Spatial ecology of moose in Sweden: Combined Sr-O-C isotope analyses of bone and antler

The study of spatial (paleo)ecology in mammals is critical to understand how animals adapt to and exploit their environment. In this work we analysed the 87Sr/86Sr, δ18O and δ13C isotope composition of 65 moose bone and antler samples from Sweden from wild-shot individuals dated between 1800 and 1994 to study moose mobility and feeding behaviour for (paleo)ecological applications. Sr data were compared with isoscapes of the Scandinavian region, built ad-hoc during this study, to understand how moose utilise the landscape in Northern Europe. The 87Sr/86Sr isoscape was developed using a machine-learning approach with external geo-environmental predictors and literature data. Similarly, a δ18O isoscape, obtained from average annual precipitation δ18O values, was employed to highlight differences in the isotope composition of the local environment vs. bone/antler. Overall, 82% of the moose samples were compatible with the likely local isotope composition (n = 53), suggesting that they were shot not far from their year-round dwelling area. 'Local' samples were used to calibrate the two isoscapes, to improve the prediction of provenance for the presumably 'non-local' individuals. For the latter (n = 12, of which two are antlers and ten are bones), the probability of geographic origin was estimated using a Bayesian approach by combining the two isoscapes. Interestingly, two of these samples (one antler and one bone) seem to come from areas more than 250 km away from the place where the animals were hunted, indicating a possible remarkable intra-annual mobility. Finally, the δ13C data were compared with the forest cover of Sweden and ultimately used to understand the dietary preference of moose. We interpreted a difference in δ13C values of antlers (13C-enriched) and bones (13C-depleted) as a joint effect of seasonal variations in moose diet and, possibly, physiological stresses during winter-time, i.e., increased consumption of endogenous 13C-depleted lipids.

New insights on Celtic migration in Hungary and Italy through the analysis of non-metric dental traits

The Iron Age is characterized by an extended interweaving of movements by Celts in Europe. Several waves of Celts from Western and Central Europe migrated southeast and west from the core area of the La Téne culture (between Bourgogne and Bohemia). Through the analysis of non-metric dental traits, this work aims to understand the biological relationship among Celtic groups arrived in Italy and the Carpathian Basin, as well as between local populations and Celtic newcomers. A total of 10 non-metric dental traits were analyzed to evaluate biological affinities among Celts (Sopron-Krautacker and Pilismarót-Basaharc) and Scythians-related populations from Hungary (Tápiószele), Celts from continental Europe (Switzerland and Austria), two Iron Age Etruscan-Celtic sites from northern Italy (Monterenzio Vecchio and Monte Bibele), 13 Iron Age central-southern Italic necropolises, and the northern Italian Bronze Age necropolis of Scalvinetto. Strontium isotopes were measured on individuals from the necropolis of Monte Bibele to infer their local or non-local origin. Results highlight the existence of statistically significant differences between Celts and autochthonous Italian groups. Celtic groups from Hungary and Italy (i.e., non-local individuals of Monterenzio Vecchio and Monte Bibele) share a similar biological background, supporting the historical records mentioning a common origin for Celts migrated to the eastern and southern borders of today's Europe. The presence of a supposed Steppean ancestry both in Celts from Hungary and Celts from northern Italy corroborates the hypothesis of the existence of a westward migration of individuals and genes from the Steppe towards northern Italy during the Bronze and Iron Age, which contributed to the biological variability of pre-Celtic and later Celtic populations, respectively. Conversely, individuals from central-southern Italy show an autochthonous pre-Iron Age background. Lastly, this work supports the existence of Celtic migratory routes in northern Italy, as shown by biological and cultural admixture between Celts and Italics living together.

Machine learning-based Sr isoscape of southern Sardinia: A tool for bio-geographic studies at the Phoenician-Punic site of Nora

Since prehistoric times, the island of Sardinia-in the western Mediterranean-has played a leading role in the dynamics of human population and mobility, in the circulation of raw materials and artefacts, idioms and customs, of technologies and ideas that have enriched the biological, linguistic and cultural heritage of local groups. For the Phoenician and Punic periods (from the 9th to the 3rd centuries BCE), the ancient site of Nora-in southern Sardinia-represents an emblematic case in the study of migratory phenomena that occurred on the Island from the Iron Age until the Roman conquest. Despite the importance of exploring (and characterising) such movements from a wider bio-cultural perspective, the application of bio-geochemical tools for geographical provenance to the ancient skeletal populations of Sardinia is yet scarce. The present work is the first step towards filling this gap with the development of the first isoscape of southern Sardinia using new bioavailable Sr isotope data and a machine-learning approach. From a geolithological point of view, Sardinia is rather heterogeneous and requires detailed studies to correctly assess the distribution of the isotopic signature of bioavailable Sr. The random forest model employed here to construct the Sr isoscape uses several external environmental and geological variables. The most important predictors are related to age and bedrock type, with additional input from local soil properties. A 10-fold cross-validation gives a mean square error of 0.0008 and an R-squared of 0.81, so the model correctly predicts the 87Sr/86Sr ratio of unknown areas. By using a Bayesian provenance assignment workflow, we tested the isoscape here produced to determine the geographic origin and the mobility of archaeological and modern fauna collected from the Phoenician-Punic site of Nora and the surrounding Pula Plain. Our results indicate that archaeological sheep and goats (87Sr/86Sr < 0.7090) are compatible with areas close to Nora and Pula Plain, in agreement with archaeological evidence of pastoralism in those areas. Modern wild and domesticated fauna (87Sr/86Sr > 0.7090) show compatibility with several natural and anthropogenic locations in southern Sardinia, as expected based on modern species distribution data. Finally, we discuss the large Sr isotopic variability of the Nora baseline, where human mobility studies of human cremated and inhumed individuals are currently underway.

Incidental cardiac uptake of 99mTc-diphosphonates is predictive of poor outcome: data from 9616 bone scintigraphies

BACKGROUND

Bone scintigraphy (BS) is highly diagnostic for amyloid transthyretin (ATTR) cardiomyopathy. Prevalence and prognostic value of BS cardiac uptake is not well established. Our aim was to assess the prevalence of subclinical cardiac ATTR amyloidosis in patients undergoing [99mTc]MDP/DPD scintigraphy and to define their phenotype and prognosis.

METHODS AND RESULTS

BS scans performed for any clinical indications from 2009 to 2020 were reviewed. Patients were stratified according to Perugini visual score of cardiac uptake. Follow-up data were collected. Among 9616 BS scans, 0.7% (n = 67) showed cardiac uptake. In 47 (70%) patients, Perugini score was 1 and in 20 (30%) patients uptake was ≥ 2, suggesting cardiac ATTR amyloidosis. Forty subjects (61%) died during the follow-up (mean 47 ± 30 months). Compared with patients with Perugini score 1, those Perugini score ≥ 2 showed increased death rate (P = .018). Two (2/67) subjects were investigated for TTR gene mutations resulting negative.

CONCLUSIONS

In patients undergoing BS for different clinical indications, cardiac uptake suggesting cardiac ATTR amyloidosis is a rare, but still neglected finding, thus preventing possible diagnosis of ATTR cardiomyopathy. Importantly, cardiac uptake negatively affects the survival. Physicians should be aware of this rare, but crucial finding for timely diagnosis and treatment.

