P534Central sleep apnea in pacing-induced cardiomyopathy: prevalence, improvement by upgrading to cardiac resynchronisation therapy and impact on structural responder rates and long-term outcome

Funding Acknowledgements

ÖNB Jubiläumsfondsprojekt Nr. 15974, ISR grant by Boston Scientific, St. Paul, MN, USA

Background

Central sleep apnea (CSA) in pacing induced cardiomyopathy (PICM) is poorly studied. Specifically, it is unknown whether upgrading from right ventricular pacing (RVP) to cardiac resynchronisation therapy (CRT) improves CSA.

Methods

Fifty-three patients with impaired left ventricular ejection fraction, frequent right ventricular pacing due to high-grade atrioventricular block and heart failure symptoms despite optimal medical therapy underwent upgrading to CRT. Within one month after left ventricular lead implantation (but still not activated), sleep apnea was assessed in all participants by single-night polysomnography (PSG). Nineteen patients with moderate or severe CSA defined by an apnea hypopnea index (AHI) > 15 events per hour were re-scheduled for a follow up PSG 3-5 months after initiation of cardiac resynchronization therapy. Of this cohort, thirteen patients with stable mild heart failure agreed to be randomized to CRT versus RVP in a cross-over design.

Results

CSA (AHI > 5 events per hour) was diagnosed in 26 (49.1%), OSA in 16 (30.2%) patients suffering from PICM . Eleven (20.8%) patients did not have any form of sleep apnea. Moderate to severe CSA (AHI > 15 events per hour) was significantly improved (without specific CPAP therapy) by 102 (96-172) days of CRT: AHI decreased from 39.4 events per hour at baseline to 21.6 by CRT (p < 0.001). Furthermore, CRT led to a substantial decrease in left ventricular endsystolic volumes: baseline 141 ml (103-155), significant improvement under CRT (102 ml, 65-138; p < 0.001), whereas no effect with ongoing RV-pacing (147 ml, 130-161; p = 0.865). Preexistent CSA did not affect the structural response of CRT (56.5% in patients with CSA, 62.5% of patients with obstructive sleep apnea and 54.5% in patients without sleep apnea; p = 0.901) and had no impact on major adverse cardiac events (p = 0.412) and/or survival (p = 0.623) during long-term follow-up.

Conclusions

CSA is highly prevalent in patients with PICM and is significantly improved by upgrading to CRT. Preexistent CSA does not hamper structural improvement and long-term outcome after upgrading to CRT. Thus, CSA seems to occur as a consequence of PICM, rather than as a pathophysiological mediator.

Abstract Figure.

Erfolgreiche Therapie mit Dupilumab bei Prurigo nodularis – 2 Fallberichte

Dupilumab ist ein humaner rekombinanter monoklonaler Antikörper, gerichtet gegen die Alpha-Untereinheit des Interleukin-4-Rezeptors und des Interleukin-13-Rezeptors. Seit September 2017 ist Dupilumab zur Behandlung der mittelschweren bis schweren Neurodermitis zugelassen, im Verlauf erfolgten Zulassungen für weitere Indikationen wie das Asthma bronchiale sowie die chronische Rhinosinusitis mit Nasenpolypen.

Prurigo nodularis (PN) ist eine chronische Dermatose, charakterisiert durch das Auftreten von stark juckenden Papeln und Nodi, meist am Stamm und an den Extremitäten. Die Patienten klagen über stechend-quälenden Juckreiz. Eine Besserung trotz intensivierter topischer und systemischer antipruriginöser Therapie wird meist nur erschwert erreicht. Dupilumab scheint vielversprechende antipruriginöse Effekte bei Prurigo nodularis zu haben, vergleichende Studien stehen jedoch aus. Wir demonstrieren hier 2 Patienten, die seit mehreren Jahren unter einer therapierefraktären Prurigo nodularis bei atopischer Diathese litten. Beide Patienten zeigten nach Beginn der Therapie mit Dupilumab eine rasche und anhaltende Besserung der pruriginösen Papeln. Relevante Nebenwirkungen traten nicht auf.

Protocol for the development of a core domain set for hand eczema trials

BACKGROUND

Clinical hand eczema trials measure a variety of outcome domains to determine the success of interventions. This considerably limits the comparability and overall confidence in the study results, and thereby the strength of recommendations for clinical practice.

