with recurrent IDH wildtype glioblastoma. Our data provide a reasonable rationale for follow-up of a larger cohort in a prospective controlled trial.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Strong Constraints on Neutrino Nonstandard Interactions from TeV-Scale ν_{μ} Disappearance at IceCube

We report a search for nonstandard neutrino interactions (NSI) using eight years of TeV-scale atmospheric muon neutrino data from the IceCube Neutrino Observatory. By reconstructing incident energies and zenith angles for atmospheric neutrino events, this analysis presents unified confidence intervals for the NSI parameter ε_{μτ}. The best-fit value is consistent with no NSI at a p value of 25.2%. With a 90% confidence interval of -0.0041≤ε_{μτ}≤0.0031 along the real axis and similar strength in the complex plane, this result is the strongest constraint on any NSI parameter from any oscillation channel to date.

Physical Activity After Heart Transplantation: Characteristics, Motifs, Barriers, and Influence of COVID-19 Pandemic

Purpose

After heart transplantation (HTX), regular physical activity (PA) is crucial to counteract transplant-related alterations and improve functional performance. Not much is known about the long-term implementation of PA and potential problems that may occur. The potential influence of COVID-19 pandemic is unknown.

Methods

Online questionnaire survey: 158 patients (53±14 yrs, 65% male, 8±7 yrs after HTX) were included. Recruitment was carried out via HTX outpatient departments, transplant sport associations, self-aid groups and social media. The questionnaire included 77 to 138 items divided into 6 categories and 3 time points (pre heart failure, after HTX before COVID-19, after HTX during COVID-19). The survey was approved by the local ethics committee.

Results

88% reported regular PA after HTX (before COVID-19) and 75% had taken up PA within the first year. Patients stated higher level of PA after HTX, compared to the pre heart failure period (p<0.05). Patients who completed cardiac rehabilitation (70%), started leisure-time PA significantly earlier (p<0.05) and with higher frequency (p<0.05). Figure 1 shows the most important motifs/barriers for regular PA and changes over the reported period. Satisfaction with sports facilities was moderate and 39% complained about the need for improvement (e.g. exercise education). 61% performed exercise training without a professional supervision. Exercise monitoring was mostly done using heart rate respond (52%), but frequently no monitoring was used (32%). During COVID-19, patients were more dissatisfied with their level of regular PA (p<0.01) or physical condition (p<0.05) and emphasized the beneficial effect of PA on their mental balance.

Conclusion

After HTX, most patients try to integrate regular PA in their leisure-time behavior, but complain about a lack of detailed exercise education and appropriate sports facilities. Participation in a cardiac rehabilitation after HTX may have positive long-term impact on PA levels.