Reproducibility of exercise-induced premature ventricular beats predicts concealed non-ischemic left ventricular scar on cardiac magnetic resonance in athletes

Background

Non-ischemic left ventricular scar (NLVS) at cardiac magnetic resonance (CMR) is a common substrate of apparently idiopathic premature ventricular beats (PVBs) in athletes. PVBs morphology, complexity and exercise-behavior are known predictors of NLVS. It remains to be established whether reproducibility of PVBs at exercise testing correlates with CMR findings.

Purpose

We aimed to evaluate the possible role of PVBs reproducibility at repeated exercise testing in predicting the presence of an underlying NLVS in athletes who underwent CMR for apparently idiopathic ventricular arrhythmias.

Methods

We included all consecutive competitive athletes referred to our center for the evidence of PVBs during pre-participation screening, who underwent two maximal exercise testings within one month (the first at the time of pre-participation screening, the second at the time of outpatient evaluation at our sports cardiology clinic). Exclusion criteria were known heart disease, family history of cardiomyopathy or channelopathy, abnormal ECG and echocardiography. We also excluded athletes with “common/usually benign” PVBs (non-exercise-induced infundibular or fascicular PVBs) as well as those on ongoing antiarrhythmic therapy. Reproducibility was defined as the presence of PVBs with same morphology and exercise-behavior in two subsequent tests. LGE on CMR was quantified with 5-SD method, using a threshold of 5% to define the presence of pathological LVNS.

Results

A total of 64 apparently healthy competitive athletes (86% males, mean age of 33±14 years old) were included. On CMR, NLVS was identified in 26 (41%). PVBs reproducibility criteria was met in 32 athletes (50%). A statistically significant difference in PVBs reproducibility was found between patients with and without LVNS [26 (100%) versus 6 (16%), p&lt;0,001], irrespective of other factors such as age, sex, biventricular volumes and function (Figure 1). Among the 26 patients with NLVS, 18 (69%) showed PVBs with right-bundle branch block (R-BBB) with superior axis configuration, alone or associated with other morphologies. These arrhythmic patterns were confirmed by a second test in all cases. Among the 38 patients with normal CMR, the first exercise test showed R-BBB/superior axis PVBs, alone or associated with other morphologies, in 22 (57%); the second test confirmed such pattern in only 6 (16%), showing instead different morphologies in 8 (21%) and no PVBs in 24 (63%). Figure 2 represents an example of two cases included in the study.

Conclusion

In apparently healthy athletes who underwent CMR for “uncommon” PVBs, the presence of underlying LVNS was predicted by ventricular arrhythmia reproducibility. Specifically, reproducibility of PVBs with RBBB/superior axis morphology was highly predictive of a positive CMR. This finding may be very relevant for appropriate prescription of CMR in athletes with apparently idiopathic ventricular arrhythmias.

Funding Acknowledgement

Type of funding sources: None.

Incidence and risk factors for pacemaker implantation in light chain and transthyretin cardiac amyloidosis

Background

The incidence and risk factors of pacemaker (PM) implantation in patients with cardiac amyloidosis (CA) are largely unexplored.

Purpose

We sought to characterise the trends in the incidence of permanent PM and to identify baseline predictors of future PM implantation in light chain (AL) and transthyretin (ATTR) CA.

Methods

Multicentre, retrospective, observational study. Consecutive patients with AL and ATTR-CA diagnosed or referred at participating Centres between 2017 and 2020 were included. Clinical data recorded within ± 1 month from baseline evaluation were collected from electronic medical records. The primary outcome of the study was the need for clinically-indicated PM implantation. Reversible causes of conduction system disease were systematically ruled out before PM implantation. Patients with PM (n=41) and/or permanent defibrillator in situ (n=13) at the time of CA diagnosis were excluded.

Results

The study population consisted of 405 patients: 29.4% AL, 14.6% variant ATTR and 56% wild-type ATTR; 82.5% were males, with median age 76 years. During a median follow-up of 33 months (interquartile range 21–46), 36 (8.9%) patients experienced the primary outcome: 10 patients with AL-CA, 2 with variant ATTR-CA and 24 with wild-type ATTR-CA (p=0.08). At multivariable analysis, history of atrial fibrillation (hazard ratio [HR] 3.80, p=0.002), PR interval (HR 1.013, p=0.002) and QRS &gt;120 ms (HR 4.7, p=0.001) on baseline ECG were independently associated with PM implantation (Figure 1). In the individual patient, the contemporary presence of these 3 factors yielded the highest risk of PM implantation (HR 6.26, p=0.003).

Conclusion

In a large cohort of AL and ATTR-CA, the incidence of PM implantation was high accounting for ≈9% of patients in the 3 years following the diagnosis. History of atrial fibrillation, longer PR interval and QRS &gt;120 ms identified CA patients at high-risk of future PM implantation (Figure 2).

CA patients with these features might need close monitoring during follow-up for the development of conduction system disease requiring PM implantation.

Funding Acknowledgement

Type of funding sources: None.

Quantification of left ventricular fibrosis in arrhythmic mitral valve prolapse patients: comparison of different semi-automated techniques assessed by cardiac magnetic resonance

Background

Left ventricular (LV) fibrosis has a key role in arrhythmogenesis in mitral valve prolapse (MVP) patients. Cardiac magnetic resonance (CMR) demonstrated able to clearly identify LV fibrosis with the post-contrast late gadolinium enhancement (LGE) images. Despite the pivotal role of LV fibrosis in the arrhythmogenesis, a quantification and identification of reproducible method able to accurately measure LGE in arrhythmic MVP patients has not been recognized.

Purpose

We aimed to measure and compare different semi-quantitative methods for LGE quantification assessed by CMR, in order to identify the most reproducible one, in arrhythmic MVP patients.

Methods

66 arrhythmic MVP patients with normal systolic function and without significant regurgitation were enrolled. Semi-automated gray-scale thresholding technique using full with at half maximum (FWHM) and 2, 3 and 5 standard deviation (SD) above the remote myocardium were used and compared with visual assessment (Fig. 1).

Results

LGE was identified in 41 arrhythmic MVP patients (62%) and quantified (Fig. 2). The mean quantity of LGE visually assessed was 2.40±1.07% or 1.40±0.82 g. With FWHM, LGE resulted 3.56±1.23% or 1.99±1.13 g. Using thresholding, the mean LGE quantity was 9.2±3.1% or 4.82±2.28 g for 2-SD, 5.72±1.75% or 3.06±1.47 g for 3-SD and 2.36±0.99% or 1.29±0.79 g for 5-SD. The 5-SD measurement in percentage demonstrated a good correlation with LGE quantification visually assessed (2.402±1.075 vs 2.363±0.9909, p: 0.543). Despite all semi-quantitative methods for LGE quantification demonstrated a good intra and inter-observer agreement, the 5-SD threshold quantification, both in percentage and in grams, revealed the less intra-observer (respectively, ICC: 0.976 and 0.966) and inter-observer variability (respectively ICC: 0.948 and 0.935) when compared with visual assessment.