OBJECTIVES

The Hand Eczema Core Outcome Set (HECOS) initiative aims to develop a core outcome set (COS) for the standardized evaluation of interventions in future hand eczema trials and reviews. This COS will define the minimum that should be measured and reported in controlled and randomized-controlled trials of therapeutic hand eczema interventions. The objective of this protocol is to specify the methods to develop a core domain set.

METHODS

In Phase 1, a list of candidate domains will be derived from a systematic literature review concerning previously measured outcomes in hand eczema trials, from qualitative patient interviews and from expert interviews. In Phase 2, a consensus study about core domains will be conducted by an online 3-round Delphi survey and a face-to-face meeting, applying predefined consensus criteria. HECOS involves hand eczema and methods experts as well as patients and further stakeholders with an interest in the initiative.

OUTLOOK

When a set of core domains has been defined, HECOS is going to identify appropriate outcome measurement instruments in a development process that will be detailed in another protocol. The COS will considerably enhance the methodological quality, comparability and usefulness of hand eczema trials for clinical decision-making and the development of new therapeutic options for hand eczema, and also reduce the effort of planning, conducting, and reporting individual hand eczema studies, reviews and meta-analyses.

Atopy patch testing with aeroallergens in a large clinical population of dermatitis patients in Germany and Switzerland, 2000-2015: a retrospective multicentre study

BACKGROUND

The diagnostic significance of the atopy patch test for the management of dermatitis possibly triggered by aeroallergens is still controversial. However, sufficiently large studies with routinely tested standardized aeroallergen patch test preparations in dermatitis patients are lacking.

OBJECTIVE

To evaluate the reaction frequency and the reaction profiles of 10 until mid-2015 commercially available, standardized aeroallergen patch test preparations of the 'Stallerpatch' test series (Stallergenes, Antony Cedex, France) in a large multicentre patient cohort.

METHODS

A retrospective data analysis of patients with suspected aeroallergen-dependent eczematous skin lesions was performed, who were patch tested in 15 Information Network of Departments of Dermatology-associated clinics between 2000 and 2015. Patients were stratified according to their atopic dermatitis (AD) status.

RESULTS

The study group included 3676 patients (median age 41 years, 34.8% males, 54.5% AD). The most common aeroallergens causing positive patch test reactions were Dermatophagoides pteronyssinus (19.6%), Dermatophagoides farinae (16.9%), birch (6.2%), timothy grass (6.0%), cat dander (5.4%), mugwort (4.9%) and dog dander (4.6%). Reactions to other pollen allergen preparations, that is 5 grasses (3.2%), cocksfoot (2.1%) and plantain (1.6%), were less common. Positive patch test reactions to aeroallergens were consistently more frequent in patients with AD. These patients showed proportionally less dubious, follicular, irritant and weak positive reactions. Independent of AD status, a patient history of past or present allergic rhinitis was associated with an increased chance of a positive aeroallergen patch test reaction to pollen allergens.

CONCLUSION

The aeroallergen patch test is a useful add-on tool in clinical routine, especially in patients with AD and/or respiratory allergy. A patch test series comprising Dermatophagoides pteronyssinus, Dermatophagoides farinae, birch, timothy grass, cat dander and mugwort seems to be suitable. Controlled studies with specific provocation and elimination procedures are required to further evaluate the diagnostic significance of the proposed screening series.

[Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR) : Consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC]

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.

The German version of the Critical-Care Pain Observation Tool for critically ill adults : A prospective validation study

BACKGROUND

The implementation of the Critical-Care Pain Observation tool (CPOT) in intensive care units (ICU) has been associated with more frequent pain assessments, a reduced number of complications, and improved administration of analgesics and sedatives. So far no German translation exists. Translating this tool into foreign languages requires further validation testing.

OBJECTIVE

The aim of this prospective observational validation study was to translate the original version of the CPOT according to scientific principles for translation and to establish the validity and reliability of the German translation of CPOT for critically ill adult patients.

MATERIAL AND METHODS

A total of 292 cardiac surgery patients from 2 ICUs of 2 German university teaching hospitals were included (114 patients at center 1 and 178 patients at center 2). Of the included patients 22.6% were female and 76.4% were male with a mean age of 68.5 years ±9.3 SD. Pain was evaluated with the CPOT, the Bhavioral Pain Scale (BPS) and with the Numeric Rating scale (NRS) at three time points (1. intubated + sedated, 2. intubated + awake, 3. extubated + awake) at rest and during nociceptive stimulus (positioning). Assessments were made separately by trained physicians and nursing staff.

