P5262Subclinical myocardial abnormalities in systemic sclerosis-associated versus non-connective tissue disease pulmonary hypertension by CMR multiparametric mapping

Introduction

Scleroderma (SSc)-associated pulmonary arterial hypertension (PAH) has the worst prognosis of all PAH subtypes despite having relatively more favourable haemodynamic and cardiac functional profiles. Myocardial abnormalities in SSc have been demonstrated by cardiovascular magnetic resonance (CMR) multiparametric tissue mapping. However, myocardial tissue characterisation studies across distinct PAH subtypes including SSc are limited.

Purpose

We compared indices of tissue characterisation by CMR multiparametric mapping between patients with SSc with and without PAH, non-connective tissue disease pulmonary hypertension (non-CTD PH) and healthy volunteers.

Methods

One-hundred and thirty-six patients underwent a CMR study over a 30-month period: 104 patients with systemic sclerosis, of whom 39 had SSc-PAH and 65 had no PH; 32 patients with idiopathic PAH, chronic thromboembolic PH or portopulmonary PH (non-CTD PH group). Patients underwent comprehensive CMR tissue characterisation including quantification of native myocardial T1 (MOLLI), myocardial T2 and ECV from automatically generated tissue maps along with conventional late gadolinium enhancement (LGE) imaging. Twenty age-matched controls underwent the same CMR study protocol. Patients were assessed for PH by right heart catheterisation.

Results

Native myocardial T1 and myocardial T2 and myocardial ECV are significantly elevated in SSc-PAH versus non-CTD PH (all p<0.05, Figure 1) despite no differences in LV systolic function between these patient cohorts. Patients with SSc have similar degrees of elevated T1, T2 and ECV irrespective of the presence or absence of PAH, suggesting a diffuse myocardial process due to SSc itself. Both SSc sub-groups have significantly higher T1, T2 and ECV compared with controls (all p<0.05).

All patients with SSc were subdivided by the presence or absence of ventricular insertion point LGE. Even in the absence of LGE, T1, T2 and ECV were significantly higher in SSc patients versus controls (all p<0.001). However, the presence of focal insertional LGE in SSc was not associated with different burdens of interstitial disease, as defined by median ECV. This highlights the unique role of multiparametric tissue maps in assessing diffuse myocardial involvement beyond the identification of focal LGE.

Conclusion

Subclinical abnormalities of the myocardium can be detected by CMR multiparametric tissue mapping in patients with SSc. The higher native myocardial T1 and T2 along with the elevated ECV in SSc-PAH are likely to be accounted for by SSc involvement itself. Abnormalities of the myocardial architecture could be a potential contributory reason for the poorer outcomes in SSc-PAH versus non-CTD PH despite the more favourable haemodynamics and right heart function observed in the former patient sub-group. Further work should be directed at determining the prognostic capacity of these metrics in SSc-PAH.

Acknowledgement/Funding

British Heart Foundation, Action Pharmaceuticals Ltd

4970Validation of ESC/ERS 2015 guidelines risk score in patients with scleroderma associated pulmonary arterial hypertension (SSc-PAH)

Background

The ESC/ERS 2015 guidelines presented a comprehensive risk assessment model with three risk categories based on different clinical and biomarkers data. Low, intermediate and high risk were defined with one-year mortality of <5%, 5–10% and >10%. Different groups suggested different methods of risk assessment based on this model.

Purpose

We applied three different methods to validate the ESC/ERS risk prediction model for one-year survival in SSc-PAH.

Methods

309 patients with SSc-PAH have been diagnosed and managed in our institution from 2006 to 2017. We used three different risk assessment models that have been previously suggested.

1. Suggested by the Swedish group 1: Having a score of 1 (low risk), 2 (intermediate risk) or 3 (high risk) resulting from the average of the sum obtained after grading each of the variables (whichever available) from 1 to 3 according to ESC/ERS guidelines cut-offs for WHO-functional class (FC), 6-minute walking distance (6MWD), NT-Pro BNP, right atrial pressure (RAP) and cardiac index (CI).