Conclusion

This is the first study that quantified and compared different CMR semi-automated methods for LGE assessment in a population of arrhythmic MVP patients. The 5-SD gray-scale threshold technique in percentage revealed the best correlation with the visual assessment and an optimal reproducibility.

Funding Acknowledgement

Type of funding sources: None.

A post processing pipeline to prepare raw data for machine learning algorithms in cardiac magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: None.

Background

Artificial Intelligence is an emergent tool in clinical practice for post processing of medical images. Machine Learning (ML) pipelines are created for data of interest extraction and algorithm application. A common issue in data extraction is represented by noisy datasets, like those of CMR studies, characterized by multiple images, acquired by different techniques, axis orientation and contrast timing.

Purpose

A ML pipeline for extraction of LGE images from raw DICOM data is presented. Additionally, steps for normalization of image number and automatically heart localization are outlined.

Methods and Results

642 consecutive CMR studies were analyzed.

Pipeline, Part 1. By looking at the metadata in raw files, ‘SequenceName’ tag was used to discard cine images, ‘ScanningSequence’ tag to select Gradient Recall and Inversion Recovery techniques (Inversion Time &gt; 100 ms), ‘SequenceVariant’ tag to discard Steady State images (See Fig. 1). Orientation of the major axis was computed and ‘Axial’ or ‘Coronal’ images removed. Scans were grouped together by image orientation (requesting a min and max number of elements per group) and only the group with the largest number of files was selected. Finally, DICOMs were grouped by image shape (demanding a min number of elements), and only the series with the highest resolution was retained. Then, for each subject, the extracted series consists of a 3D-array (N,H,W), with N number of slices, and (H,W) image resolution. The attributes were not homogeneous between subjects.

Pipeline, Part 2. Given a desired final number of slices and resolution, the 3D-array was reshaped through a spline interpolation. In order to have a focus on the heart, a Region of Interest (ROI) extractor was implemented, based on a YOLO network for object detection. The network was applied on all the slices (Fig. 2); then the images were cropped by keeping the largest bounding box. This step allowed us to remove the background by only selecting the relevant ROIs. To manage the data more easily, images were saved as a NumPy Array, while other useful Dicom metadata (e.g. weight, age, …) were stored using the json standard.

At the end of the ML pipeline, images can be reduced to a common resolution and forwarded to ML algorithms.

By using this pipeline, a great amount of information not needed for LGE analysis can be discarded, granting a significant reduction in terms of data storage. In our series, the original dataset extended for about 200 GB; by requesting 10 slices per subject with a resolution of 128 by 128 pixels (also extracting heart ROI) the final dimension was reduced to 108 MB.

Conclusions

In this work, we presented a post-processing pipeline for CRM images and LGE analysis. Given in input raw CRM the pipeline is able to (i) remove unuseful data, (ii) extract heart ROIs storing also Dicom metadata, (iii) normalize slices and image resolution, and (iv) store the processed CRM into ready-format for ML techniques. Fig.1:Pipeline Schematic RepresentationFig.2:YOLO Heart Extraction

Myocardial fibrosis detection using kernel methods: preliminary results from a cardiac magnetic resonance study

Funding Acknowledgements

Type of funding sources: None.

Background

Asserting the presence of myocardial fibrosis from cardiac magnetic resonance (CMR) images is sometimes a complex task, even for experienced cardiac imagers. The application of artificial intelligence models to the evaluation process can be of help for enhancing diagnostic accuracy.

Purpose

In this work, we tested two different Machine Learning (ML) algorithms, namely kernel methods with Support Vector Machine (SVM) and Convolutional Neural Network (CNN) to a cohort of consecutive CMR studies. The goal was a binary classification task, aimed to identify myocardial scar (present/absent).

Methods

Dataset consisted of 642 CMR scans, equally divided into healthy and fibrosis-affected. Raw DICOM files were preprocessed through an automated pipeline, in order to retrieve only short-axis post contrast acquisitions. Heart regions were then individuated using a YOLO network, in order to remove the background and focus only on data of interest. Finally, for each subject 10 slices were extracted through interpolation, and all images resized to 128 by 128 pixels. Dataset was divided into training and test sets, with proportions 80%-20%.

Results

The first analysis was based on state-of-the-art CNN models, pre-trained on the ImageNet dataset. The training of the models was optimized using "reduce learning rate on the plateau", "early stopping", and standard data augmentation techniques. Experiments showed that CNNs-based models led to poor performances.

The second attempt was based on kernel methods and SVM. Before feeding the input to the algorithm, dimensionality reduction was implemented using a Principal Component Analysis retaining 99% of the variance. The resulting 335 features were passed as input to an SVM, testing different kernels (e.g. Linear, Gaussian, Cossim). Models were trained and optimized using a Grid Search with a 5-fold Cross-Validation. The best SVM configuration displayed an accuracy of 68% and a sensitivity of 60%.

Improved results could be obtained using state-of-the-art Multiple Kernel Learning algorithms, leading to 71% accuracy and sensitivity of 72% (with a 12% increment with respect to the previous algorithm).

Conclusions

Our preliminary results of this study showed the possibility for a ML system to learn to identify myocardial fibrosis, directly from raw CMR images. In particular, kernel methods were able to achieve good and significant results, even with small amounts of data, suggesting room for improvement. In future works, we plan to furtherly explore kernel methods to improve the results and to build an end-to-end solution for cardiac imagers.

C75 PHEOCHROMOCYTOMA–INDUCED CARDIOGENIC SHOCK: A MULTICENTER ANALYSIS OF CLINICAL PROFILES, MANAGEMENT AND OUTCOMES

Background

Pheochromocytoma is a rare neuroendocrine tumor that arises from the adrenal gland and overproduces catecholamines; it is an infrequent cause of cardiogenic shock (CS). Several case reports have investigated pheochromocytoma–induced CS, but larger studies have not yet been carried out.

Objectives

Our work aims to describe a multicenter experience in the diagnosis and management of patients with pheochromocytoma–induced CS, and to raise awareness around this rare condition. Methods: We enrolled all patients with a diagnosis of pheochromocytoma–induced CS admitted to the intensive care units of 8 European referral Hospitals.

Results

Among the 17 patients (47% males, mean age 49,5 years), we found that pulmonary congestion was the mostly represented clinical feature (82%). The most represented echocardiographic left ventricle (LV) pattern was the reverse Takotsubo (TTS) pattern with apical hyperkinesis associated with basal– to mid–ventricular hypokinesis (47%). Elevated systemic vascular resistances (SVR) were observed. Endomyocardial biopsy of the LV was performed in one patient showing contraction band necrosis, oedema and inflammatory reaction. 76% of patients were treated with dobutamine, 70% needed noradrenaline, 29% adrenaline, 23.5% were treated with levosimendan and 17% with milrinone. Mechanical circulatory support devices (MCS) were necessary for 65% of patients. All patients benefited from pheochromocytoma’s surgical excision, with 4 patients operated on while under ECLS. All patients recovered, excepted one (presenting a severe left ventricular dilatation at admission) who required cardiac transplantation.

Conclusion

Pheochromocytoma is an infrequent cause of CS, with most often a TTS–like presentation. It should be suspected in case of a CS with high initial SVR and rapid deterioration. MCS must be considered in the most severe cases. The main challenge is to stabilize the patient, mostly with MCS, since it remains a reversible cause of CS with a low mortality rate. Adrenalectomy can safely be performed even when the patient is under MCS.

