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.

Correlation of trastuzumab-based treatment with clinical characteristics and prognosis in HER2-positive gastric and gastroesophageal junction cancer: A retrospective single center analysis

Attempts for identifying targeted therapy strategies in metastatic gastric and gastroesopheal junction cancer (upper-GI) revealed that the inhibition of human epidermal growth factor receptor-2 (HER2) by monoclonal antibody trastuzumab improves survival of these patients. Hence, adding trastuzumab to doublet chemotherapy has become the standard treatment in this setting. Although the patient survival is extended among clinical trials, the knowledge on the real-time setting is limited. With this retrospective, single center analysis of the patient data of the Medical University of Vienna, we sought to investigate the clinical characteristics and outcome of patients, who received trastuzumab-based chemotherapy for metastatic upper-GI tumor. All patients, who received trastzumab at least once were included to the analysis. Clinical and pathological data were recorded. This search revealed 33 patients. The demographic data was comparable with that of the previous clinical trials. Progression free survival (PFS) was 11 months, whereas overall survival (OS) was 21 months. OS was significantly associated with initially favorable response to treatment. Thirteen patients (39%) received trastuzumab as maintenance treatment with a median cycle number of 6. Toxicity profile was acceptable with only one patient detected to have cardiotoxicity. Taken together, trastuzumab based treatment induced a considerable PFS and OS in metastatic or advanced upper-GI tumors with acceptable toxicity profile. The maintenance therapy with trastuzumab was safe and effective in patients who had initially a favorable response to chemotherapy. The optimal duration of the maintenance therapy should be tested in future clinical trials.

Programmed death-ligand 1 expression in rectal cancer

Background

Colorectal cancer (CRC) is the fourth most common cause of death worldwide. Approximately 30 % of all CRC occurs in the rectum. Improvements in survival rates were achieved thanks to multimodal therapy, combining surgery and chemoradiation. Nevertheless, the prognosis of patients suffering from rectal cancer (RC) remains poor. Programmed cell death protein 1 (PD-1) and its ligand programmed death ligand 1 (PD-L1) regulate tumor immune response. The aim of this study was to analyze the expression of PD-L1 in RC pre- and post-neoadjuvant therapy and evaluate PD-L1 as a biomarker and potential target for therapy.

Methods

In all, 29 patients with RC treated at the Medical University Vienna who received preoperative chemoradiation were retrospectively enrolled in this study. Expression of PD-L1 was investigated by immunohistochemistry with two different anti-PD-L1 antibodies.

Results

No PD-L1 expression on cancer cells could be observed in all 29 cases in the specimens before chemoradiation as well as in the surgical specimens after neoadjuvant therapy. In one of the two staining methods performed, five (17.24 %) post-chemoradiation cases showed faint lymphohistiocytic staining.

Conclusion

No expression of PD-L1 in RC cells before and after chemoradiation was found in our collective of 29 patients. Further investigations to evaluate the role of PD-L1 as a potential therapeutic target in RC are urgently needed.

Tissue damage within normal appearing white matter in early multiple sclerosis: assessment by the ratio of T1- and T2-weighted MR image intensity

Histopathological and magnetic resonance imaging (MRI) studies have shown white matter (WM) damage in early stages of multiple sclerosis (MS) beyond the apparent T2-hyperintense lesions. These changes in normal appearing WM (NAWM) are important with regard to the clinical picture and prognosis. However, the detection of changes within NAWM has so far required special imaging techniques commonly not available in clinical routine and, hence, at large scale. The purpose of this study was to detect MS-related damage of NAWM by conventional MRI. As, within NAWM, the myelin content mainly drives the T1-weighted (T1w) signal, we scaled it by the T2w signal. We tested the hypothesis that the mean T1w/T2w ratio of NAWM is decreased in MS compared to healthy controls (HC) and that it correlates with clinical measures. We developed a pipeline to determine the individual mean values of this ratio within NAWM. We studied 244 patients in early disease stages of MS (mean age 37 ± 10 years, mean disease duration 3.1 ± 2.3, Expanded Disability Status Scale 1.3 ± 1), and 78 HC (mean age 31 ± 8 years). Compared to HC, the mean T1w/T2w ratio was lowered in the patient group (P < 0.001). The difference remained significant after restricting the analysis to patients with a disease duration of 5 years or less and without disease modifying drugs. Our measures also correlated with clinical scores. We believe that the mean T1w/T2w ratio is a promising candidate to assess MS-related tissue damage within NAWM at large scale.