RESULTS

Good results for interrater reliability and internal consistency could be demonstrated (weighted Cohen's kappa of 0.73, Cronbach's coefficient alpha of 0.8). Spearman correlation between CPOT and NRS was moderate but significant. The receiver operating characteristic (ROC) analysis to obtain optimal thresholds of CPOT to detect pain revealed different results during rest and stimulus and in intubated and extubated patients.

CONCLUSION

The validated German CPOT translation is a reliable tool for pain assessment in cardiac ICU patients in the absence of patients' ability for self-reporting. The use of this German version of CPOT now allows a better international comparability of corresponding data in future studies.

Ferromagnetic Resonance with Magnetic Phase Selectivity by Means of Resonant Elastic X-Ray Scattering on a Chiral Magnet

Cubic chiral magnets, such as Cu_{2}OSeO_{3}, exhibit a variety of noncollinear spin textures, including a trigonal lattice of spin whirls, the so-called skyrmions. Using magnetic resonant elastic x-ray scattering (REXS) on a crystalline Bragg peak and its magnetic satellites while exciting the sample with magnetic fields at gigahertz frequencies, we probe the ferromagnetic resonance (FMR) modes of these spin textures by means of the scattered intensity. Most notably, the three eigenmodes of the skyrmion lattice are detected with large sensitivity. As this novel technique, which we label REXS FMR, is carried out at distinct positions in reciprocal space, it allows us to distinguish contributions originating from different magnetic states, providing information on the precise character, weight, and mode mixing as a prerequisite of tailored excitations for applications.

P5584Causes of death within the first year after transcatheter aortic valve implantation: Lessons from EVERY-TAVI registry

Background

According to current recommendations, transcatheter aortic valve implantation (TAVI) should only be performed among patients with a life expectancy of at least one year. However, many deaths occur within the first year after TAVI.

Purpose

To assess the causes of death within one year after TAVI.

Methods

Data was taken between November 2007 and December 2017 from the EVERY-TAVI registry. Patients who died during TAVI or experienced mechanical complications requiring surgery were excluded from the analysis. We assessed the causes of death over 3 periods post-TAVI: within the first 30 days, between 30 and 90 days, and between 90 and 365 days.

Results

Overall, 2389 patients underwent TAVI without mechanical complications. Among them, 320 (1.3%) died within one year. Age was the main cause of death, accounting for 73 deaths (22.8%), followed by heart failure (20.6%) and infections (18.7%). During the first month, cardiogenic shock was the main cause of death (25.4%), followed by infections (22.2%) and terminal heart failure (20.6%), while age was responsible of only one death (1.6%). During the two following months, heart failure was the main cause of death (33.3%), followed by infections (21.2%), and the percentage of deaths due to age increased to 18.2%. After 3 months, age was the main cause of death (31.4%), followed by infection (16.8%) and heart failure (16.2%).

Causes of death within one year of TAVI Cause of death All (n=320) <30 days (n=63) 30–90 days (n=66) >90 days (n=191) Older age, n (%) 73 (22.8) 1 (1.6) 12 (18.2) 60 (31.4) Terminal heart failure, n (%) 66 (20.6) 13 (20.6) 22 (33.3) 31 (16.2) Infection, n (%) 60 (18.7) 14 (22.2) 14 (21.2) 32 (16.8) Terminal renal failure, n (%) 26 (8.1) 4 (6.3) 5 (7.6) 17 (8.9) Cardiogenic shock, n (%) 26 (8.1) 16 (25.4) 4 (6.1) 6 (3.1) Malignancies, n (%) 18 (5.6) 0 (0.0) 2 (3.0) 16 (8.4) Sudden death, n (%) 17 (5.3) 6 (9.5) 2 (3.0) 9 (4.7) Stroke, n (%) 12 (3.7) 4 (6.3) 2 (3.0) 6 (3.1) Accident, n (%) 7 (2.2) 2 (3.2) 0 (0.0) 5 (2.6) Myocardial infarction, n (%) 7 (2.2) 2 (3.2) 2 (3.0) 3 (1.6) Non-cardiac surgery, n (%) 5 (1.6) 1 (1.6) 1 (1.5) 3 (1.6) Pulmonary embolism, n (%) 3 (0.9) 0 (0.0) 0 (0.0) 3 (1.6)

Conclusion

Cardiogenic shock is the main cause within the first month after TAVI, while older age is the main cause overall and after the initial months, highlighting the need to more carefully selection of patients undergoing TAVI.