2. Suggested by the French group 2: Having none, 1, 2, 3 or 4 of the following low-risk criteria of; FC, 6MWD, RAP and CI.

3. Instead of the invasive data, The French group also suggested the use of a non-invasive model including NT-Pro BNP.

Patients were divided into different risk groups according to data obtained at baseline and at their 6-month follow-up. Survival analysis over a 5-year period was performed using Kaplan-Meier analysis.

Results

Overall median follow-up was 33.3 months. One year survival was significantly different between the risk groups (p<0.001) using either baseline or follow-up data. Applying the French group non-invasive model, almost two thirds of the population ended up in the higher risk group. Whilst applying the Swedish model, two thirds of the population ended up in the intermediate risk group. In all the models used, there were significantly less number of patients in the lower risk groups at onset with improvement of risk profile at follow up. An important advantage of the Swedish model, that it can be calculated even in the presence of missing data, a problem commonly encountered. The French models are easier to calculate but they cannot be applied when there is missing data.

5-year survival with different models

Conclusion

All models used were valuable in risk prediction of SSc-PAH both at onset and at follow up. However, each model has some caveats which should be considered. In all the methods used, the prevalence of high risk criteria is higher amongst the SSc-PAH population which indicates the higher risk profile at the time of diagnosis in comparison to other PAH populations, which could explain the poorer outcome.

Thermal requirements for growth, survival and aerobic performance of weatherfish larvae Misgurnus fossilis

Thermal requirements of larval weatherfish Misgurnus fossilis were investigated in terms of growth, survival and aerobic performance. Growth and survival of M. fossilis larvae acclimated to five temperatures (11, 15, 19, 23 and 27° C) were measured over 25 days. In the upper temperature treatments (19, 23 and 27° C), survival of larvae was stable throughout the entire rearing period (>75%), whereas 11 and 15° C resulted in severe declines in survival (to <10%). Growth of larvae (expressed as dry mass and total length) was highest at 19 and 23° C, but significantly decreased at 27° C. Routine metabolic rate of 3 days post-hatch larvae was estimated as oxygen consumption rate (ṀO₂ ) during acute exposure (30 min to 1 h) to seven temperatures (11, 15, 19, 23, 27, 31 and 35° C). Larval oxygen uptake increased with each consecutive temperature step from 11 to 27° C, until a plateau was reached at temperatures >27° C. All larvae of the 35° C regime, however, died within the ṀO₂ measurement period. M. fossilis larvae show greater than expected tolerance of high temperatures. On the other hand, low temperatures that are within the range of likely habitat conditions are critical because they might lead to high mortality rates when larvae are exposed over periods >10 days. These findings help to improve rearing conditions and to identify suitable waters for stocking and thus support the management of re-introduction activities for endangered M. fossilis.

Modell Donaustadt: A best practice example for treatment of mental and physical comorbidity in long-term care

Evidence consistently demonstrates that people with long-term mental health conditions develop serious physical comorbidities at an earlier age than the average population. These physical comorbidities are often exacerbated because long-term psychiatric conditions reduce the patient's ability to manage somatic symptoms effectively, thus hindering treatment. This highlights the critical importance of continuous support by primary care physicians and nursing staff. People with persistent mental illnesses typically require long-term care significantly earlier than people without mental illness.

As a consequence, elderly patients with chronic mental illnesses who are essentially unable or unprepared to function in the outside world or are in need of constant medical attention are typically placed into long-term care facilities and nursing homes geared to serving physically disabled elderly.

These LTC institutions have no capacity to provide specific care for mentally ill patients. Difficulties in treating psychiatric patients in these LTC facilities often result in transfers to and repeated admissions in acute psychiatric hospitals.

