OP0038 VITAMIN D AND MARINE n-3 FATTY ACID SUPPLEMENTATION FOR PREVENTION OF AUTOIMMUNE DISEASE IN THE VITAL RANDOMIZED CONTROLLED TRIAL: OUTCOMES OVER 7 YEARS

Background

Strong biologic rationale supports both vitamin D and marine omega-3 (n-3) fatty acids for prevention of autoimmune disease (AD). Within the randomized, double-blind, placebo-controlled VITamin D and OmegA-3 TriaL (VITAL), we tested the effects of these supplements on AD incidence. We previously reported results after 5.3 years of randomized follow-up showing overall protective effects for vitamin D on AD incidence (HR 0.78, 95% CI 0.61-0.99) and suggestive results for n-3 fatty acids (HR 0.85, 95%CI 0.67-1.08)1.

Objectives

We aimed to test effects of these supplements with two more years of post-intervention follow-up in VITAL.

Methods

VITAL enrolled and randomized men and women (age ≥50 and ≥55 years, respectively) in a 2-by-2 factorial design to vitamin D3 (2000 IU/d) and/or n-3 fatty acids (1000 mg/d) or placebo and followed for median 5.3 years. Here, we followed participants for another 2 years of observation to assess for sustained effects. Incident AD diagnoses were reported by participants annually and confirmed by medical record review by expert physicians using existing classification criteria. The primary endpoint was total incident AD, including rheumatoid arthritis (RA), polymyalgia rheumatica (PMR), autoimmune thyroid disease (AITD), psoriasis, and all others. Pre-specified secondary endpoints included individual common AD; and probable AD. Cox models calcuated hazard ratios (HR) for incident ADs.

Results

Of 25,871 participants randomized, 71% self-reported non-Hispanic Whites, 20% Black, 9% other racial/ethnic groups, 51% women, mean age was 67.1 years. During 7.5 years median follow-up, confirmed AD was diagnosed in 156 participants in vitamin D arm vs 198 in vitamin D placebo arm, HR 0.79 (0.64-0.97). Incident AD was confirmed in 167 participants in n-3 fatty acid arm and 187 in n-3 fatty acid placebo arm, HR 0.89 (0.72-1.10). For vitamin D, HRs trended toward reduction for RA 0.67 (0.37- 1.21), PMR 0.69 (0.46-1.03) and psoriasis 0.57 (0.33-0.99). For n-3 fatty acids, HRs trended toward reduction for RA 0.55 (0.30-1.10) and AITD 0.61 (0.33-1.12). Vitamin D’s effect on AD incidence was stronger in those with body mass index (BMI) < 25 (HR 0.65, 0.44-0.96) than ≥ 25 kg/m2 (p interaction 0.01).

Conclusion

Supplementation for 5.3 years with 2000 IU/day vitamin D (compared to placebo), followed by 2 years of observational follow-up, significantly reduced overall incident AD by 21% in older adults. HRs for RA, PMR and psoriasis trended toward reduction with vitamin D, with stronger effect in those with normal BMI. Supplementation with 1000 mg/day n-3 fatty acids did not significantly reduce total AD.

References

[1]Hahn J et al, BMJ, 2022 Jan 26;376: e066452.

Table 1.

Hazard Ratios for Primary and Secondary Endpoints, by Randomized Assignment to Vitamin D/Placebo (Left), N-3 Fatty Acids/Placebo (Right)a

EndpointVitamin D3(N=12,927)Placebo (N=12,944)Hazard Ratio (95% CI)pN-3 Fatty Acids (N=12,933)Placebo (N=12,938)Hazard Ratio (95% CI)pPrimary: Confirmed AD1561980.79 (0.64-0.97)0.031671870.89 (0.72-1.10)0.27Secondary:Confirmed + probable AD2653210.83 (0.70-0.97)0.022713150.86 (0.73-1.01)0.06Excluding subjects with any pre-randomization AD Confirmed AD1271620. 79 (0.62-0.99)0.041411480.95 (0.75-1.20)0.66 Confirmed + probable AD2112700. 78 (0.65-0.94)0.0072322490.93 (0.78-1.11)0.41Excluding first 2 years follow-up Confirmed AD861300.66 (0.50-0.87)0.0031041120.92 (0.71-1.21)0.56 Confirmed + probable AD1472050.72 (0.58-0.89)0.0021721800.95 (0.77-1.17)0.63Individual ADb RA18270.67 (0.37-1.21)0.1816290.55 (0.30-1.01)0.06 PMR39570.69 (0.46-1.03)0.0746500.92 (0.61-1.37)0.67 AITD27181.50 (0.82-2.71)0.1917280.61 (0.33-1.12)0.11 Psoriasis20350.57 (0.33-0.99)0.0534211.62 (0.94-2.79)0.08