An ABCA12 missense variant in a Shorthorn calf with ichthyosis fetalis

Two clinical forms of ichthyosis in cattle have been reported, ichthyosis fetalis and congenital ichthyosis. Ichthyosis poses animal welfare and economic issues and the more severe form, ichthyosis fetalis, is lethal. A Shorthorn calf with ichthyosis fetalis was investigated and a likely causal missense variant on chromosome 2 in the ABCA12 gene (NM_001191294.2:c.6776T>C) was identified by whole genome sequencing. Mutations in the ABCA12 gene are known to cause ichthyosis fetalis in cattle and Harlequin ichthyosis in humans. Sanger sequencing of the affected calf and the dam confirmed the variant was homozygous in the affected calf and heterozygous in the dam. Further genotyping of 130 Shorthorn animals from the same property revealed an estimated allele frequency of 3.8%. The presented findings enable genetic testing for breeding and diagnostics.

Compound heterozygosity for TNXB genetic variants in a mixed-breed dog with Ehlers-Danlos syndrome

The Ehlers-Danlos syndromes (EDSs) are a heterogeneous group of inherited connective tissue disorders characterized by skin hyperextensibility, joint hypermobility and tissue fragility. Inherited disorders similar to human EDS have been reported in different mammalian species. In the present study, we investigated a female mixed-breed dog with clinical signs of EDS. Whole-genome sequencing of the affected dog revealed two missense variants in the TNXB gene, encoding the extracellular matrix protein tenascin XB. In humans, TNXB genetic variants cause classical-like EDS or the milder hypermobile EDS. The affected dog was heterozygous at both identified variants. Each variant allele was transmitted from one of the case's parents, consistent with compound heterozygosity. Although one of the variant alleles, XM_003431680.3:c.2012G>A, p.(Ser671Asn), was private to the family of the affected dog and absent from whole-genome sequencing data of 599 control dogs, the second variant allele, XM_003431680.3:c.2900G>A, p.(Gly967Asp), is present at a low frequency in the Chihuahua and Poodle population. Given that TNXB is a functional candidate gene for EDS, we suggest that compound heterozygosity for the identified TNXB variants may have caused the EDS-like phenotype in the affected dog. Chihuahuas and Poodles should be monitored for EDS cases, which might confirm the hypothesized pathogenic effect of the segregating TNXB variant.

[Core outcome measurements in hand eczema trials : The HECOS initiative]

BACKGROUND

To enhance the informative value and comparability of hand eczema trials, the consensus of a set of core outcomes is necessary.

OBJECTIVES

How is success of therapeutic and preventive interventions currently determined in hand eczema trials? Which standard should apply in the future?

MATERIALS AND METHODS

As a first step, a systematic literature review was conducted to describe the status in controlled and randomized-controlled hand eczema trials from 2000-2017 and to identify the applied outcomes. The Hand Eczema Core Outcome Set (HECOS) initiative follows the guidelines of the Cochrane Skin Group Core Outcomes Set Initiative (CS-COUSIN) so that its further process is going to ensure the validity of the proposed measurement instruments and the appropriate inclusion of patients', physicians', and researchers' perspectives.

RESULTS

Previous trials predominantly assessed erythema, scaling, fissures, vesicles, or pruritus as clinical signs and symptoms of hand eczema. These variables were often not reported separately but as part of a variety of scores. Only few hand eczema scores were applied in more than one trial-most commonly the Hand Eczema Severity Index (HECSI, in 10% of the trials). Overall skin condition, without mentioning specific signs or symptoms, was assessed in 51% of the trials.

CONCLUSIONS

Although certain clinical signs and symptoms were assessed by a majority of hand eczema trials, comparability of results was not ensured because various measurement instruments were applied. HECOS is going to agree on a set of relevant and valid core outcome measurement instruments.

[Type IV contact allergies in the food processing industry: an update]

BACKGROUND

The food sector is one of the high-risk areas for occupational irritative and allergic contact eczema.

OBJECTIVES

The present work provides an overview of the main allergens as well as sensitization frequencies and risk in various food industry occupations.

METHODS

The literature on type IV sensitization in the food sector is summarized.