Cost-effectiveness of the cardiovascular pre-participation screening in children practicing sport

Funding Acknowledgements

Type of funding sources: None.

Introduction

In Italy, preparticipation screening of competitive athletes is mandatory. The age at which pre-participation screening (PPS) should start is established by each sport federation and it is sometimes under 10 years old. The aim of this study is to detect both PPS efficacy and cost in paediatric age and to define the cut-off age from which it is more cost-effective.

Methods

We retrospectively enrolled 25251 athletes aged ≤15 to evaluate the prevalence of cardiovascular (CV) diseases and cost-effectiveness ratio who underwent PPS from 2011 to 2020. In addition, we retrospectively studied a subgroup of 1307 competitive athletes aged 7-15 who underwent PPS from January 2019 to February 2020 for an in-depth analysed regarding costs. Cardiovascular preparticipation screening included first-line investigations (history, physical examination, resting ECG and exercise testing) and further examinations in case of abnormalities at first-line tests.

Results

In the period 2010-2020, 66 athletes were permanently disqualified for a CV disease (0,11%), 26 for a CV disease at risk of sudden cardiac death (0.05%), with a prevalence of 0.15% over 12 years old versus 0.01% under 12 (p&lt;0.001). In the cost analysis subgroup, second-line investigations were prescribed to 5% of athletes because of abnormalities at first line tests: 1 was disqualified for a CV disease (0,07%). The cost for each athlete was 69,80€. Between 2011 and 2020, 58185 PPS were carried out. The overall cost of PPS was about €4 million, the cost for each diagnosis of any CV disease was 61.535€, and for each CV disease at risk of sudden cardiac death was 156.204€.

Conclusion

The cost-effectiveness of PPS before competitive sports in the pediatric age is lower than reported for older athletes in previously published studies. According to our data, starting PPS before 12 years of age does not appear to be justified.

Left ventricular thrombosis following apical myocardial infarction: may CMR strain analysis tell us something?

Funding Acknowledgements

Type of funding sources: None.

Background

 Left ventricular thrombosis (LVT) is a possible complication following myocardial infarction (MI). Besides infarct size, risk factors for LVT include ST-elevated MI (STEMI), anterior and apical location, reduced left ventricular ejection fraction (LVEF) and the presence of microvascular obstruction. Echocardiography quantified myocardial strain has been associated with LVT following MI. Recently, global longitudinal strain, calculated with feature tracking (FT) - CMR, emerged as an independent predictor of major cardiovascular events following MI. Anyway, the relationship between abnormalities on FT-CMR and LVT following MI is still unexplored. Aim of our study is to investigate the possible association between abnormal strain on FT-CMR and LVT following apical STEMI.

Methods

 We performed a retrospective analysis including all patients with a previous apical STEMI, who underwent CMR at our Institute between August 2013 and October 2020. Patients with ongoing anticoagulant therapy were excluded. Differences in global and segmental strain on CMR between patients with and without LVT were tested in a propensity-matched sample, using LVEF, age, gender, time from MI diagnosis and number of LV segments with transmural late gadolinium enhancement (LGE) as covariates to assign propensity score. Furthermore, difference in terms of apical to global radial strain percentual deviation (AGD), calculated as [(Global Radial Strain – Apical Radial Strain)/Global Radial Strain] * 100, was tested. 

Results

 Of 356 patients with apical STEMI undergoing CMR at our center, 37 (10.4%) were diagnosed with LVT. After performing a propensity score matching, we obtained a sample of 36 pairs, with a mean age of 65 (SD 11) years, and a median EF of 35% (IQR 27-42); 59 (82%) of them were male. A significant difference in terms of apical radial strain was found between the two groups, with a median strain of 10.75 (IQR 6.8–16.5) in patients without LVT compared to a value of 5.25 (IQR 2.7–9-6) in patients with LVT (p = 0.007). No differences were found in terms of global longitudinal, radial and circumferential strain (p = 0.19, p= 0.2 and p= 0.49 respectively) and segmental circumferential and longitudinal strain. When considering the AGD parameter, a significant difference was found between the two groups, with a median deviation of 12% (IQR -20; +48) in patients without LVT and 51% (IQR +47; +75) in patients with LVT (p= 0.0003). Furthermore, an AGD value of 26% was found to be the most accurate in terms of sensitivity and specificity applying a Receiver Operating Characteristic (ROC) curve analysis (AUC 0.74; CI 0.62-0.85).

Conclusions

 Among patients with transmural MI involving LV apex, reduced apical radial strain on FT-CMR is associated with the presence of LV thrombosis. Furthermore, among patients developing LV thrombi, a greater apical radial strain deviation from the global one was found, with a threshold value of 26% at ROC curve analysis.

Left ventricular myocardial deformation abnormalities in arrhythmic mitral valve prolapse: which comes first?

Funding Acknowledgements

Type of funding sources: None.

Background. Arrhythmic mitral valve prolapse (MVP) is characterized by left ventricular (LV) fibrosis in the basal inferolateral wall and papillary muscles. We hypothesized that LV fibrosis are driven by excessive mechanical forces acting on myocardial susceptible cells, representing the last step in the MVP-induced myocardial stretch process. Purpose. We aimed to evaluate the LV myocardial deformation, using strain assessed with cardiac magnetic resonance (CMR), in arrhythmic MVP patients with normal LV ejection fraction (LVEF) and absent/trivial mitral regurgitation (MR) and its correlation with the presence of LV fibrosis, detected by late gadolinium enhancement (LGE) in post-contrast CMR images. Methods. We enrolled consecutive arrhythmic MVP patients with normal LVEF and no/trivial MR. Sixty-nine (39 female; median age: 40 years) patients without MVP, arrhythmias or cardiovascular history served as control group. All patients underwent CMR for identification of LGE and evaluation of LV myocardial deformation. Results. A total of 66 patients were enrolled (47 female; median age: 44 years). In the overall MVP population, LGE was present in 41 patients (62.1%). MVP patients without LGE (25 patients, 37.9%) presented a higher global radial (median: 42.19 vs 33; p: &lt;0.0001) and higher global longitudinal strain (median: -21.61 vs -18.10; p: &lt;0.0001), compared to the control group. A reduction of regional basal posterolateral radial (BPL median: 50.60 vs 67.30; p: 0.0015) and longitudinal strain (BPL median: -23.50 vs -26.70; p: 0.0186) were observed in the MVP patients as compared with controls (Figures A-D). Conversely to the basal region, mid anterolateral and posterolateral region presented a higher radial (MAL median: 52.60 vs 31.10; p: &lt; 0.0001 and MPL median: 52.80 vs 21.50; p: &lt; 0.0001) and longitudinal strain (MAL median: -24.80 vs -18.30; p: &lt; 0.0001 and MPL median: -25.30 vs -14.80; p: &lt; 0.0001), when compared to control group. MVP patients with LGE had a lower global radial (median: 36.48 vs 42.19; p: &lt;0.0047), longitudinal (median: -19.18 vs -21.61; p: 0.0013) and circumferential strain (median: -17.80 vs -19.28; p: 0.0134) compared with those without fibrosis. According to MVP patients without LGE, the presence of fibrosis is associated with a lower regional radial (BAL median: 64.40 vs 82.80; p: 0.0481; MAL median: 42.60 vs 52.60; p: 0.0287) and circumferential strain (BAL median: -21.90 vs -24.20; p: 0.0174; BPL median: -16.80 vs -18.80; p: 0.0411; MPL median: -15.50 vs -19.40; p: 0.0077) in the LV basal-mid lateral walls (Figures E-I). Conclusions. Arrhythmic MVP patients with normal LV systolic function and absent/trivial MR presented an abnormal myocardial deformation pattern. The reduced strain in BPL wall of MVP patients without LGE could be considered as an early marker of MVP-induced myocardial stress, that could promote, time by time, LV fibrosis and arrhythmias in MVP patients.