aAnalyses from Cox regression models controlled for age, sex, race, and other (n-3 fatty acid or vitamin D) randomization group bConfirmed AD.

Figure 1.

Disclosure of Interests

Karen Costenbader Consultant of: Astra Zeneca, Glaxo Smith Kline, Neutrolis, Grant/research support from: Merck, Exagen, Gilead, Nancy Cook: None declared, I-min Lee: None declared, Jill Hahn: None declared, Joseph Walter: None declared, Vadim Bubes: None declared, Gregory Kotler: None declared, Nicole Yang: None declared, Sonia Friedman: None declared, Erik Alexander: None declared, JoAnn Manson: None declared.

Interleukin-4 reduces lesion volume and improves neurological function in the acute phase after experimental traumatic brain injury in mice

Little is known about the impact of Interleukin-4 (IL-4) on secondary brain damage in the acute phase after experimental traumatic brain injury (TBI). Therefore, we evaluated the effect of IL-4-Knockout on structural damage as well as functional impairment in the acute phase after experimental TBI in mice. 28 C57Bl/6 wildtype and 20 C57BL/6-Il4tm1Nnt/J Interleukin-4-Knockout (IL-4-KO) mice were subjected to Controlled Cortical Impact (CCI). Contusion volumes, body weight and functional outcome (Video Open Field Test (VOF), Hole Board Test (HB), CatWalkXT®) were determined on postoperative days one (D1), three (D3) and seven (D7). Contusion volume (13.45 +/- 0.88 mm³ vs. 9.50 +/- 0.97 mm³, p=0.015) and weight loss (-2.92 +/- 0.52% vs. -0.85 +/- 0.67%, p=0.027) were significantly higher and exploration behavior significantly more impaired (e.g., 150.44 +/- 18.71 fields explored vs. 211.56 +/- 18.90 fields explored, p=0.028 in the VOF; 23.31 +/- 2.03 holes explored vs. 35.65 +/- 1.93 holes explored, p<0.001 in the HB) in IL-4-KO mice on D1. Gait impairment was significantly more pronounced in IL-4-KO mice throughout the first week after CCI (e.g., 0.07 +/- 0.01s vs. 0.00 +/- 0.01s, p=0.047 for right hindpaw Swing on D1; -1.76 +/- 1.34 U vs. 2.53 +/- 0.90 U, p=0.01 for right forepaw Mean Intensity on D3; -0.01 +/- 0.01cm² vs. 0.05 +/- 0.01cm², p=0.015 for left forepaw Mean Area on D7). In conclusion, IL-4 reduces structural damage and improves functional outcome in the acute phase after CCI. Neurobehavioral outcome assessment in IL-4-related studies should focus on motor function on the first three days after trauma induction.

The Local Intraarterial Administration of Nimodipine Might Positively Affect Clinical Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage and Delayed Cerebral Ischemia

