Manganese enhanced magnetic resonance imaging in type 1 and type 2 diabetes mellitus

Background

The pathophysiology of diabetic cardiomyopathy has yet to be established although pre-clinical studies suggest a role for altered myocardial calcium handling. Manganese-enhanced magnetic resonance imaging (MEMRI) is a novel non-invasive method of assessing in vivo myocardial calcium handling.

Purpose

To investigate whether myocardial calcium handling is impaired in patients with either type 1 or type 2 diabetes mellitus in the absence of underlying heart disease.

Methods

In a prospective case-control study, patients with type 1 (n=19) or type 2 (n=10) diabetes mellitus and healthy volunteers (n=15) underwent MEMRI. Participants with prior coronary artery disease, cardiomyopathy or an abnormal electrocardiogram were excluded. Manganese dipyridoxyl diphosphate (0.1 mL/kg) was administered over 10 min and myocardial T1 mapping was performed prior to and every 2.5 min for 30 min after contrast infusion (Figure 1). Quantitative manganese uptake analysis was performed by measuring T1 relaxation times in a region of interest within the interventricular septum and compared to the left ventricular blood pool. The rate of myocardial manganese uptake was determined by Patlak modelling [1].

Results

Participants with type 1 and type 2 diabetes mellitus were older (50±13 and 55±15.3 years) than the healthy volunteers (32±10 years). All participants had preserved left ventricular ejection fraction (type 1 diabetes mellitus, 67.7±6.1%; type 2 diabetes mellitus, 66.8±3.2%; healthy volunteers, 65±3.5%). Mean myocardial manganese uptake was reduced in participants with both type 1 (6.4±0.6 mL/100 g of tissue/min) and type 2 (6.4±0.5 mL/100 g of tissue/min) diabetes mellitus compared with healthy volunteers (8.3±0.5 mL/100 g of tissue/min; p<0.0001 for both, Figure 2). There were no differences in myocardial manganese uptake between those with type 1 or type 2 diabetes mellitus (p=0.22). There was no statistically significant correlation between myocardial manganese uptake and age in the study population (r=−0.28, p=0.07).

Conclusion

Using MEMRI, we have demonstrated that myocardial calcium handling is impaired in patients with either type 1 or type 2 diabetes mellitus even in the absence of left ventricular systolic dysfunction. This suggests altered myocardial calcium handling may underlie, or contribute to, diabetic cardiomyopathy which has implications developing novel therapeutic targets for the prevention and treatment of diabetic cardiomyopathy.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): British Heart Foundation - Clinical Research Training Fellowship (FS/CRTF/20/24087)AstraZeneca - Investigator initiated award (ESR-19-20118)

Manganese-enhanced magnetic resonance imaging in Takotsubo syndrome

Background

Takotsubo syndrome is an increasingly common acute cardiac emergency characterised by profound transient left ventricular systolic dysfunction following a stressful event. Its pathophysiology remains poorly understood and a third of patients will have a major adverse cardiac or cerebrovascular event by 5 years [1]. Defective myocardial calcium homeostasis is central to contractile dysfunction and may be implicated in its pathophysiology. Manganese-enhanced magnetic resonance imaging is a novel non-invasive imaging technique that assesses myocardial manganese uptake as a measure of myocardial calcium handling [2]. Our aim was to investigate myocardial calcium handling using manganese-enhanced magnetic resonance imaging during the acute and recovery phase of takotsubo syndrome.

Methods

This single centre case-controlled observational longitudinal cohort study was conducted in accordance with the Declaration of Helsinki and ethical committee approval with written informed consent. Twenty patients with takotsubo syndrome and 20 age, sex and cardiovascular risk factor matched volunteers were recruited between March 2020 and September 2021. Patients underwent gadolinium and manganese-enhanced magnetic resonance imaging during the index event with repeat manganese-enhanced magnetic resonance imaging after 3 months. Myocardial manganese uptake was characterised by Patlak modelling.