[Isolation and Characterization of Multipotent Precursor Cells from Murine Adipose Tissue using a Clinically Approved Cell Separation System]

INTRODUCTION

Recent studies underscored the clinical potential of adipose-derived multipotent stem-/precursor cells (ASPCs). One of the main hurdles en route to clinical application was to isolate cells without having to perform expansion cultures outside the OR. A new generation of clinically approved, commercially available cell separation systems claims to provide ASPCs ready for application without further expansion cultures. However, it is unclear if the new systems yield sufficient cells of adequate quality for the use in autologous murine models. The aim of this study was to isolate and characterize adipose-derived precursor cells taken from the inguinal fat pat of wistar rats using InGeneron's clinically approved ARC™-cell separation system.

MATERIALS AND METHODS

We isolated cells from the inguinal fat pad of 3 male Wistar rats according to the manufacturer's protocol. In order to reduce the influence of the atmospheric oxygen on the multipotent precursor cells, one half of the cell suspension was cultivated under hypoxia (2% O2) simulating physiological conditions for ASPCs. As a control, the other half of the cells were cultivated under normoxia (21% O2). Cell surface markers CD90, CD29, CD45 and CD11b/c were analyzed by FACS, and osteogenic and adipogenic differentiation of the ASPCs was performed. Finally, cellular growth characteristics were assessed by evaluation of the cumulative population doublings and CFU assay, and metabolic activity was evaluated by WST-1 assay.

RESULTS

Processing time was 90 (± 12) min. 1 g of adipose tissue yielded approximately 60 000 plastic adhering cells. Both groups showed a high expression of the mesenchymal stem cell markers CD90 and CD29 while they were negative for the leucocyte markers CD45 and CD11b/c. A strong osteogenic differentiation and a sufficient adipogenic differentiation potential was proven for all ASPCs. Under hypoxia, ASPCs showed increased proliferation characteristics and CFU efficiency as well as a significantly increased metabolic activity.

CONCLUSION

This study showed that sufficient multipotent ASPCs of appropriate quality can be isolated from the inguinal fat pad of Wistar rats using the ARC™-cell separation system. As shown in previous studies, cultivation of cells under hypoxic conditions increased their stemness. Our findings will enable future studies that focus on autologous transplantation of ASPCs in a rat model, which most closely resembles a possible clinical application.

[Obligation to operate splenic injuries in polytrauma patients using MS-CT criteria]

PURPOSE

The aim of this study is to evaluate the validity of multi-slice computed tomography (MS-CT) in predicting the need to operate on spleen injuries in polytrauma patients using selected grading systems; the Thompson screening test (TST) and the extended TST (ETST).

PATIENTS AND METHODS

A retrospective evaluation of 2791 patients who presented spleen injuries in polytrauma MS-CTs in the period between 12/2002 and 06/2010 was undertaken. On the basis of CT morphology, and by using the above mentioned grading systems, the probability of the need to operate on a splenic injury was defined.

RESULTS

From a sample of 2791 patients, an MS-CT polytrauma scan was used to identify 139 splenic injuries. In correlation with the actual interventions carried out on the spleen, the applied grading systems showed sensitivities of 91 % (TST) and 69 % (ETST) as well as specificities of 78 % (TST) and 93 % (ETST). Regarding interventions on a splenic injury, positive predictive values were 57 % (TST) and 76 % (ETST), and the accordant negative predictive values were 96 % (TST) and 91 % (ETST). Thereby we ascertained significantly lower results than Thompson et al.

CONCLUSION

The applied grading systems based on the findings of MS-CT do not reliably predict the need to operate on spleen injuries in polytrauma patients.