The effect of the intraarterial administration of nimodipine as a rescue measure to treat delayed vasospasm after aSAH remains understudied; therefore, we evaluated its effect on short- and long-term functional and neuropsychological outcomes after aSAH. In this prospective observational study, a total of 107 consecutive patients treated for aSAH of WFNS grades I−V were recruited. At follow-up visits 3-, 12- and 24-months after the hemorrhage, functional outcome was assessed using the Extended Glasgow Outcome (GOSE) and modified Rankin (mRS) scales, while neurocognitive function was evaluated using the screening module of the Neuropsychological Assessment Battery (NAB-S). The outcome of patients, who had received rescue therapy according to the local standard treatment protocol (interventional group, n = 37), and those, who had been treated conservatively (conservative group, n = 70), were compared. Even though significantly more patients in the interventional treatment group suffered from high-grade aSAH (WFNS Grades IV and V, 54.1% vs. 31.4%, p = 0.04) and required continuous drainage of cerebrospinal fluid at discharge (67.7% vs. 37.7%, p = 0.02) compared to the control group, significant differences in functional outcome were present only at discharge and three months after the bleeding (GOSE > 4 in 8.1% vs. 41.4% and 28.6% vs. 72.7%, p < 0.001 and p = 0.01 for the interventional and control group, respectively). Thereafter, group differences were no longer significant. While significantly more patients in the intervention group had severe neuropsychological deficits (76.3% vs. 36.0% and 66.7% vs. 29.2%, p = 0.04 and 0.05, respectively) and were unable to work (5.9% vs. 38.1%, p = 0.03 at twelve months) at three and twelve months after the hemorrhage, no significant differences between the two groups could be detected at long-term follow-up. The presence of moderate neuropsychological impairments did not significantly differ between the groups at any timepoint. In conclusion, despite initially being significantly more impaired, patients treated with intraarterial administration of nimodipine reached the same functional and neuropsychological outcomes at medium- and long-term follow-up as conservatively treated patients suggesting a potential beneficial effect of intraarterial nimodipine treatment for delayed vasospasm after aSAH.

Hydrodynamic simulations of sedimenting dilute particle suspensions under repulsive DLVO interactions

We present guidelines to estimate the effect of electrostatic repulsion in sedimenting dilute particle suspensions. Our results are based on combined Langevin dynamics and lattice Boltzmann simulations for a range of particle radii, Debye lengths and particle concentrations. They show a simple relationship between the slope K of the concentration-dependent sedimentation velocity and the range χ of the electrostatic repulsion normalized by the average particle-particle distance. When χ → 0, the particles are too far away from each other to interact electrostatically and K = 6.55 as predicted by the theory of Batchelor. As χ increases, K likewise increases as if the particle radius increased in proportion to χ up to a maximum around χ = 0.4. Over the range χ = 0.4-1, K relaxes exponentially to a concentration-dependent constant consistent with known results for ordered particle distributions. Meanwhile the radial distribution function transitions from a disordered gas-like to a liquid-like form. Power law fits to the concentration-dependent sedimentation velocity similarly yield a simple master curve for the exponent as a function of χ, with a step-like transition from 1 to 1/3 centered around χ = 0.6.

Focal lesion size poorly correlates with motor function after experimental traumatic brain injury in mice

Background

It remains unclear whether neurobehavioral testing adds significant information to histologic assessment of experimental traumatic brain injury (TBI) and if automated gait assessment using the CatWalk XT^®, while shown to be effective in in the acute phase, is also effective in the chronic phase after experimental TBI. Therefore, we evaluated the correlation of CatWalk XT^® parameters with histologic lesion volume and analyzed their temporal and spatial patterns over four weeks after trauma induction.

Methods

C57Bl/6 mice were subjected to controlled cortical impact (CCI). CatWalk XT^® analysis was performed one day prior to surgery and together with the histological evaluation of lesion volume on postoperative days one, three, seven, 14 and 28. Temporal and spatial profiles of gait impairment were analyzed and a total of 100 CatWalk XT^® parameters were correlated to lesion size.

Results

While in the first week after CCI, there was significant impairment of nearly all CatWalk XT^® parameters, impairment of paw prints, intensities and dynamic movement parameters resolved thereafter; however, impairment of dynamic single paw parameters persisted up to four weeks. Correlation of the CatWalk XT^® parameters with lesion volume was poor at all timepoints.

Conclusion

As CatWalk XT^® parameters do not correlate with focal lesion size after CCI, gait assessment using the CatWalk XT^® might add valuable information to solitary histologic evaluation of the injury site. While all CatWalk XT^® parameters can be used for gait assessments in the first week after CCI, dynamic single paw parameters might be more relevant in the chronic phase after experimental TBI.

Derivation and validation of a novel 3-hour pathway for the observe-zone of the ESC 0/1h-algorithm

Background

The latest non-ST elevation myocardial infarction (NSTEMI) guidelines from the European Society of Cardiology (ESC) recommend a 3h cardiac troponin determination in patients triaged to the observe-zone of the ESC 0/1h-algorithm; however, no specific cut-off for further triage is endorsed.