Postmelting hydrogen enrichment in the oceanic lithosphere

The large range of H₂O contents recorded in minerals from exhumed mantle rocks has been challenging to interpret, as it often records a combination of melting, metasomatism, and diffusional processes in spatially isolated samples. Here, we determine the temporal variations of H₂O contents in pyroxenes from a 24-Ma time series of abyssal peridotites exposed along the Vema fracture zone (Atlantic Ocean). The H₂O contents of pyroxenes correlate with both crustal ages and pyroxene chemistry and increase toward younger and more refractory peridotites. These variations are inconsistent with residual values after melting and opposite to trends often observed in mantle xenoliths. Postmelting hydrogen enrichment occurred by ionic diffusion during cryptic metasomatism of peridotite residues by low-degree, volatile-rich melts and was particularly effective in the most depleted peridotites. The presence of hydrous melts under ridges leads to widespread hydrogen incorporation in the oceanic lithosphere, likely lowering mantle viscosity compared to dry models.

Comparative efficacy and acceptability of psychological interventions for the treatment of adult outpatients with anorexia nervosa: a systematic review and network meta-analysis

BACKGROUND

No consistent first-option psychological interventions for adult outpatients with anorexia nervosa emerges from guidelines. We aimed to compare stand-alone psychological interventions for adult outpatients with anorexia nervosa with a specific focus on body-mass index, eating disorder symptoms, and all-cause dropout rate.

METHODS

In this systematic review and network meta-analysis, we assessed randomised controlled trials about stand-alone pharmacological or non-pharmacological treatments of adult outpatients with anorexia nervosa, defined according to standardised criteria, with data for at least two timepoints relating to either body-mass index or global eating disorder psychopathology. We searched Cochrane CENTRAL, CINAHL, MEDLINE, and PsychINFO for published and unpublished literature from inception until March 20, 2020. The primary outcomes were the change in body mass index and clinical symptoms, and the secondary outcome was all-cause dropout rate, which were all assessed for treatment as usual, cognitive behavioural therapy (CBT), Maudsley anorexia treatment for adults, family-based treatment, psychodynamic-oriented psychotherapies, a form of CBT targeting compulsive exercise, and cognitive remediation therapy followed by CBT. Global and local inconsistencies for the network meta-analysis were measured, and CINeMA was used to assess the confidence in evidence for primary outcomes. The protocol is registered in PROSPERO (CRD42017064429).

FINDINGS

Of 14 003 studies assessed for their title and abstract, 16 (0·1%) randomised controlled trials for psychological treatments were included in the systematic review, of which 13 (0·1%) contributed to the network meta-analysis, with 1047 patients in total (of whom 1020 [97·4%] were female). None of the interventions outperformed treatment as usual in our primary outcomes, but the all-cause dropout rate was lower for CBT than for psychodynamic-oriented psychotherapies (OR 0·54, 95% CI 0·31-0·93). Heterogeneity or inconsistency emerged only for a few comparisons. Confidence in the evidence was low to very low.

INTERPRETATION

Compared with treatment as usual, specific psychological treatments for adult outpatients with anorexia nervosa can be associated with modest improvements in terms of clinical course and quality of life, but no reliable evidence supports clear superiority or inferiority of the specific treatments that are recommended by clinical guidelines internationally. Our analysis is based on the best data from existing clinical studies, but these findings should not be seen as definitive or universally applicable. There is an urgent need to fund new research to develop and improve therapies for adults with anorexia nervosa. Meanwhile, to better understand the effects of available treatments, participant-level data should be made freely accessible to researchers to eventually identify whether specific subgroups of patients are more likely to respond to specific treatments.

FUNDING

Flinders University, National Institute for Health Research Oxford Health Biomedical Research Centre.

Relationship between papillary muscles abnormalities and apparently unexplained infero-lateral T-wave inversion in athletes

Aims

To evaluate by cardiac magnetic resonance (CMR) if left ventricle papillary muscle abnormalities, such as hypertrophy and abnormal location, may be the anatomo-functional substrates responsible for TWI inversion in lateral or infero-lateral leads in otherwise healthy athletes.

Methods

We included competitive athletes with TWI in lateral or infero-lateral leads in the absence of cardiac diseases detected by CMR. The control population included healthy athletes with normal ECG, matched for age and gender. We compared thickness, volume (both absolute and relative to the cardiac mass) and position of the papillary muscles between cases and controls.

Results

We included 53 athletes with apparently unexplained TWI in the lateral or infero-lateral leads (median age 20 years (17–42), 86.8% males) and 53 athletes with no TWI matched for age and gender. 4 patients (7.6%) had family history for cardiomyopathy or sudden cardiac death. Athletes with TWI showed more hypertrophic papillary muscles compared to controls, with statistically significant difference in diameter, area and volume (p&lt;0.01). The median ratio between the papillary muscles and the left ventricular mass was 4.4% among athletes with TWI versus 3% among those without TWI (p&lt;0.001). Papillary muscles showed apical displacement in 47% of cases, compared to 17% in the control group (p=0.001).

Conclusions

Idiopathic TWI in lateral or infero-lateral leads is associated with left ventricle papillary muscle hypertrophy and their apical displacement detected by CMR. The comprehension of clinical and prognostic significance of papillary muscle abnormalities responsible for these ventricular repolarization alterations requires further studies.

Example

Funding Acknowledgement

Type of funding source: None

Prognostic role of left ventricular late gadolinium enhancement (LV-LGE) in patients who received implantable cardioverter defibrillator (ICD) for secondary prevention

Introduction

LV myocardial fibrosis detected as LGE on cardiac magnetic resonance (CMR) is a predictor of arrhythmic risk in primary prevention both in ischaemic and non-ischaemic cardiomyopathy. However, we still do not know the prognostic role of LV-LGE in patients who suffered cardiac arrest (CA).

Purpose

To evaluate the prognostic role of CMR, and in particular of LV-LGE suggesting myocardial scar, in predicting appropriate ICD interventions in secondary prevention patients.

Methods

Ninety-seven consecutive patients 1) aged ≥14 years 2) hospitalized for CA because of ventricular arrhythmias from 2009/01/01 3) who underwent/undergoing a CMR within one month from the event 4) who received/receiving an ICD for secondary prevention and 5) with at least 1 year-follow-up, were enrolled for this multicentric study.

