The clinical profile of NMOSD in Australia and New Zealand

Neuromyelitis optica spectrum disorders (NMOSD) are an inflammation of the central nervous system associated with autoantibodies to aquaporin-4. We have undertaken a clinic-based survey of NMOSD in the Australia and New Zealand populations with the aim of characterising the clinical features and establishing the value of recently revised diagnostic criteria. Cases of possible NMOSD and age and sex-matched controls with multiple sclerosis (MS) were referred from centres across Australia and New Zealand. Cases were classified as NMOSD if they met the 2015 IPND criteria and remained as suspected NMOSD if they did not. Clinical and paraclinical data were compared across the three groups. NMOSD was confirmed in 75 cases and 89 had suspected NMOSD. There were 101 controls with MS. Age at onset, relapse rates and EDSS scores were significantly higher in NMOSD than in MS. Lesions and symptoms referable to the optic nerve were more common in NMOSD whereas brainstem, cerebellar and cerebral lesions were more common in MS. Longitudinally extensive spinal cord lesions were seen in 48/71 (68%) of cases with NMOSD. Elevations of CSF, white cell count and protein were more common in NMOSD. We have confirmed a clinical pattern of NMOSD that has been seen in several geographical regions. We have demonstrated the clinical utility of the current diagnostic criteria. Distinct patterns of disease are evident in NMOSD and MS, but there remains a large number of patients with NMOSD-like features who do not meet the current diagnostic criteria for NMOSD and remain a diagnostic challenge.

P206 Immediate impact of coronary revascularization on global and regional myocardial function evaluated by speckle tracking echocardiography

Funding Acknowledgements

No.

OnBehalf

No.

Background

The immediate effect on myocardial function and deformation after coronary revascularization is incompletely studied. Effective revascularization along with perioperative myocardial injury compromises improved regional and global left ventricular function and leads to the risks of adverse perioperative events following coronary artery bypass grafting (CABG) surgery. Global longitudinal strain (GLS) assessed by speckle-tracking echocardiography (STE) has been reported as a better predictor and a more sensitive marker for postoperative ventricular remodeling.

Purpose

This study aimed to evaluate changes of left ventricular (LV) systolic function and GLS in the perioperative period during CABG and to investigate the value of GLS using two-dimensional STE in predicting short-term outcome.

Methods

A total of 22 patients who underwent elective CABG surgery (EuroSCORE II 1.84 ± 1.2) were evaluated. Transesophageal echocardiography was performed, 2D and three-dimensional echocardiography (3DE) data was acquired before sternotomy, before cardiopulmonary bypass (CPB), after bypass and after chest closure. LV GLS and tissue motion annular displacements (TMAD) of the mitral valves were quantified by 2D STE using CMQ software. LV volumes and ejection fraction (EF) were evaluated by 3DE at the same timepoints. Short-term outcomes were defined as death, stroke, myocardial infarction, acute kidney dysfunction, rehospitalization and repeated revascularization in a one-month period after surgery.

Results

Both 2D and 3DE of all patients were analyzed. The cohort had a mean age of 68.2 ± 7.2 years and 9.1% was women. Before sternotomy, GLS was -15.7 ± 2.9%. Despite little change in 3D LVEF, GLS was immediately impaired after coronary artery bypass graft (before bypass vs after chest closure, -15.9 ± 3.6% vs -13.5 ± 4.0%, P = 0.001). There was strong correlation between GLS and 3D LVEF (r=-0.77, P < 0.001), moderate correlations between GLS and absolute value of TMAD (r=-0.61, P < 0.05), between GLS and percentage of TMAD (r=-0.64, P < 0.05). Patients with poor outcome (n = 6) had a lower longitudinal strain (LS) in the apical 2-chamber (A2C) views (-14.5 ± 4.6% vs -10.8 ± 1.3%, P = 0.007) but no statistical difference between A3C and A4C views. The ROC analysis demonstrated a cut­off value -11.8% for A2C-LS to predict adverse events (AUC 0.81, P = 0.027, 95% CI 0.632-0.993), with an 83.3% sensitivity and 81.2% specificity, followed by 3D LVEF (AUC = 0.29), absolute and percentage of TMAD (AUC = 0. 21, 0.23) as less sensitive predictors of poor postoperative outcome.

Conclusion

Direct effects of myocardial deformation related to revascularization can be characterized by STE during CABG surgery. GLS could be a more sensitive parameter in the perioperative environment, which correlates well with LV global function assessed by 3D LVEF and TMAD. Early impairment of anterior and inferior wall myocardial strain after CABG may contribute to short-term adverse clinical outcome.

Abstract P206 Figure.

The critical role of histology in distinguishing sarcoidosis from common variable immunodeficiency disorder (CVID) in a patient with hypogammaglobulinemia

Background

Common variable immunodeficiency disorders (CVID) are a rare group of primary immune defects, where the underlying cause is unknown. Approximately 10–20% of patients with typical CVID have a granulomatous variant, which has closely overlapping features with sarcoidosis.

Case presentation

Here we describe a young man who sequentially developed refractory Evans syndrome, cauda equina syndrome and most recently renal impairment. Following immunosuppression, he has made a recovery from all three life-threatening autoimmune disorders. As the patient was hypogammaglobulinemic for most of the time while on immunosuppression, vaccine challenges and other tests were not possible. Histological features were in keeping with sarcoidosis rather than the granulomatous variant of CVID. In the brief period when immunosuppression was lifted between the cauda equina syndrome and renal impairment, he normalised his immunoglobulins, confirming sarcoidosis rather than CVID was the underlying cause.