RESULTS

The relative risk of developing a work-related eczema in food processing is increased by more than 3 times. The comparison group was calculated on the basis of the proportion of documented cases in the IVDK (Informationsverbund Dermatologischer Kliniken) network per 100,000 working persons in relation to the average of the years 2005 and 2010. For this purpose, the average risk of all patients was set as reference to 1. Bakers, pastry chefs, cooks and meat and fish processors are mainly affected. In addition to irritant contact eczema, allergic contact eczema and protein contact dermatitis often occur. Leading haptens (main allergens) are rubber ingredients, but also disinfectants and compositae.

CONCLUSION

Only a few contact allergens are responsible for the majority of job-relevant sensitizations in the food industry.

Therapierefraktäres atopisches Ekzem − erfolgreiche Therapie mit Dupilumab

Bis vor Kurzem standen zur Behandlung der atopischen Dermatitis, im Gegensatz zur Psoriasis vulgaris, keine Biologika zur Verfügung, sodass die therapeutischen Möglichkeiten, insbesondere bei schweren Verläufen und fehlendem Ansprechen auf die bisher einzige zugelassene Systemtherapie mit Ciclosporin A, sehr begrenzt waren. Mit Dupilumab ist seit Januar 2018 erstmals ein Biologikum zur Behandlung der atopischen Dermatitis zugelassen. Hierbei handelt es sich um einen vollständig humanen monoklonalen Antikörper gegen die Alpha-Untereinheit des Interleukin (IL)-4-Rezeptors, wodurch die IL-4/IL-13-Signalwege gehemmt werden. Hier beschreiben wir den Fall eines 46-jährigen asiatischen Patienten mit einer schweren therapierefraktären atopischen Dermatitis sowie einer nebenbefundlich bestehenden eosinophilen pustulösen Follikulitis und den Verlauf seiner Erkrankung unter Dupilumab.

A second KRT71 allele in curly coated dogs

Major characteristics of coat variation in dogs can be explained by variants in only a few genes. Until now, only one missense variant in the KRT71 gene, p.Arg151Trp, has been reported to cause curly hair in dogs. However, this variant does not explain the curly coat in all breeds as the mutant ¹⁵¹ Trp allele, for example, is absent in Curly Coated Retrievers. We sequenced the genome of a Curly Coated Retriever at 22× coverage and searched for variants in the KRT71 gene. Only one protein-changing variant was present in a homozygous state in the Curly Coated Retriever and absent or present in a heterozygous state in 221 control dogs from different dog breeds. This variant, NM_001197029.1:c.1266_1273delinsACA, was an indel variant in exon 7 that caused a frameshift and an altered and probably extended C-terminus of the KRT71 protein NP_001183958.1:p.(Ser422ArgfsTer?). Using Sanger sequencing, we found that the variant was fixed in a cohort of 125 Curly Coated Retrievers and segregating in five of 14 additionally tested breeds with a curly or wavy coat. KRT71 variants cause curly hair in humans, mice, rats, cats and dogs. Specific KRT71 variants were further shown to cause alopecia. Based on this knowledge from other species and the predicted molecular consequence of the newly identified canine KRT71 variant, it is a compelling candidate causing a second curly hair allele in dogs. It might cause a slightly different coat phenotype than the previously published p.Arg151Trp variant and could potentially be associated with follicular dysplasia in dogs.

Response of the Skyrmion Lattice in MnSi to Cubic Magnetocrystalline Anisotropies

We report high-precision small-angle neutron scattering of the orientation of the Skyrmion lattice in a spherical sample of MnSi under systematic changes of the magnetic field direction. For all field directions the Skyrmion lattice may be accurately described as a triple-Q[over →] state, where the modulus |Q[over →]| is constant and the wave vectors enclose rigid angles of 120°. Along a great circle across ⟨100⟩, ⟨110⟩, and ⟨111⟩ the normal to the Skyrmion-lattice plane varies systematically by ±3° with respect to the field direction, while the in-plane alignment displays a reorientation by 15° for magnetic field along ⟨100⟩. Our observations are qualitatively and quantitatively in excellent agreement with an effective potential, which is determined by the symmetries of the tetrahedral point group T and includes contributions up to sixth order in spin-orbit coupling, providing a full account of the effect of cubic magnetocrystalline anisotropies on the Skyrmion lattice in MnSi.