Results

97 patients (68 males, 70%), mean age 46±16 years, were enrolled. Seventy-six percent of patients received bystander cardiopulmonary resuscitation (CPR) and ventricular fibrillation (VF) was the first rhythm in 86% of cases. ST elevation was present in 18% of cases at the admission; however, angiography was found negative in 80% of patients. Myocardial oedema and LGE were identified in 26% and 64% of patients respectively. A diagnosis was made in 83.5% of cases, while in the remaining 16.5% CA was considered idiopathic. During a four-year-follow-up, 25% of patients had appropriate ICD therapy (10% of which ATP only). A significant correlation between LGE and appropriate ICD intervention was not found (p=0.89).

Conclusions

One fourth of patients who received ICD for secondary prevention had appropriate ICD therapy during a four-year-follow-up. In this setting, LV-LGE does not provide a prognostic value.

Funding Acknowledgement

Type of funding source: None

Predictors of left ventricular scar at cardiac magnetic resonance in athletes with apparently idiopathic ventricular arrhythmias

Introduction

In athletes with ventricular arrhythmias (VA) and otherwise unremarkable clinical findings, cardiac magnetic resonance (CMR) may reveal concealed pathological substrates. The aim of this multicentre study was to evaluate which VA characteristics were associated with CMR abnormalities.

Methods

We enrolled a consecutive series of 251 competitive athletes (74% males, mean age 28.5±14.5 years) who underwent CMR for evaluation of VA. We included athletes with &gt;100 premature ventricular beats (PVBs)/24-hour or ≥1 repetitive VA (couplets, triplets or non-sustained ventricular tachycardia) on 12-lead 24-hour ambulatory ECG monitoring and negative family history, electrocardiogram and echocardiogram. Features of VA that were evaluated included number, morphology, repetitivity and response to exercise testing.

Results

Left-ventricular late gadolinium-enhancement (LGE) was documented in 28 (11%) athletes, mostly (N=25) with a subepicardial/midmyocardial (non-ischemic) distribution. On 24-hour ECG monitoring, PVBs with a right-bundle-branch-block and intermediate/superior axis configuration or multiple morphologies were documented in 24/28 (86%) athletes with versus 55/223 (25%) without LGE (p&lt;0.001). More than 2000 PVBs were recorded in 6 (21%) athletes with versus 127 (57%) without positive CMR (p&lt;0.001). At exercise testing, repetitive VA occurred at high work-load in 12 (43%) athletes with versus 26 (12%) without LGE (p&lt;0.001). At multivariable analysis, all three VA features independently correlated with CMR abnormalities.

Conclusions

In athletes with apparently idiopathic VA, simple characteristics such as number and morphology of PVBs on 12-lead 24-hour ambulatory ECG monitoring and response to exercise testing predicted the presence of concealed myocardial abnormalities on CMR. These findings may help cost-effective CMR prescription.

Flow chart

Funding Acknowledgement

Type of funding source: None

Maximizing the use of social and behavioural information from secondary care mental health electronic health records

PURPOSE

The contribution of social and behavioural factors in the development of mental health conditions and treatment effectiveness is widely supported, yet there are weak population level data sources on social and behavioural determinants of mental health. Enriching these data gaps will be crucial to accelerating precision medicine. Some have suggested the broader use of electronic health records (EHR) as a source of non-clinical determinants, although social and behavioural information are not systematically collected metrics in EHRs, internationally.

OBJECTIVE

In this commentary, we highlight the nature and quality of key available structured and unstructured social and behavioural data using a case example of value counts from secondary mental health data available in the UK from the UK Clinical Record Interactive Search (CRIS) database; highlight the methodological challenges in the use of such data; and possible solutions and opportunities involving the use of natural language processing (NLP) of unstructured EHR text.

CONCLUSIONS

Most structured non-clinical data fields within secondary care mental health EHR data have too much missing data for adequate use. The utility of other non-clinical fields reported semi-consistently (e.g., ethnicity and marital status) is entirely dependent on treating them appropriately in analyses, quantifying the many reasons behind missingness in consideration of selection biases. Advancements in NLP offer new opportunities in the exploitation of unstructured text from secondary care EHR data particularly given that clinical notes and attachments are available in large volumes of patients and are more routinely completed by clinicians. Tackling ways to re-use, harmonize, and improve our existing and future secondary care mental health data, leveraging advanced analytics such as NLP is worth the effort in an attempt to fill the data gap on social and behavioural contributors to mental health conditions and will be necessary to fulfill all of the domains needed to inform personalized interventions.

No benefit from flexible titration above minimum licensed dose in prescribing antidepressants for major depression: systematic review

BACKGROUND

In fixed-dose antidepressant trials, the lower range of the licensed dose achieves the optimal balance between efficacy and tolerability. Whether flexible upward titration while side-effects permit provides additional benefits is unknown.

METHODS

We did a systematic review of placebo-controlled randomized trials that examined selective serotonin reuptake inhibitors (SSRIs), venlafaxine or mirtazapine in the acute treatment of major depression. Our primary outcome was response, defined as 50% or greater reduction in depression severity. Secondary outcomes included drop-outs due to adverse effects and drop-outs for any reason. We conducted random-effects meta-analyses to calculate the ratios of odds ratios (RORs) between trials comparing the flexible dose titrating above the minimum licensed dose against placebo and those comparing the fixed minimum licensed dose against placebo.

RESULTS

We included 123 published and unpublished randomized controlled trials (29 420 participants). There was no evidence supporting efficacy of the flexible dosing over the fixed low dose of SSRIs (ROR 0.96, 95% CI: 0.73 to 1.25), venlafaxine (1.24, 0.96 to 1.60) or mirtazapine (0.77, 0.33 to 1.78). No important differences were noted for tolerability or for any subgroup analyses except the superior efficacy of venlafaxine flexible dosing between 75 and 150 mg over the fixed 75 mg (1.30, 1.02 to 1.65).

CONCLUSION

There was no evidence to support added value in terms of efficacy, tolerability or acceptability of flexibly titrating up the dosage over the minimum licensed dose of SSRIs or mirtazapine. For venlafaxine, increased efficacy can be expected by flexibly titrating up to 150 mg.

Enamel peptides reveal the sex of the Late Antique 'Lovers of Modena'

Recent work has disclosed the critical role played by enamel peptides in sex classification of old skeletal remains. In particular, protein AMELY (amelogenin isoform Y) is present in the enamel dental tissue of male individuals only, while AMELX (isoform X) can be found in both sexes. AMELY can be easily detected by LC-MS/MS in the ion extracted chromatograms of the SM(ox)IRPPY peptide (monoisotopic [M + 2 H]+2 mass = 440.2233 m/z). In this paper, we exploited the dimorphic features of the amelogenin protein to determine the sex of the so-called 'Lovers of Modena', two Late Antique individuals whose skeletons were intentionally buried hand-in-hand. Upon discovery, mass media had immediately assumed they were a male-female couple, even if bad preservation of the bones did not allow an effective sex classification. We were able to extract proteins from the dental enamel of both individuals (~1600 years old) and to confidently classify them as males. Results were compared to 14 modern and archaeological control samples, confirming the reliability of the ion chromatogram method for sex determination. Although we currently have no information on the actual relationship between the 'Lovers of Modena' (affective? Kin-based?), the discovery of two adult males intentionally buried hand-in-hand may have profound implications for our understanding of funerary practices in Late Antique Italy.