Results

During the acute presentation, most patients had an “apical” pattern of takotsubo syndrome with reduced left ventricular ejection fraction (51±11 versus 67±8%, P<0.001, Figure 1), elevated left ventricular mass (89±11 versus 57±14 g/m2, P<0.01) and native T1 (1358±49 versus 1211±28 ms, P<0.001) and T2 (60±7 versus 38±3 ms, P<0.001) values compared to matched volunteers. Patlak modelling demonstrated reduced myocardial manganese uptake (5.1±0.5 versus 8.0±1.0 mL/100g of tissue/min, P<0.0001) consistent with a major abnormality of myocardial calcium handling. Reduced myocardial manganese uptake attributable to apical takotsubo syndrome could be seen in one patient, scanned 18 days after symptom onset despite apparent resolution of cardiac function. Beyond 3 months of convalescence, left ventricular mass, ejection fraction, native T1 and T2 values were comparable to matched volunteers. Despite this, myocardial calcium handling remained abnormal compared to matched volunteers (6.7±0.7 versus 8.0±1.0 mL/100 g of tissue/min, P<0.001, Figure 2).

Conclusions

In patients with takotsubo syndrome, there is a profound perturbation of myocardial calcium handling which is most marked acutely but persists after apparent recovery of left ventricular ejection fraction and resolution of myocardial oedema. Abnormal myocardial calcium handling is implicated in the pathophysiology of takotsubo syndrome and manganese-enhanced magnetic resonance imaging could play a major role in the diagnosis and risk stratification of patients with takotsubo syndrome.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Medical Research CouncilBritish Heart Foundation

Impaired myocardial calcium handling in people with type 2 diabetes: an in vivo manganese-enhanced magnetic resonance imaging study

Background

There is a high prevalence of subclinical cardiac dysfunction in people with type 2 diabetes (T2D) which is associated with subsequent development of heart failure. Dysregulated myocardial calcium handling has been demonstrated in animal models of T2D and may be a key mechanism driving the development of heart failure. Manganese-enhanced cardiac magnetic resonance imaging (MEMRI) provides a unique method to assess in vivo myocardial calcium handling.

Purpose

To determine whether myocardial calcium handling is perturbed in people with T2D with no history of cardiovascular disease. We hypothesised that myocardial manganese uptake would be reduced in people with T2D compared with healthy volunteers.

Methods

Cross-sectional case-control study, adults with (n=20) and without (n=9) T2D underwent both gadolinium-enhanced MRI and MEMRI. Standard gadolinium-enhanced MRI was used to assess cardiac structure, function and tissue characteristics. MEMRI scans were performed within two weeks of the initial scan. Native T1 maps were obtained in the mid-short axis slice position using a Modified Look-Locker Inversion recovery sequence. An intravenous infusion of manganese dipyridoxyl diphosphate (5 μmol/kg (0.1 mL/kg) at 1 mL/min) was administered and T1 maps at the same location were repetitively acquired every 2.5 min for 30 min. Regions of interest were drawn in the inferoseptal segment and blood pool for all T1 maps from 0 to 30 min by a single observer. The primary outcome was the rate of manganese uptake which was assessed by Patlak modelling as a measure of myocardial calcium handling. Manganese uptake constants were compared using analysis of co-variance, with age, sex and body mass index as co-variates.

Results

Subjects with T2D were older (62±7 vs. 57±5 years, p=0.046) but body mass index (29.0±4.5 vs. 26.2±3.4 kg/m2, p=0.106), systolic (135±16 vs. 134±17 mmHg, p=0.809) and diastolic (81±10 vs. 83±9 mmHg, p=0.736) blood pressures were similar. Compared to control subjects, participants with T2D had normal systolic function but more concentric left ventricular remodelling (mass/volume ratio 0.90±0.14 vs. 0.71±0.06 g/mL, p<0.001) and reduced peak early diastolic strain rate (0.64±0.17 vs. 0.91±0.26 s–1, p=0.002). Myocardial manganese uptake was substantially reduced in people with T2D compared with controls (6.51±1.46 vs. 8.45±2.52 ml/100 g of tissue/min, p=0.003) (Figure 1).