C4.4A as a candidate marker in the diagnosis of colorectal cancer

C4.4A is a member of the Ly-6 family with restricted expression in non-transformed tissues. C4.4A expression in human cancer has rarely been evaluated. Thus, it became important to explore C4.4A protein expression in human tumour tissue to obtain an estimate on the frequency of expression and the correlation with tumour progression, the study focusing on colorectal cancer. The analysis of C4.4A in human tumour lines by western blot and immunoprecipitation using polyclonal rabbit antibodies that recognize different C4.4A epitopes revealed C4.4A oligomer and heavily glycosylated C4.4A isoform expression that, in some instances, inhibited antibody binding and interaction with the C4.4A ligand galectin-3. In addition, tumour cell lines released C4.4A by vesicle shedding and proteolytic cleavage. C4.4A was expressed in over 80% of primary colorectal cancer and liver metastasis with negligible expression in adjacent colonic mucosa, inflamed colonic tissue and liver. This compares well with EpCAM and CO-029 expression in over 90% of colorectal cancer. C4.4A expression was only observed in about 50% of pancreatic cancer and renal cell carcinoma. By de novo expression in colonic cancer tissue, we consider C4.4A as a candidate diagnostic marker in colorectal cancer, which possibly can be detected in body fluids.

Prospective study on bright lumen magnetic resonance colonography in comparison with conventional colonoscopy

The aim of this prospective trial was to evaluate sensitivity and specificity of bright lumen magnetic resonance colonography (MRC) in comparison with conventional colonoscopy (CC). A total of 120 consecutive patients with clinical indications for CC were prospectively examined using MRC (1.5 Tesla) which was then followed by CC. Prior to MRC, the cleansed colon was filled with a gadolinium-water solution. A 3D GRE sequence was performed with the patient in the prone and supine position, each acquired during one breathhold period. After division of the colon into five segments, interactive data analysis was carried out using three-dimensional post-processing, including a virtual intraluminal view. The results of CC served as a reference standard. In all patients MRC was performed successfully and no complications occurred. Image quality was diagnostic in 92% (574/620 colonic segments). On a per-patient basis, the results of MRC were as follows: sensitivity 84% (95% CI 71.7-92.3%), specificity 97% (95% CI 89.0-99.6%). Five flat adenomas and 6/16 small polyps (< or =5 mm) were not identified by MRC. MRC offers high sensitivity and excellent specificity rates in patients with clinical indications for CC. Improved MRC techniques are needed to detect small polyps and flat adenomas.

National character does not reflect mean personality trait levels in 49 cultures

Most people hold beliefs about personality characteristics typical of members of their own and others' cultures. These perceptions of national character may be generalizations from personal experience, stereotypes with a "kernel of truth," or inaccurate stereotypes. We obtained national character ratings of 3989 people from 49 cultures and compared them with the average personality scores of culture members assessed by observer ratings and self-reports. National character ratings were reliable but did not converge with assessed traits. Perceptions of national character thus appear to be unfounded stereotypes that may serve the function of maintaining a national identity.

[Cine MRI of the temporomandibular joint in comparison to static MRI and axiography]

PURPOSE

To evaluate Cine MRI (cMRI) of the temporomandibular joint in comparison to static MRI (sMRI) and axiography.

MATERIALS AND METHODS

In a prospective study with 57 healthy volunteers as well as 33 patients after temporomandibular joint (TMJ) surgery or with severe joint dysfunction, we measured the mobility of both condyle and disc as well as the sagittal angle of condylar inclination with sMRI and cMRI. Measurements and image analysis were performed by a radiologist and a maxillofacial surgeon in consensus. The results of axiography served as standard of reference.

RESULT

Concerning the assessment of the discoligamentous complex, sMRI was superior to cMRI in the patient-group (sensitivity sMRI 85 %, cMRI 76 %), while no significant difference was found in the volunteer-group (sensitivity sMRI 97.4 %, cMRI 98.3 %). The results of cMRI and sMRI showed a highly significant correlation with each other, as well as with the axiographic reference tracings (r = 0.90). The average mobility of the disc and condyle was 6 % and 10 % higher in sMRI compared to cMRI (p = 0.001) and showed a slightly higher variance (0.043 vs. 0.038). Concerning the condylar inclination angle, both MRI-procedures had the best correlation (r = 0.94) with each other and axiography.

CONCLUSION

Real-time MRI of the TMJ is comparable to axiography in its accuracy and is a useful adjunct to conventional static MRI.

Tumors of the urinary bladder: technique, current use, and perspectives of MR and CT cystography

In comparison with other applications of virtual endoscopy, reports about virtual cystocopy are limited. In this update article, the various techniques of magnetic resonance (MR) and computed tomographic (CT) cystography are explained with their inherent advantages and disadvantages. The principal methods of postprocessing are presented, and future technical developments of MR and CT cystography are described. The present clinical applications and the possible role of MR and CT cystography in the future are discussed.