In an effort to resolve the “revolving-door” situation of these patients and reduce the rates of re-admission to acute psychiatric hospitals, Modell Donaustadt was developed. In the talk, Modell Donaustadt will be presented as a best practice example for the treatment of mental and physical comorbidities in long-term care.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Exploring the impacts of two separate mixtures of pesticide and surfactants on estrogenic activity in male fathead minnows and rainbow trout

In this study, male fathead minnows (FHM) (Pimephales promelas) and juvenile rainbow trout (RT; Oncorhynchus mykiss) were exposed to two different surfactant mixtures of analytical-grade nonlyphenol, 4-tert octyphenol, octylphenol ethoxylates, nonylphenol ethoxylates, and the herbicide 2,4-dichlorophenoxyacetic acid (2,4-D). After a 7-days exposure to environmentally relevant concentrations of these compounds, there was no difference in the relative mRNA expression of vitellogenin (VTG) in male juvenile RT exposed to individual compounds or the 2,4-D-surfactant mixture compared with the control. In male FHM, there was a significant increase in VTG mRNA expression in the high individual treatments of 2,4-D and the surfactants but not the 2,4-D-surfactant mixtures compared with the control. These results were compared with another study exposing male FHM to individual and a mixture of alkylphenols and alkylphenol ethoxylates in two different combinations with the herbicide diuron and the insecticide bifenthrin. There were no differences in the relative expression of VTG mRNA amongst individual exposures and the control. Interestingly, when the ethoxylate mixture was combined with diuron, there was a significant decrease in the relative mRNA expression of VTG compared with the control. However, when the ethoxylate mixture was combined with both diuron and bifenthrin, there was a significant increase in the relative mRNA expression of VTG in male compared with all other groups in the multichemical mixture. The results of this study highlight differences between species and measurements of VTG in assessing the risk of mixtures to aquatic organisms.

Chronischer Rückenschmerz mit suppressiver Schmerzverarbeitung - Zur Optimierung des Rehabilitationserfolgs einer bislang vernachlässigten Rehabilitandengruppe

In view of a frequently poor success rate of rehabilitation programmes in patients with low back pain, a specific intervention programme was developed addressing the subgroup of patients with endurant pain coping behaviour and evaluated within a research project sponsored by the National federation of pension insurers, VDR. In terms of a control group design with 4 points of measurement (beginning and end of rehabilitation, 6- and 12-months follow-up), an intervention group (n = 163) was compared to a control group (standard programme of an orthopaedic rehabilitation clinic, n = 252). Data were collected using the KSI, BDI, IRES, FFbH-R and a pain questionnaire. Subjects were blue-collar insurants, aged 46 on average with a pain history of 9.6 years. Findings show a stronger reduction of pain intensity and strain, significant enhancement of functional capacity as well as a greater decrease of sick leave days and pension requests. These results are presented over the course of the 4 points of measurement as well as in relation to the intervention programme, which focuses on the endurant pain coping behaviour. The consequences of implementing such therapy components into standard rehabilitation programmes are discussed.

[Cluster formation - an operationalization of rehabilitation success in rehabilitants with chronic low back pain]

To investigate the impact of the way of allocation for rehabilitation on rehabilitation success in patients with chronic low back pain it was necessary to define appropriate criteria of success. A multidimensional model of success is presented in this article. First, the outcomes of rehabilitation are described and statistically tested. No statistically or clinically relevant changes between pre and post measurements were found. For further analysis of predictors and group comparisons it is necessary to define multidimensional success. For this purpose, cluster analyses are introduced as a possible model, resulting in three groups of patients with differing outcomes, i. e.: 20 % patients with declined pain symptoms, 40 % patients without any changes, 40 % patients with increased symptoms. No impact of the way of allocation for rehabilitation could be verified.

Behandlungsspezifik beim chronischen Rückenschmerz: Ist die optimierte Rehabilitationszuweisung ausreichend?