Conclusions

For the first time, we have demonstrated in vivo that despite no history of cardiovascular disease and normal systolic function, patients with T2D have marked impairment of myocardial calcium handling. This has potential major implications for the pathogenesis, diagnosis and treatment of diabetic cardiomyopathy.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation and National Institute for Health Research

Rickettsial Infection amongst Febrile Illness Patient in a Tertiary Care Hospital: A Retrospective Cross-sectional Study

Background Rickettsial infection is an emerging neglected tropical disease in the Southeast Asia. In past few years Nepal is also reporting escalating prevalence of rickettsia. The under evaluation is resulting it as undiagnosed or are simply labeled as pyrexia of unknown origin. Objective To find out the prevalence of rickettsia in a hospital setting, assess the sociodemographic and other relevant clinical features of the rickettsia patients. Method This is a hospital based retrospective cross-sectional study from October 2020 to October 2021. This study reviewed the medical records of the department. Result The study included 105 eligible patients and the prevalence rate was 4.38 per 100 patients. The mean age of the participants was 42 years, and the mean hospital stay was 3 (SD ±2.06) days. More than 55% of the participants had fever for less than or equal to 5 days and 9% had Eschar present. Vomiting, headache, and myalgia were the most common symptoms and hypertension, and diabetes were the common comorbidities. Pneumonia and the acute kidney injury were the two complications of the patients as stated in the study. The severity of the thrombocytopenia deducted from admission time to discharge, and the case fatality was 4%. Conclusion The future studies shall consider on collaborative clinical and entomological research. This would help in better understanding of the etiology of supposedly unknown febrile illness and the under-investigated field of emerging rickettsia in Nepal.

Perioperative Challenges in the Management of Rhino-Orbital Cerebral Mucormycosis: An Observational Study from a Tertiary Care Hospital

Background

Coronavirus disease 2019 (COVID-19) pandemic is the biggest threat of the century. Associated with this disease, are a number of rhino orbital cerebral mucormycosis cases seen as post COVID sequelae. Amphotericin B and surgical debridement are the treatment modalities.

Aims

This study aimed to describe the clinical characteristics and perioperative outcomes of patients with ROCM.

Settings and Design

This was a prospective, observational study.

Materials and Methods

We carried out a study of 238 patients with confirmed ROCM posted for functional endoscopic sinus surgery, craniotomies, maxillofacial surgeries, and orbital exenteration under general anesthesia and the perioperative challenges therein.

Statistical Analysis Used

Data were entered in the excel sheet. Descriptive statistics were used to summarize the data. Analysis was done using the Statistical Package for the Social Sciences (SPSS) version 27:0. Categorical variables were expressed as counts and percentages.

Results

78% had diabetes mellitus, 64% had received steroids, 59% had a preoperative oxygen saturation of less than 90%, 86% had a 4-6 zone involvement on chest radiograph, and more than 50% had an anticipated difficult airway. Postsurgery, 13% of patients required intensive care. The 15-day mortality rate was 3% among the operated cases.

Conclusion

Post-COVID ROCM is challenging in terms of preoperative poor general condition, difficult airway, intraoperative concerns due to pathophysiology of the disease and its effect on organ systems, and the requirement of postoperative vigilant monitoring.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Comparison of different types of exercise training on resting blood pressure in 30-45 years old adults: a randomised controlled trial