Transhumance pastoralism of Roccapelago (Modena, Italy) early-modern individuals: Inferences from Sr isotopes of hair strands

OBJECTIVES

In this work, we use Sr isotopes to analyze human hair and determine short-term movements of a contemporary human traveler and of early-modern individuals from an archaeological site (Roccapelago, Modena, Italy, 16th-18th century).

MATERIALS AND METHODS

Analyses were performed using a Neptune MC-ICP-MS. We first set up and tested the procedure on scalp hair of a contemporary human, who spent some time between Brazil and Italy. We then analyzed the ⁸⁷ Sr/⁸⁶ Sr ratios of eight exceptionally well-preserved archaeological hair specimens associated with human mummies from Roccapelago. Trace elements were analyzed by LA-ICP-MS on single-hair specimens to check the preservation of the archaeological samples.

RESULTS

The strontium isotope composition of modern human hair varies from 0.7087 to 0.7093. The ⁸⁷ Sr/⁸⁶ Sr ratios of the Roccapelago hair strands range from 0.7082 to 0.7137, with an average of 0.7093 ± 0.0031 (2σ), revealing also intra-individual differences in isotopic composition along the length of the hair shaft. Data were compared with local archaeological rodent bones and teeth and with published isotopic values of water and outcropping rocks. Trace element abundances of archaeological and modern human hair are similarly low in terms of Rare Earth Element (REE) and metal contents, in particular after HNO₃ leaching.

DISCUSSION

The variable modern human hair ⁸⁷ Sr/⁸⁶ Sr ratios show that high-resolution hair sampling tracks the movements of this individual between the two continents. The Sr isotope composition of the mummy hair is consistent with sub-annual human movements from Roccapelago to an area with different ⁸⁷ Sr/⁸⁶ Sr ratios. Historical sources indicate that individuals from Roccapelago travelled with their herds to Tuscany for transhumance pastoralism practices. The high radiogenic ⁸⁷ Sr/⁸⁶ Sr ratios (>0.71) found in some of the hair are possibly consistent with the Tuscan Magmatic Province and the Tuscan Metamorphic Complex isotope signature. To our knowledge, this is the first study in an archaeological context where the Sr isotope evidence of mobility is corroborated by historical documents.

Initial severity of major depression and efficacy of new generation antidepressants: individual participant data meta-analysis

OBJECTIVE

The role of baseline severity as effect modifier in various psychiatric disorders is a topic of controversy and of clinical import. This study aims to examine whether baseline severity modifies the efficacy of various antidepressants for major depression through individual participant data (IPD) meta-analysis.

METHOD

We identified all placebo-controlled, double-blind randomised trials of new generation antidepressants in the acute phase treatment of major depression conducted in Japan and requested their IPD through the public-private partnerships (PPPs) between the relevant academic societies and the pharmaceutical companies. The effect modification by baseline depression severity was examined through six increasingly complex competing mixed-effects models for repeated measures.

RESULTS

We identified eleven eligible trials and obtained IPD from six, which compared duloxetine, escitalopram, mirtazapine, paroxetine or bupropion against placebo (total n = 2464). The best-fitting model revealed that the interaction between baseline severity and treatment was not statistically significant (coefficient = -0.04, 95% confidence interval: -0.16 to 0.08, P = 0.49). Several sensitivity analyses confirmed the robustness of the findings.

CONCLUSION

We may expect as much benefit from antidepressant treatments for mild, moderate or severe major depression. Clinical practice guidelines will need to take these findings into consideration.

A global reference database of crowdsourced cropland data collected using the Geo-Wiki platform

A global reference data set on cropland was collected through a crowdsourcing campaign using the Geo-Wiki crowdsourcing tool. The campaign lasted three weeks, with over 80 participants from around the world reviewing almost 36,000 sample units, focussing on cropland identification. For quality assessment purposes, two additional data sets are provided. The first is a control set of 1,793 sample locations validated by students trained in satellite image interpretation. This data set was used to assess the quality of the crowd as the campaign progressed. The second data set contains 60 expert validations for additional evaluation of the quality of the contributions. All data sets are split into two parts: the first part shows all areas classified as cropland and the second part shows cropland average per location and user. After further processing, the data presented here might be suitable to validate and compare medium and high resolution cropland maps generated using remote sensing. These could also be used to train classification algorithms for developing new maps of land cover and cropland extent.

Suspected limited mobility of a Middle Pleistocene woman from Southern Italy: strontium isotopes of a human deciduous tooth

We present the Sr isotopic composition of enamel of the most ancient deciduous tooth ever discovered in Italy to assess human mobility in Middle Pleistocene. Reconstructing ancient mobility is crucial for understanding human strategy at exploiting temporally and spatially patchy resources, with most studies focusing on indirect evidences, ultimately affecting our interpretation on hominin territoriality and energetic costs invested by hominin groups. Here, we use the high spatial resolution and micro-destructivity options offered by the Laser Ablation Multi-Collector Inductively Coupled Plasma Mass Spectrometry technique, to determine the ⁸⁷Sr/ ⁸⁶Sr intra-tooth variability of a human deciduous incisor from the Middle Pleistocene layers of the Isernia La Pineta site (Italy). We compared these data with the Sr isotopic signature of local micro-mammals, the broadest home-range of the macro-mammals and with modern plant samples. Our study reveals that while macro-mammals have possibly migrated through the landscape for up to 50 km, the pregnant woman from Isernia was probably local, given that the isotopic ratio of the enamel falls within the local range and is comparable with the signature of the local plants in a radius of 10 km. This is the first case study of Sr isotopic composition determination in such ancient deciduous tooth.

Study protocol for a randomised pragmatic trial comparing the clinical and cost effectiveness of lithium and quetiapine augmentation in treatment resistant depression (the LQD study)

BACKGROUND

Approximately 30-50% of patients with major depressive disorder can be classed as treatment resistant, widely defined as a failure to respond to two or more adequate trials of antidepressants in the current episode. Treatment resistant depression is associated with a poorer prognosis and higher mortality rates. One treatment option is to augment an existing antidepressant with a second agent. Lithium and the atypical antipsychotic quetiapine are two such add-on therapies and are currently recommended as first line options for treatment resistant depression. However, whilst neither treatment has been established as superior to the other in short-term studies, they have yet to be compared head-to-head in longer term studies, or with a superiority design in this patient group.

METHODS

The Lithium versus Quetiapine in Depression (LQD) study is a parallel group, multi-centre, pragmatic, open-label, patient randomised clinical trial designed to address this gap in knowledge. The study will compare the clinical and cost effectiveness of the decision to prescribe lithium or quetiapine add-on therapy to antidepressant medication for patients with treatment resistant depression. Patients will be randomised 1:1 and followed up over 12 months, with the hypothesis being that quetiapine will be superior to lithium. The primary outcomes will be: (1) time to all-cause treatment discontinuation over one year, and (2) self-rated depression symptoms rated weekly for one year via the Quick Inventory of Depressive Symptomatology. Other outcomes will include between group differences in response and remission rates, quality of life, social functioning, cost-effectiveness and the frequency of serious adverse events and side effects.