Purpose

To derive and internally, as well as externally, validate a novel 3-hour pathway for the observe-zone of the ESC 0/1h-algorithm.

Methods

In an ongoing multicentre international diagnostic study, we prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of myocardial infarction (MI). Final diagnoses were centrally adjudicated by two independent cardiologists applying the 4th universal definition of MI, based on complete cardiac work-up including cardiac imaging, serial high sensitivity cardiac troponin T (hs-cTnT) sampling and 90-day follow-up information. High sensitivity-cTnT concentrations were measured at presentation and after 1 and 3 hours. The primary outcome was safety, quantified by the sensitivity and NPV for early rule out of NSTEMI. External validation was performed in an independent multicentre international study.

Results

Among 2076 eligible patients, application of the ESC 0/1h-algorithm triaged 1512 patients (72.8%) to either rule-out or rule-in of NSTEMI, remaining 564 patients (27.2%) in the observe-zone (adjudicated NSTEMI prevalence 120/564 patients, 21.3%). The novel derived 3h-pathway for the observe-zone patients ruled-out NSTEMI with a 3h hs-cTnT concentration &lt;15 ng/L and a 0/3h-hs-cTnT absolute change &lt;4 ng/L, triaging 138 patients (25%) towards rule-out, resulting in a sensitivity of 99.2% (95% CI 96.0–99.9) and a NPV of 99.3% (95% CI 95.4–99.9). A 0/3h-hs-cTnT absolute change ≥6 ng/L ruled-in 63 patients (11.2%), resulting in a specificity of 98% (95% CI 96.2–98.9) and a PPV of 85.7% (95% CI75.0–92.3). The novel 3h-pathway reduced the number of patients in the observe zone by 36%, and the number of T1MI by 50% (Figure 1). Findings were confirmed in both internal and external validation.

Conclusions

A novel derived pathway combining a 3h hs-cTnT concentration &lt;15 ng/L and a 0/3h absolute change &lt;4 ng/L allowed to very safely rule-out NSTEMI in patients remaining in the observe-zone of the ESC 0/1h-algorithm.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Swiss Heart FoundationThe Swiss National Science Foundation Figure 1

Discordance in prognostic ability between physician assessed NYHA classification and self-reported health status in patients with acute heart failure

Background

Especially in patients with acute heart failure (AHF) the NYHA classification remains of uncertain representation of patients' actual health state. Alternatively, patient's subjective well-being, in terms of health-related quality of life (HRQL), showed to have an excellent prognostic ability in out clinic patients with chronic heart failure.

Objectives

It is unknown whether HRQL instruments can assess a more reliable prognostication in patients hospitalized due to AHF than the NYHA classification.

Methods

Goal Directed Afterload Reduction in Acute Congestive Cardiac Decompensation Study (GALACTIC) was a multicenter, randomized, open-label blinded-end-point trial that emphasized early intensive and sustained vasodilation in adult patients hospitalized due to AHF with NYHA functional class III/IV, however provided neutral findings. HRQL was assessed by the generic EQ-5D-3L which is a 3-leveled 5-item instrument and the disease-specific Kansas City Cardiomyopathy Questionnaire (KCCQ). Unadjusted and adjusted Cox regression models were performed after patients were grouped into low (EQ-5D −0.074&lt;0.25; KCCQ 0&lt;25), moderately low (0.25&lt;0.5; 25&lt;50), moderately high (0.5&lt;0.75; 50&lt;75) and high HRQL (0.75–1.0; 75–100).

Results

781 patients were enrolled in 10 centres in 5 countries over 2 continents among which 536 (69%) patientshad completed theEQ-5D and 419 (54%) the KCCQ shortly after admission. Within 180 days of follow-up69 (13%) and 54 (13%) patients died and 151 (28%) and 122 (29%) died or were rehospitalized due to AHF, respectively. Cumulative incidence as well as HRs in patients grouped according to NYHA (n=536) indicated a comparable or significantly lower risk in patients with NYHA IV: e.g. for the combined outcome HR 1.07 (95% CI 0.777–1.473) and aHR 0.463 (95% CI 0.245–0.875). Whereas HRs in patients grouped according to both, EQ-5D (n=536) and KCCQ (n=419), increased from the group with highest to the group with the lowest HRQL: e.g. aHR for moderately high 1.11 (95% CI 0.718–1.715), for moderately low 1.721 (95% CI 1.102–2.688) and for low EQ-5D index 1.891 (95% CI 1.136–3.149) referenced to high HRQL (EQ-5D index 0.75–1.0).