[Development of a 3-dimensional method to determine the tibial slope with multislice-CT]

AIM

The measurement or, respectively, the correction of the tibial slope is an important subject in the field of knee arthroplasty and in the procedure of cruciate ligament reconstruction. However, a valid value of the tibial slope cannot be obtained from the conventional plain X-rays in a reproducible way. The aim of this study was to evaluate the proximal tibial slope with a new CT measurement system and to compare the values with the X-ray method.

METHOD

Using 6 cadaver tibiae, the antero-posterior slope of the proximal tibia was measured at 0 degrees, 2.5 degrees, 5 degrees, 10 degrees, 15 degrees, 20 degrees, 30 degrees internal rotation using the plain X-ray and spiral CT (3D-MPR reconstruction). Both methods were compared.

RESULTS

The variation of the measurement of the tibial slope with the X-ray method was > 5 degrees even if the optimal 0 degrees rotation in the lateral view was applied. Moreover, the measurement error increased to 14 degrees while increasing the rotation of the tibia. Using the new CT system, the error was less than 3 degrees in all measurements.

CONCLUSION

The measurement of the tibial slope in the conventional X-ray technique showed a high variation of the values depending on the rotation of the tibia in the lateral view. In contrast, the measurements with the new CT system represented a precise method with a small variation of the tibial slope values. For this reason detailed questions regarding the precise anatomy of the proximal tibia cannot be answered precisely with plain X-rays.

[Virtual endoscopy of the urinary tract]

This review article depicts the technique of virtual uro-endoscopy and its diagnostic value and highlights future aspects. The raw data are acquired using CT, MR, or ultrasound. Sufficient contrast between the wall of the hollow organ and its interior is reached by administering gas or contrast medium into the bladder or injecting contrast media i.v. After processing of these data, virtual endoscopic procedures can be watched on a screen in the same way as a cine-film of a conventional endoscopic operation. Virtual endoscopy is a reliable method with a high sensitivity for pathologies larger than 0.5 cm. It is not invasive, and there are situations that cause difficulties in conventional endoscopy (e.g. gross hematuria, diverticula, strictures) that cause no technical problems in virtual endoscopy. Problems encountered in virtual endoscopy are due to its poor sensitivity for pathologies smaller than 0.5 cm, for carcinoma in situ, and for ureteral calculi. So far there are no routine-indications for virtual endoscopy in urology. Nevertheless, it can be of additional value in diagnosis providing the indications are carefully controlled. In future, virtual endoscopy will probably become integrated into the spectrum of urologic diagnostics investigations.

[Role of antiphospholipid antibodies in 147 patients with spontaneous abortions and stillbirths: a retrospective and prospective analysis]

Antiphospholipid antibodies (aPL) are a family of autoantibodies including lupus anticoagulant (LA), anticardiolipin antibodies (aCL), and ect. That appear to react with negatively charged phospholipids. These antibodies induce thrombosis and pregnancy complications including recurrent spontaneous abortions (RSA), recurrent stillbirth (SB), preeclampsia and intra-uterine growth retardation, although their exact pathogenic mechanisms remain poorly defined. The aim of this study was to investigate the frequency and the role of a aPL women with a history of RSA and SB due to positive aPL. The study included 147 women with a history of RSA and 48 women with a history of SB and to investigate the histological changes in the heams and stillborn fetuses in aCL positive women. We established that: 1, aCL were significantly increased in 62.2% (n = 92) in women with history of RSA and in 71% (n = 34) in women with history of SB; 2. aTr antibodies were positive in 22.7% (n = 5) in women with history of SB; 3. Tr activation status was increased in 77.3% (n = 17) in women with history of SB.

CONCLUSION

The investigation of aPL in women with history of RSA and SB provides new insights into the disease and offers promise for prophylaxis and treatment in subsequent pregnancies.

Local calibrated bone mineral density in the mandible presented using a color coding scheme

Calibrated information on bone mineral density (BMD) may be used in dental implantology to measure "bone quality". It can be used to estimate the expected primary implant stability preoperatively and to guide the surgeon in selecting optimum implant types and operation techniques. Using a preoperative dental computed tomography (Dental-CT) scan, all of this information can be obtained without additional examinations and thus without additional X-ray exposure of the patient. In contrast to bone mineral determination in other body regions, local BMD values are important in the jaw bone. Therefore, a regimen where color-coded information on local bone mineralization is superimposed on Dental-CT images is proposed using the original CT volumes as well as reformatted views.