Conclusion

We discuss diagnostic difficulties distinguishing the two conditions, and the value of histological features in our diagnostic criteria for CVID in identifying sarcoidosis, while the patient was hypogammaglobulinemic. The key message from this case report is that the characteristic histological features of CVID can be very helpful in making (or excluding) the diagnosis, particularly when other tests are not possible.

P2550The influence of tonic-clonic seizures on heart rate variability in patients with refractory epilepsy

Background

Heart Rate Variability (HRV) is an increasing area of interest in patients with epilepsy. The effects of epilepsy on the autonomic control of the heart are not completely understood and that autonomic dysfunction has been implicated in some cases of Sudden Unexpected Death in Epilepsy (SUDEP).

Objective

To study the influence of generalized tonic-clonic seizures (GTCS) on HRV of patients with focal refractory epilepsy.

Method

We prospectively evaluated (January 2015 to July 2018) 121 patients admitted to our institution's Epilepsy Monitoring Unit. All patients performed a 48-hour Holter recording. Patients who had GTCS during the recording were included and we selected the first GTCS as the index seizure. HRV (AVNN, SDNN, RMSSD, pNN50, and LF/HF) was evaluated by analyzing 5-min-ECG epochs during inter-ictal and post-ictal periods: baseline, pre-ictal (5 min before the GTCS seizure), post-ictal (5 min after the seizure), and late post-ictal (>5 hours after the seizure). We compared HRV data from these patients with normative values for a healthy population (controlling age and gender). The study was approved by our Institution Ethics Committee and all patients gave informed consent.

Results

Twenty three patients were included (mean age: 38.61±11.58; 70% Female). Thirty percent presented cardiovascular risk factors without known cardiac disease. We found significant differences between the analyzed periods for all but one (LF/HF) HRV metrics (using Friedman test, p<0.05, two-tailed). Specifically during the post-ictal period, we found a significant reduction for AVNN, SDNN, RMSSD and pNN50 (Wilcoxon test, p<0.05; two-tailed). LF/HF was increased during this period, but changes were not statistically significant. There was also a tendency for a reduction of AVNN, SDNN, RMSSD and pNN50 and an increase of LF/HF in our patients during all the analyzed periods when compared to normative healthy population values.

Conclusion

Our work shows reduced HRV after a GTCS in patients with focal resistant epilepsy, both in inter-ictal and post-ictal periods, when compared to normative healthy population values. These results might reflect long term structural changes in autonomic centers. The HRV changes were significant particularly during the post-ictal period, and should prompt further investigation, giving this period is critical for SUDEP.

P5346The effect of seizure type on ictal and early post-ictal Heart Rate Variability in patients with focal resistant epilepsy

Background

Seizures commonly affect the heart rate and its variability. The increased interest in this area of research is related to the possible connection with sudden unexpected death in epilepsy (SUDEP). Generalized tonic-clonic seizures (GTCS) are reported as the most consistent risk factor for SUDEP. However, the general risk of seizures (and their type) on cardiac function still remains uncertain.

Purpose

To evaluate the influence of seizure type (GTCS vs non-GTCS) on ictal and early post-ictal Heart Rate Variability (HRV) in patients with refractory epilepsy.

Methods

From January 2015 to July 2018, we prospectively evaluated 121 patients admitted to our institution's Epilepsy Monitoring Unit with focal resistant epilepsy. All patients underwent a 48-hour Holter recording. We included only patients who had both GTCS and non-GTCS during the recording and selected the first seizure of each type to analyze. HRV (AVNN, SDNN, RMSSD, pNN50, and LF/HF) was evaluated by analyzing 5-min-ECG epochs, starting with the seizure onset (ictal and early post-ictal period). The study was approved by our Institution Ethics Committee and all patients gave informed consent.

Results

Fourteen patients were included (7 Females, 4 patients with Temporal Lobe Epilepsy). The median age was 39 years (min-max, 18–57). Thirty-six percent presented cardiovascular risk factors without known cardiac disease.

A significant statistical reduction was found for AVNN (p=0.013), RMSSD (p=0.008), pNN50 (p=0.005) and HF (p=0.003), during GTCS when compared with non-GTCS (Wilcoxon test, p<0.05; two tailed).

Conclusion

Our study shows a significant reduced vagal tone during GTCS when compared with non-GTCS. Hence, GTCS had a more pronounced impact on HRV changes than other seizure types, which can be associated with higher SUDEP risk after GTCS.

Constraining the Neutron Star Compactness: Extraction of the ^{23}Al(p,γ) Reaction Rate for the rp Process

The ^{23}Al(p,γ)^{24}Si reaction is among the most important reactions driving the energy generation in type-I x-ray bursts. However, the present reaction-rate uncertainty limits constraints on neutron star properties that can be achieved with burst model-observation comparisons. Here, we present a novel technique for constraining this important reaction by combining the GRETINA array with the neutron detector LENDA coupled to the S800 spectrograph at the National Superconducting Cyclotron Laboratory. The ^{23}Al(d,n) reaction was used to populate the astrophysically important states in ^{24}Si. This enables a measurement in complete kinematics for extracting all relevant inputs necessary to calculate the reaction rate. For the first time, a predicted close-lying doublet of a 2_{2}^{+} and (4_{1}^{+},0_{2}^{+}) state in ^{24}Si was disentangled, finally resolving conflicting results from two previous measurements. Moreover, it was possible to extract spectroscopic factors using GRETINA and LENDA simultaneously. This new technique may be used to constrain other important reaction rates for various astrophysical scenarios.