Conclusions

These findings corroborate and extend previous work suggesting that NYHA classification poorly discriminates AHF patients' prognosis and challenge its' extensive application. HRQL might be a possible alternative to easily assess these patients' heath state.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation A. 180-day mortality; B. composite outcome

Determination of the yield, mass and structure of silver patches on colloidal silica using multiwavelength analytical ultracentrifugation

Anisotropic nanoparticles offer considerable promise for applications but also present significant challenges in terms of their characterization. Recent developments in the electroless deposition of silver patches directly onto colloidal silica particles have opened up a simple and scalable synthesis method for patchy particles with tunable optical properties. Due to the reliance on patch nucleation and growth, however, the resulting coatings are distributed in coverage and thickness and some core particles remain uncoated. To support process optimization, new methods are required to rapidly determine patch yield, thickness and coverage. Here we present a novel approach based on multiwavelength analytical ultracentrifugation (MWL-AUC) which permits simultaneous hydrodynamic and spectroscopic characterization. The patchy particle colloids are produced in a continuous flow mixing process that makes use of a KM-type micromixer. By varying the process flow rate or metal precursor concentration we show how the silver to silica mass ratio distribution derived from the AUC-measured sedimentation coefficient distribution can be influenced. Moreover, through reasoned assumptions we arrive at an estimation of the patch yield that is close to that determined by arduous analysis of scanning electron microscopy (SEM) images. Finally, combining MWL-AUC, electrodynamic simulations and SEM image analysis we establish a procedure to estimate the patch thickness and coverage.

Early standardized clinical judgement for syncope diagnosis in the emergency department

BACKGROUND

The diagnosis of cardiac syncope remains a challenge in the emergency department (ED).

OBJECTIVE

Assessing the diagnostic accuracy of the early standardized clinical judgement (ESCJ) including a standardized syncope-specific case report form (CRF) in comparison with a recommended multivariable diagnostic score.

METHODS

In a prospective international observational multicentre study, diagnostic accuracy for cardiac syncope of ESCJ by the ED physician amongst patients ≥ 40 years presenting with syncope to the ED was directly compared with that of the Evaluation of Guidelines in Syncope Study (EGSYS) diagnostic score. Cardiac syncope was centrally adjudicated independently of the ESCJ or conducted workup by two ED specialists based on all information available up to 1-year follow-up. Secondary aims included direct comparison with high-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) concentrations and a Lasso regression to identify variables contributing most to ESCJ.

RESULTS

Cardiac syncope was adjudicated in 252/1494 patients (15.2%). The diagnostic accuracy of ESCJ for cardiac syncope as quantified by the area under the curve (AUC) was 0.87 (95% CI: 0.84-0.89), and higher compared with the EGSYS diagnostic score (0.73 (95% CI: 0.70-0.76)), hs-cTnI (0.77 (95% CI: 0.73-0.80)) and BNP (0.77 (95% CI: 0.74-0.80)), all P < 0.001. Both biomarkers (alone or in combination) on top of the ESCJ significantly improved diagnostic accuracy.

CONCLUSION

ESCJ including a standardized syncope-specific CRF has very high diagnostic accuracy and outperforms the EGSYS score, hs-cTnI and BNP.