Observation of the swallowing process by application of videofluoroscopy and real-time magnetic resonance imaging-consequences for retronasal aroma stimulation

The process of eating and drinking was observed in vivo by application of videofluoroscopy, a dynamic X-ray technique, as well as real-time magnetic resonance imaging. The study was aimed at elucidating the timing and performance of the physiological organs involved in mastication and swallowing, mainly the tongue, the pharynx and the soft palate (velum palatinum). It was shown for the first time that effective physiological barriers do exist during food consumption that are capable of retaining volatiles such as helium within the oral cavity. These barriers allow the access of odorants to the nasal cavity only at certain times during the eating process. Their effectiveness is related to the texture of the food as well as the amount of food material present in the oral cavity and, thereby, directly influences retronasal aroma perception.

[Virtual endoscopy of the urinary tract from T(2)-weighted and gadolinium-enhanced T(1)-weighted MR urographic images]

PURPOSE

To determine the diagnostic performance of T(2)-weighted (T2w) and gadolinium-enhanced T(1)-weighted (T1w-Gd-enhanced) MR urographic images for virtual endoscopy of the urinary tract.

MATERIALS AND METHODS

36 patients underwent MR urography at 1.5 T. In each patient a T2w (3D-TSE, respiration-triggered) and a T1w-Gd-enhanced sequence (T1-FFE, breathhold) were acquired. Data reconstruction was performed as maximum intensity projection (MIP) and virtual endoscopy (VE).

RESULTS

Combined analysis of MIP and VE delineated 32 of 36 pathologies; 86 % (19/22) of intraluminal pathologies could be depicted by VE and 15 % (3/22) by MIP (p </= 0.01). For the assessment of the renal pelvis, MIP was superior to VE in 55 % (39/71). Concerning the ureter, MIP was equal in 52 % (37/71) and superior to VE in 45 % (32/71). For virtual ureterorenoscopy both data sets were comparable in their diagnostic performance. T2w data sets were superior for virtual cystoscopy because no contrast medium is required in cases of renal failure and sedimentation artifacts can be avoided.

CONCLUSION

For the depiction of the upper urinary tract, MIP is in most cases equally good or superior to VE. However, virtual endoscopy of the urinary tract, especially virtual cystoscopy, is a useful tool for the depiction of intraluminal pathology.

Heparin plus aspirin as a "single" therapy for recurrent spontaneous abortion associated with both allo- and autoimmunity

PROBLEM

The aim of this study was to contribute to the study of the pathogenesis and the treatment of recurrent spontaneous abortion (RSA) associated with immune alterations.

METHOD OF STUDY

This is a prospective clinical trial with 11 patients with RSA associated with allo- and autoimmunity not receiving lymphocyte immunizations but only heparin and aspirin preconceptionally and through pregnancy. A concurrent group of 8 patients receiving a complete therapy (lymphocyte immunizations, heparin, and aspirin) but not receiving heparin and aspirin preconceptionally is also included in this report.

RESULTS

The rate of pregnancy success in these patients was 90.9% (10/11), and the rate of success of the concurrent group was 75.0% (6/8).

CONCLUSIONS

The results are in agreement with the working hypothesis regarding the possible final common mechanism in the pathogenesis of abortion associated with allo- and autoimmunity. The "single" therapy with heparin and aspirin was effective, less costly, and logistically simpler to provide than a complete therapy including lymphocyte immunizations.

Crossreactivity of workshop monoclonal antibodies with canine blood leukocytes

A selection of 164 monoclonal antibodies for determinants on porcine cells were tested on canine leukocytes by flow cytometry. Eighteen mAbs proved to be crossreacting and 16 of these reacted uniformly with cells of three unrelated dogs while two displayed a polymorphic reaction pattern.

Immigration and slow-growth economies: the experience of South Australia and Tasmania

"This paper examines national immigration processes and demographic change in South Australia and Tasmania over the last four decades. Particular attention is paid to the inter-censal period 1986-1991.... The paper investigates the impact of the historic make-up of immigrant flows on settlement patterns, and examines the impact on policies intended to increase immigrant settlement in these states. It argues that the policies being pursued by state and federal governments are unlikely to add to the numbers settling in these states, because they pay too little attention to migration processes, and especially the attraction of others from the source country."