DISCUSSION

The trial aims to help shape the treatment pathway for patients with treatment resistant depression, by determining whether the decision to prescribe quetiapine is superior to lithium. Strengths of the study include its pragmatic superiority design, broad inclusion criteria (external validity) and longer follow up than previous studies.

TRIAL REGISTRATION

ISRCTN registry: ISRCTN16387615 , registered 28 February 2016. ClinicalTrials.gov: NCT03004521 , registered 17 November 2016.

Efficacy and tolerability of lithium in treating acute mania in youth with bipolar disorder: protocol for a systematic review

BACKGROUND

Epidemiological, clinical, and high-risk studies have provided evidence that the peak period for onset of diagnosable episodes of mania and hypomania starts in mid-to-late adolescence. Moreover, clinically significant manic symptoms may occur even earlier, especially in children at familial risk. Lithium is the gold standard treatment for acute mania in adults, yet to our knowledge, there is no published systematic review assessing lithium treatment of mania in children or adolescents. This is a major gap in knowledge needed to inform clinical practice.

AIM

As a working group within the ISBD Task Force on Lithium Treatment ( http://www.isbd.org/active-task-forces ), our aim is to complete a systematic review of the efficacy, tolerability, and acceptability of lithium compared with placebo and other active drugs in treating mania in children and adolescents diagnosed with bipolar disorder.

METHODS

We will include double- or single-blind randomized controlled trials in patients aged less than 18 years. No restrictions will be made by study publication date or language. Several electronic databases will be searched along with secondary sources such as bibliographies and trial registry websites for published and unpublished studies. Response rates to lithium compared with placebo or other active drugs will be the primary efficacy outcome. Primary tolerability and acceptability outcomes will be rates of serious adverse events and dropouts, respectively. Secondary outcomes will include rates of remission, severity of manic symptoms at different time points, and incidence of specific adverse events.

DISCUSSION

Findings from this systematic review are critically needed to inform clinical practice. We should not generalize findings from adult studies, as children and adolescents are undergoing accelerated physiological and brain development. Therefore, efficacy, tolerability, and acceptability of lithium treatment of acute mania in children compared to adults may be very different. This systematic review has been registered in PROSPERO (CRD42017055675).

A systematic review of calcium channel antagonists in bipolar disorder and some considerations for their future development

l-type calcium channel (LTCC) antagonists have been used in bipolar disorder for over 30 years, without becoming an established therapeutic approach. Interest in this class of drugs has been rekindled by the discovery that LTCC genes are part of the genetic aetiology of bipolar disorder and related phenotypes. We have therefore conducted a systematic review of LTCC antagonists in the treatment and prophylaxis of bipolar disorder. We identified 23 eligible studies, with six randomised, double-blind, controlled clinical trials, all of which investigated verapamil in acute mania, and finding no evidence that it is effective. Data for other LTCC antagonists (diltiazem, nimodipine, nifedipine, methyoxyverapamil and isradipine) and for other phases of the illness are limited to observational studies, and therefore no robust conclusions can be drawn. Given the increasingly strong evidence for calcium signalling dysfunction in bipolar disorder, the therapeutic candidacy of this class of drugs has become stronger, and hence we also discuss issues relevant to their future development and evaluation. In particular, we consider how genetic, molecular and pharmacological data can be used to improve the selectivity, efficacy and tolerability of LTCC antagonists. We suggest that a renewed focus on LTCCs as targets, and the development of 'brain-selective' LTCC ligands, could be one fruitful approach to innovative pharmacotherapy for bipolar disorder and related phenotypes.

Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.

Mapping global cropland and field size

A new 1 km global IIASA-IFPRI cropland percentage map for the baseline year 2005 has been developed which integrates a number of individual cropland maps at global to regional to national scales. The individual map products include existing global land cover maps such as GlobCover 2005 and MODIS v.5, regional maps such as AFRICOVER and national maps from mapping agencies and other organizations. The different products are ranked at the national level using crowdsourced data from Geo-Wiki to create a map that reflects the likelihood of cropland. Calibration with national and subnational crop statistics was then undertaken to distribute the cropland within each country and subnational unit. The new IIASA-IFPRI cropland product has been validated using very high-resolution satellite imagery via Geo-Wiki and has an overall accuracy of 82.4%. It has also been compared with the EarthStat cropland product and shows a lower root mean square error on an independent data set collected from Geo-Wiki. The first ever global field size map was produced at the same resolution as the IIASA-IFPRI cropland map based on interpolation of field size data collected via a Geo-Wiki crowdsourcing campaign. A validation exercise of the global field size map revealed satisfactory agreement with control data, particularly given the relatively modest size of the field size data set used to create the map. Both are critical inputs to global agricultural monitoring in the frame of GEOGLAM and will serve the global land modelling and integrated assessment community, in particular for improving land use models that require baseline cropland information. These products are freely available for downloading from the http://cropland.geo-wiki.org website.

Clinical and regulatory implications of active run-in phases in long-term studies for bipolar disorder

OBJECTIVE

The integration of new treatments into the market and routine clinical practice should be dependent on robustness of evidence from randomised controlled trials (RCTs). We assessed study designs of long-term studies for bipolar disorder of all second-generation antipsychotics (SGAs) submitted to the Food and Drug Administration (FDA) and the completeness of evidence submitted to the regulatory agency.

METHOD

Systematic review of double-blind RCTs comparing SGAs with placebo or active drugs in adults. FDA website and electronic databases were searched until July 2013.

RESULTS

Six placebo-controlled trials comparing aripiprazole, olanzapine, quetiapine and ziprasidone were found in the FDA website. Electronic searches found four additional RCTs about aripiprazole, olanzapine or quetiapine. All RCTs (either submitted to FDA or not) selected patients who responded to acute treatment to increase the treatment effect observed in the long-term phase (enrichment design). By contrast, in the prescribing information sheets for all SGAs, the reported indication was 'maintenance treatment of bipolar disorder'.

CONCLUSION

Extrapolation of results from enrichment studies to the more general population of patients should be carried out cautiously because average treatment benefits are likely to be less in unselected patients. Clear guidance for regulatory submission of RCTs is needed.

Downgrading recent estimates of land available for biofuel production

Recent estimates of additional land available for bioenergy production range from 320 to 1411 million ha. These estimates were generated from four scenarios regarding the types of land suitable for bioenergy production using coarse-resolution inputs of soil productivity, slope, climate, and land cover. In this paper, these maps of land availability were assessed using high-resolution satellite imagery. Samples from these maps were selected and crowdsourcing of Google Earth images was used to determine the type of land cover and the degree of human impact. Based on this sample, a set of rules was formulated to downward adjust the original estimates for each of the four scenarios that were previously used to generate the maps of land availability for bioenergy production. The adjusted land availability estimates range from 56 to 1035 million ha depending upon the scenario and the ruleset used when the sample is corrected for bias. Large forest areas not intended for biofuel production purposes were present in all scenarios. However, these numbers should not be considered as definitive estimates but should be used to highlight the uncertainty in attempting to quantify land availability for biofuel production when using coarse-resolution inputs with implications for further policy development.