The multidimensional and heterogeneous etiogenesis of chronic low back pain requires multimodal as well as specific treatment programmes. Aim of the present study was to increase the specificity of treatment already at the interface "family health care - assigning institution - rehabilitation clinic" by supporting the assignment to orthopaedic or psychosomatic rehabilitation through extensive diagnostics and deriving a patient's profile of risk factors in the forefield of rehabilitation. In a prospective randomized control group design the rehabilitation success in 309 persons (age 22 - 58) suffering from chronic low back pain was compared on risk factor specific vs. conventional assignment. Between 22 % and 27 % of the assignments following conventional criteria have to be considered as false. On the other hand, rehabilitation success did not turn out to have been increased by specific assignment. In conclusion, implications for more far-reaching change in treatment programmes within and subsequent to stationary rehabilitation are discussed.

Focal Point: Analytical Technology: Quality Assurance of Analytical Data: Measurement Uncertainty and Traceability in View of ISO 17025

Definition, determination and consequences of analytical measurement uncertainty were discussed. After a thorough explanation of actual procedures to handle uncertainty, the focus was switched to practical applications in process control, the meaning of qualitative analysis near the limit of detection, a case study involving doping in sports events and the problems involved in setting legal limits (e.g. ILAC rules). Five experts from academia, industry, and governmental organizations as well as from R&D-driven companies gave their interpretation from different points of view.

Monte Carlo simulations of the imaging performance of metal plate/phosphor screens used in radiotherapy

The imaging performance of metal plate/phosphor screens which are used for the creation of portal images in radiotherapy is investigated by using Monte Carlo simulations. To this end the modulation transfer function, the noise power spectrum and the detective quantum efficiency [DQE(f)] are calculated for different metals and phosphors and different thicknesses of metal and phosphor for a range of spatial resolutions. The interaction of x-rays with the metal plate/phosphor screen is modeled with the EGS4 electron gamma shower code. Optical transport in the phosphor is modeled by simulating scattering and reabsorption events of individual optical photons. It is shown that metals with a high atomic number perform better than lighter metals in maximizing the DQE(f). It is furthermore shown that the DQE(f) for the metal plate/phosphor screen alone is nearly x-ray quantum absorption limited up to spatial frequencies of 0.4 cycles/mm. In addition, it is argued that the secondary quantum sink of optical photons imposed by the optical chain (mirror, lenses and video camera) leads to a significant degradation of the signal-to-noise ratio at spatial frequencies which are most important for successful registration of portal images. Therefore, the conclusion is that a replacement of the optical chain by a flat array of photodiodes placed directly under the phosphor will lead to a substantial improvement in image quality of portal images.

[Comparison of knee and functional outcomes of patients lost to follow-up with patients remaining in a prospective total knee arthroplasty study]

PURPOSE

Survival analysis is correct when patients lost to follow-up are as healthy as patients still being followed. Therefore, the results of patients who missed the follow-up visits were determined and compared with the results of the patients still in the study. Revision surgery and the reasons for failing to reattend the follow-up visits were recorded.

METHODS

Of 680 unconstrained total knee arthroplasties implanted between 1989 and 1994 with yearly patient evaluation according to the Knee Society 53 patients with 60 implants died, 17 patients with 19 implants could not be used for the study and 21 patients with 24 implants were interviewed by telephone. 56 patients with 61 implants lost to follow-up were examined by visiting them at their homes (drop-outs) and compared to the 460 patients with 516 implants still in the study.

RESULTS

The drop-outs were older at surgery and had more medical infirmity than the remaining patients. Drop-outs had a lower mean function score and a tendency to a lower mean knee score at follow-up compared with the patients in the study. No revision surgery was performed in drop-out knees. Reasons for not reattending the follow-up were mainly long travel and health.

CONCLUSIONS

Patients reattending a study are healthier than drop-outs. This censoring mechanism limits correct survival analysis. A complete follow-up of patients and separate assessment of knee and functional status with reliable and valid instruments is required.