Probing sedimentation non-ideality of particulate systems using analytical centrifugation

Analytical centrifugation is a versatile technique for the quantitative characterization of colloidal systems including colloidal stability. The recent developments in data acquisition and evaluation allow the accurate determination of particle size, shape anisotropy and particle density. High precision analytical centrifugation is in particular suited for the study of particle interactions and concentration-dependent sedimentation coefficients. We present a holistic approach for the quantitative determination of sedimentation non-ideality via analytical centrifugation for polydisperse, plain and amino-functionalized silica particles spanning over one order of magnitude in particle size between 100 nm and 1200 nm. These systems typically behave as neutral hard spheres as predicted by auxiliary lattice Boltzmann simulations. The extent of electrostatic interactions and their impact on sedimentation non-ideality can be quantified by the repulsion range, which is the ratio of the Debye length and the average interparticle distance. Experimental access to the repulsion range is provided through conductivity measurements. With the experimental repulsion range at hand, we estimate the effect of polydispersity on concentration-dependent sedimentation properties through a combination of lattice Boltzmann and Brownian dynamics simulations. Finally, we determine the concentration-dependent sedimentation properties of charge-stabilized, fluorescently-labeled silica particles with a nominal particle size of 30 nm and reduced interparticle distance, hence an elevated repulsion range. Overall, our results demonstrate how the influence of hard-sphere type and electrostatic interactions can be quantified when probing sedimentation non-ideality of particulate systems using analytical centrifugation even for systems exhibiting moderate sample heterogeneity and complex interactions.

A16 FIBER SUPPLEMENTATION DIFFERENTIALLY MODULATES RESPONSES TO FECAL MICROBIAL TRANSPLANTATION IN PATIENTS WITH METABOLIC SYNDROME AND SEVERE OBESITY: A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED PILOT TRIAL

Background

Fecal microbial transplantation (FMT) from lean donors to obese patients with metabolic syndrome (MS) has been associated with promising yet short-term metabolic improvements. The concept of using dietary or fiber supplementation to enhance effects induced by FMT has been much discussed in the literature, but to date no human trials have examined this concept.

Aims

The aim of this study was to determine if fiber supplementation following FMT was able to enhance or sustain FMT-mediated metabolic benefits.

Methods

We performed a 12-wk double-blind randomized placebo-controlled trial in patients with severe obesity and MS recruited from Edmonton’s Bariatric Clinic from 2018 to 2019. Patients were stratified by sex and block randomized 1:1:1:1 amongst one of four groups: (1) Placebo FMT and a non-fermentable fiber (NF) (2) Placebo FMT and fermentable fiber (FF); (3) FMT and non-fermentable fiber (FMT-NF); and (4) FMT and fermentable fiber (FMT-FF). Patients received a single dose of FMT (50g donor stool) with 20 oral capsules followed by a 6-wk period of daily fiber. The primary outcome was evaluating mean differences (MD) in insulin sensitivity from baseline to 6-wks using the homeostatic model assessment of insulin resistance (HOMA2-IR).

Results

Sixty-eight patients were randomized with 61 completing the primary outcome (NF = 17; FF = 15; FMT-NF = 14; FMT-FF = 15) and evaluated using a modified intent-to-treat analysis. Baseline characteristics were similar with a mean BMI 45 ± 7 kg/m2, a female predominance (83.6%), and a HOMA2-IR of 3.43 ± 2.2. There were no baseline differences in clinical characteristics, metabolic parameters, medications, or dietary intake. FMT-NF had improvements in HOMA2-IR (MD -24.0% ± 12.0%; p=0.02), insulin sensitivity (MD 27.6% ± 12.3%; p=0.02), and insulinemia (MD -25.4% ± 12.3%; p=0.02) from baseline to 6-wks (Figure 1). These benefits were associated with increased microbial richness and improvements in GLP-1 metabolism. Linear mixed model regression revealed that select bacterial taxa including Phascolarctobacterium, Ruminococcaeceae, and B. stercoris correlated with increased insulin sensitivity. Findings occurred in the absence of changes in anthropometric parameters, dietary intake, medication regimen and were not observed in groups receiving fermentable fiber or in any group following cessation of fiber.

Conclusions

This proof-of-concept trial provides evidence that a single FMT dose combined with daily non-fermentable fiber supplementation can successfully improve insulin resistance in patients with metabolic syndrome and severe obesity on optimized medical therapy.

Funding Agencies

W. Garfield Weston Foundation

The neuropsychological assessment battery (NAB) is a valuable tool for evaluating neuropsychological outcome after aneurysmatic subarachnoid hemorrhage

Background

Detecting and treating neuropsychological deficits after aneurysmatic subarachnoid hemorrhage (aSAH) play a key role in regaining independence; however, detecting deficits relevant to social and professional reintegration has been difficult and optimal timing of assessments remains unclear. Therefore, we evaluated the feasibility of administering the Neuropsychological Assessment Battery screening module (NAB-S) to patients with aSAH, assessed its value in predicting the ability to return to work and characterized clinical as well as neuropsychological recovery over the period of 24 months.