Hypertension is the most metastasizing non-communicable disease, which has affected more than 1.4 billion people, worldwide. Exercise is the core management strategy for hypertensive individuals. Extensive literature is available for each kind of exercise that is isometric hand grip training (IHGT), resistance training (RT), and aerobic training (AT). However, the comparison between these exercise regimens has not been done in a single trial. The trial was conducted on 126 subjects in Hisar, an urban area of Haryana (INDIA), from July 2017 to December 2018. Subjects were randomly assigned to four groups: control (n=33), IHGT (n=32), RT (n=31), and AT (n=30). Study variables were measured at baseline, 2nd week, 4th week, 6th week, and also after the 8th week of intervention. Experimental groups showed significant reduction in all the components of blood pressure in comparison to control group. The RT group showed maximum reduction in blood pressure in comparison to other regimens (systolic blood pressure: RT > IHGT > AT; diastolic blood pressure: RT > AT > IHGT). However, the difference between the groups is not statistically significant (P>0.05). The study findings reveal that different kind of exercise regimens are equally effective in lowering blood pressure among pre hypertensive and stage 1 hypertension adults.

Remission of T2DM by digital twin technology with reduction of cardiovascular risk: interim results of randomised controlled clinical trial

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): TWIN HEALTH INC

Background

 Twin Precision Treatment (TPT) is a novel intervention designed to improve glycemia and reverse T2D using a Whole-Body Digital Twin (WBDT) platform powered by Artificial Intelligence and the Internet of Things. Technology enabled precision nutrition, a combination of macro, micro and biota nutrients, along with Continuous Glucose Monitoring (CGM) have been demonstrated to be a key for reversal of diabetes. WBDT platform captures 174 health markers and 3000 daily data points through a panel of blood tests and connected devices that measure weight, physical activity, sleep and BP. CGM is used initially and then the algorithm predicts personalized glucose responses from multiple inputs. Nutritional, physical activity and sleep counseling is through an app or phone to provide individualized meal plans that balance 87 macro, micro and probiotic nutrients to reduce glucotoxicity and lipotoxicity. Program physicians titrate medications and monitor metabolic outcomes. 

Purpose

 To assess the initial change, in glycemic, extra glycemic, cardiovascular parameters for patients who completed 3 months longitudinal follow up.

Methods

 We performed an interim analysis [n = 173, 139 TWIN Intervention arm (T), 34 Control group (C)] of ongoing randomized controlled trial of TPT across India

Results

 The mean age (years) in the T was 43.04 (±8.6, 95% CI 41.57 to 44.52) which was significantly less as compared to the C 51.4 (±9.6, 95% CI 48.3 to 54.5); p < 0.0001. The mean duration of diabetes (years) in the T was 3.5 (±2.6) which was comparable to the C 4.3 (±2.6); p = 0.12 ns. In the T there were 113 male (84.3%) and 21 female (15.6%) as compared to C, 15 male (38.4%) and 24 female (61.5%); p < 0.0001. The difference of change for HbA1c (%), small dense LDL-C sdLDL (mg/dL), TG/HDL Ratio, HOMA 2IR (%), Visceral Adiposity Index (VAI), Systolic BP (mmHg), BMI (kg/m2), Framingham Risk Score (%), in T when compared to C, were significant. The mean reduction HbA1c, sdLDL, HOMA 2IR, VAI, SBP, BMI, FRS in T was -3.2 % (8.8 to 5.6), -14.1 mg/dL, (52.6 to 38.5), -0.9 % (1.9 to 1), -2.3 (4.6 to 2.3), -10.3mmHg (128.4 to 118.1), -2.9 kg/m2 (27.1 to 24.2), -7.9% (16 to 8.1), respectively. (figure) At baseline in T, mean daily intake of medication was 1.7 which reduced significantly (p < 0.0001) to 0.05. 96 patients in T were able to stop anti-diabetic medications

Discussion

 The initial results are an early indicator for the translation of the scientific rationale for the technological intervention, through digital twin technology, powered by Internet of Things and Artificial Intelligence, as a modality to enable reversal of diabetes. TPT appears to have potential to mitigate the cardiovascular risk as assessed by Framingham Risk Score and modulate the non glycemic parameters, including BMI and SBP. However, larger, long-term studies would yield precise insights for the durability of the significant change that has been observed in this study Abstract Figure. Comparison for the Change in the Glycemi