Kawan bronchial brush/cell block technique. Facilitation of the routine diagnosis of bronchial neoplasms

OBJECTIVE

To evaluate cell block preparations as a tool for the diagnosis of pulmonary malignancy and to correlate the findings with those from brush cytology and histology from forceps biopsy.

STUDY DESIGN

One hundred twenty consecutive samples from patients with primary or metastatic lung cancer were routinely processed and stained for cytologic and histologic examination. In addition to smears, a cell block was prepared from each brushing sample. Brush smears, cell blocks and biopsy specimens were compared and evaluated for their diagnostic accuracy.

RESULTS

Brush cytology samples were interpreted as positive for malignancy in all 120 cases. In 42 cases immunohistochemistry performed on cell blocks led to the final precise type diagnosis. Owing to technical problems (stenosis, bleeding, peripheral location), forceps biopsy specimens were obtained from only 51 patients.

CONCLUSION

In addition to lower patient risk, cell block preparation yields high diagnostic accuracy and may thus be considered an improvement in quality assurance.

Multiple fistulas and tracheobronchial stenoses require extensive stenting of the central airways and esophagus in squamous-cell carcinoma

We report here on two cases of double airway and esophageal stenting in patients with multiple esophagotracheal fistulas and stenoses of the airways and esophagus due to squamous-cell carcinoma. Dumon stents and a Strecker device were used for tracheobronchial stenting. Covered Gianturco Z-stents were implanted into the esophagus. In one case, extrinsic compression of the trachea and tumor progression required recanalization by Nd:YAG laser. Clinical improvement led to discharge of the patients within two weeks after the procedure. The results show that simultaneous implantation of stents in the central airways and covered Gianturco Z-stents in the esophagus is an effective therapeutic strategy in patients with tracheal and esophageal obstructions and esophagorespiratory fistulas. Further systematic studies evaluating double stenting are warranted.

Retention of antibacterial activity and bacterial colonization of antiseptic-bonded central venous catheters

We determined how long antiseptic impregnation with silver sulphadiazine and chlorhexidine (SCC) on polyurethane central venous double- or triple-lumen catheters is retained in vivo. A total of 116 antiseptic catheters were tested for antibacterial activity in an in-vitro bioassay after various periods of iv catheterization. Segments from the subcutaneous (sc) and intravenous (iv) portions of the catheters were cultured. The results of test antiseptic catheters were compared with those from 117 noncoated control (c) catheters. Retention of antibacterial activity followed an exponential curve and lasted for up to 520 h after catheter insertion. Significant differences (P = 0.0001) between SSC and C catheters were noticed with regard to the quantitative level of bacterial colonization (SSC-sc 87 +/- 34 vs C-sc 584 +/- 122; SSC-iv 52 +/- 17 vs C-iv 286 +/- 57; all values are given as mean cfu +/- S.E.M.), and the frequency of bacterial colonization (SSC-sc 20.7% vs C-sc 38.5%, P = 0.0047; SSC-iv 18.1% vs C-iv 30.8%, P = 0.0361). There was no significant difference between the incidence of catheter-related bacteraemia in the test (n = 0) and control groups (n = 3) (P = 0.2573). Further prospective studies are required to delineate the role of antiseptic catheters in preventing catheter-related infections.

How much brushing is enough for the diagnosis of lung tumors?

BACKGROUND

Bronchoscopic investigations of lung tumors require high diagnostic accuracy. Sometimes the combination of brush biopsy with cytologic and histologic examination of forceps-obtained biopsy specimens fails to diagnose tumors. Techniques with a minimum risk and low cost when repeated several times could increase the efficiency of tumor diagnosis and help to avoid rebronchoscopy.

METHODS

Repeated brush biopsies were done during one bronchoscopic examination in 270 patients with pulmonary neoplasias using a flexible fiberoptic bronchoscope guided by radiographic video fluoroscopy. The results of up to five brush biopsies were compared for their diagnostic sensitivity.