Methods

A total of 104 consecutive patients treated for aSAH were recruited. After acute treatment, follow up visits were conducted at 3, 12 and 24 months after the hemorrhage. NAB-S, Montreal Cognitive Assessment (MoCA) and physical examination were performed at each follow up visit.

Results

The NAB-S could be administered to 64.9, 75.9 and 88.9% of the patients at 3, 12 and 24 months, respectively. Moderate impairment of two or more neuropsychological domains (e.g speech, executive function, etc.) significantly correlated with inability to return to work at 12 and 24 months as well as poor outcome assessed by the extended Glasgow Outcome Scale (GOSE) at 3, 12 and 24 months. The number of patients with favorable outcomes significantly increased from 25.5% at discharge to 56.5 and 57.1% at 3 and 12 months, respectively, and further increased to 74.1% after 24 months.

Conclusion

The NAB-S can be administered to the majority of patients with aSAH and can effectively detect clinically relevant neuropsychological deficits. Clinical recovery after aSAH continues for at least 24 months after the hemorrhage which should be considered in the design of future clinical trials.

Validation of the Canadian syncope risk score in a large prospective international multicenter study

Background

Management and risk stratification of patients with syncope in the emergency department (ED) is often challenging. In an effort to support ED physicians in disposition decisions, the Canadian Syncope Risk Score (CSRS) was developed to predict 30-day serious outcomes.

Methods

The CSRS was developed in a Canadian multicenter study and contains nine predictors: predisposition to vasovagal syncope, heart disease, systolic pressure &lt;90 or &gt;180mmHg in the ED, troponin level &gt;99th percentile, abnormal QRS axis, QRS duration &gt;130ms, QTc interval &gt;480ms and an ED diagnosis of vasovagal or cardiac syncope. Patients can achieve a CSRS score between −3 and +11 points. We validated the CSRS in a large prospective international multicenter study recruiting patients 40 years or older presenting to the ED with a syncopal event within the last 12 hours. Recruitment centers contained smaller provincial hospitals, as well as big University Hospitals in eight countries on three continents. Primary outcome measure were 30-day serious arrhythmic and non-arrhythmic adverse events, as defined by the authors of the original score.

Results

1581 patients were eligible for this analysis. The population in this validation cohort was older (mean age 68 vs 54 years) and had a considerably higher rate of serious outcomes compared to the derivation cohort (n=186 (11.8%) vs n=147 (3.6%)). The area under the receiver operating characteristic curve (AUC) for the CSRS was 0.88 (95% confidence interval (CI) 0.86–0.91) and significantly higher compared to the validated OESIL score (AUC 0.75, 95% CI 0.71–0.78, p&lt;0.001). Calibration curve analysis showed an underestimation of risk in patients with a low CSRS and an overestimation in patients with a high CSRS. The rate of observed serious outcomes within 30d increased from 0.8% in the very low risk group (CSRS equal to or below −2) to 48% in the (very) high risk group (CSRS equal to or above 4, Hazard ratio 79.4, 95% CI 11.1–570.9). A Kaplan-Meier plot was used to visualize rates of serious outcomes in three different risk groups (Figure).

Conclusion

This is the first validation of the Canadian Syncope Risk Score in a large international syncope cohort. The prognostic discrimination of the CSRS for 30-day serious outcomes was very good in our validation cohort and comparable to that of the Canadian derivation study. Despite suboptimal calibration, prognostic analysis showed a high rate of serious outcomes in the CSRS (very) high risk group and a low rate of serious outcomes in the very low risk group. Allowing the clinical judgement of the ED physician in the form of suspected syncope etiology to be a part of the score seems to largely contribute to the high performance of the CSRS. Additional validation studies might be needed to further increase the accuracy of the CSRS in different patient populations with a different incidence of outcomes in settings outside of Canada.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation; Swiss Heart Foundation

Influence of Organic Solvents on Secondary Brain Damage after Experimental Traumatic Brain Injury

Many compounds tested for a possible neuroprotective effect after traumatic brain injury (TBI) are not readily soluble and therefore organic solvents need to be used as a vehicle. It is, however, unclear whether these organic solvents have intrinsic pharmacological effects on secondary brain damage and may therefore interfere with experimental results. Thus, the aim of the current study was to evaluate the effect of four widely used organic solvents, dimethylsulfoxide (DMSO), Miglyol 812 (Miglyol^®), polyethyleneglycol 40 (PEG 40), and N-2-methyl-pyrrolidone (NMP) on outcome after TBI in mice. A total of 143 male C57Bl/6 mice were subjected to controlled cortical impact (CCI). Contusion volume, brain edema formation, and neurological function were assessed 24 h after TBI. Test substances or saline were injected intraperitoneally (i.p.) 10 min before CCI. DMSO, Miglyol, and PEG 40 had no effect on post-traumatic contusion volume after CCI; NMP, however, significantly reduced contusion volume and brain edema formation at different concentrations. The use of DMSO, Miglyol, and PEG 40 is unproblematic for studies investigating neuroprotective treatment strategies as they do not influence post-traumatic brain damage. NMP seems to have an intrinsic neuroprotective effect that should be considered when using this agent in pharmacological experiments; further, a putative therapeutic effect of NMP needs to be elucidated in future studies.

Development and validation of an ECG-based cardiac syncope risk calculator

Background

The early diagnosis of cardiac syncope is often challenging. We therefore developed an ECG-based risk calculator as an aid for rapid rule-out or rule-in of cardiac syncope and aimed to validate this decision tool.

Methods

In a prospective diagnostic international multicenter study (derivation cohort), 2007 patients, 40 years or older, presenting with syncope to the emergency department were recruited. The primary diagnostic outcome, cardiac syncope, was centrally adjudicated by two independent cardiologists using all clinical information obtained during syncope work-up including 12-month follow up. 12-lead ECG was recorded at presentation and read by residents blinded to clinical information. Significant ECG predictors of cardiac syncope were identified using penalized backward selection. Findings were validated in an independent US multicenter cohort with 2'269 syncope patients.

Results

In the derivation cohort (median age 71 years, 40% women), centrally adjudicated cardiac syncope was present in 267 patients (16%). Seven ECG criteria (rhythm, heart rate, corrected QT-interval, ST-segment depression, atrioventricular-block, bundle-branch-block and ventricular extrasystole/non-sustained ventricular tachycardia) were identified as significant predictors for cardiac syncope and combined into the bAseL Ecg Risk calculaTor for Cardiac Syncope (ALERT-CS). Diagnostic accuracy of ALERT-CS for cardiac syncope, as quantified by the area under the receiver-operating characteristics curve (AUC), was high (0.80, 95%-confidence interval (CI) 0.77–0.83) and significantly higher compared to the EGSYS score (0.73, 95% CI 0.70–0.76, p&lt;0.001). In combination, ALERT-CS significantly increased the AUC of BNP (0.82, 95% CI 0.79–0.85 vs 0.77, 95% CI 0.74–0.81, p=0.003), hs-cTnT (0.84, 95% CI 0.0.81–0.87 vs 0.77, 95% CI 0.74–0.80, p&lt;0.001) and integrated clinical judgment in the ED (0.90, 95% CI 0.89–0.92 vs 0.87, 95% CI 0.84–0.90, p&lt;0.001).

A predicted probability for cardiac syncope below 5.5% by ALERT-CS identified 138 patients (8%) eligible for triage towards rapid rule-out of cardiac syncope with a sensitivity of 99%. A predicted probability above 37.5% identified 181 patients (11%) eligible for triage towards rapid rule-in of cardiac syncope with a specificity of 95%. Prognostic verification for 30-day major adverse cardiac events (MACE) showed a high rate of MACE in the rule-in group and a very low rate of MACE in the rule-out group (Figure).

External validation (median age 72 years, 48% women) showed similar diagnostic accuracy (AUC 0.76, 95% CI 0.73–0.79) and prognostic results.

Conclusion

Combining seven ECG criteria within the simple ALERT-CS may aid ED physicians in the early rule-out or rule-in of cardiac syncope.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, Swiss Heart Foundation