RESULTS

Singly, 68-77% of the specimens showed malignant findings. With repeated brushing, the sensitivity of the diagnostic accuracy increased to 89.6%. In the periphery of the bronchial tree, the sensitivity of brush biopsy was slightly lower in bronchoscopically invisible tumors. In 222 of 242 (91.7%) patients with positive results of brush biopsy, there was agreement in the final typing of tumor morphology.

CONCLUSION

For routine bronchoscopy, repeated brush biopsy should be done to obtain the highest diagnostic yield.

[Acinar cell carcinoma of the salivary glands]

Between 1972 and 1985, eleven cases of acinic cell carcinoma were treated at the ENT clinic of the University Hospital Geneva. Eight of them were located in the parotid gland, three in minor salivary glands, two of these on the hard palate and one on the lower lip. Local recurrence occurred in four cases: two were recurrences of a parotid gland carcinoma and two of a minor salivary gland carcinoma. Three patients developed metastases, two in cervical lymph nodes and one in the lungs. Two tumours presented a very aggressive local development. Hence, the acinic cell carcinoma has a significant tendency to recur, to produce metastases, and may have an aggressive evolution. Radical treatment by surgery is necessary.

Proteolytic activity of Candida albicans and other yeasts

Clinical isolates of C. albicans (75 strains) and other yeasts (20 strains) were evaluated for their ability to produce a carboxyl acid proteinase in an effort to assess its potential role as a virulence factor. Yeasts were categorized as to the infectious process present in the patient: (1) isolates from patients with invasive disease, (2) isolates from patients with possible invasive disease, (3) isolates from superficially infected patients and (4) isolates from noninfected, colonized patients. Yeasts were grown for 7 days in medium containing bovine serum albumin (BSA) as the sole nitrogen source. The amount of extracellular proteinase was measured at pH 3.2, using BSA as substrate. The majority (97%) of C. albicans isolates produced a detectable proteinase. Some non-C. albicans isolates produced proteinase; however, the amount of activity was generally less than for C. albicans. No correlation was found between the amount of proteolytic activity and the degree of invasiveness of the strains.

Long-term results of prosthetic ureteral replacement in minipigs

In a 3-year study, silicone rubber prostheses were implanted in 6 minipigs as ureteric replacement. A Dacron velour cuff was applied for the proximal anastomosis and a disc of the same material implanted into the bladder wall to anchor the prosthesis distally. The silicone tube incorporated a metal spiral to prevent kinking. On autopsy all anastomoses were firm and resistant to tearing except in 1 animal where the proximal end of the prosthesis had loosened without further complications. Incrustation or leakage never occurred. On histology dense ingrowth of collagen fibres into the meshes of Dacron velour was evident. Malignant cells could never be demonstrated. The findings are compared with a previous 12-month study. The growth of polypoid structures occluding the prosthesis was found to be a new problem with long-term alloplastic ureteric replacement. The best results were achieved with unilateral prostheses after contralateral nephrectomy.

Protection of mice against 7,12-dimethylbenz(a)anthracene-induced skin tumors by immunization with a fluorinated analog of the carcinogen

5-Fluoro-12-methylbenzanthryl-7-acetic acid (5-FMBAAA) is an analog of the carcinogen 7,12-dimethylbenz(a)anthracene (DMBA) with little or no carcinogenic activity. CD-1 mice immunized with 5-FMBAAA conjugated to bovine serum albumin (BSA) developed serum antibodies capable of binding DMBA. As a means of testing whether this immunization protected against DMBA-induced tumors, a low-dose carcinogenesis model system was developed, entailing the repeated skin application of 25 ng DMBA in dodecane alternating with applications of the tumor promoter, phorbol myristate acetate. Mice immunized with the 5-FMBAAA:BSA conjugate and subsequently exposed to this low-dose regimen for 40 weeks developed significantly fewer skin tumors (0.23 papilloma/mouse) than did unimmunized mice, mice immunized with BSA, or mice immunized with an unconjugated mixture of BSA and 5-FMBAAA (0.47 to 0.54 papilloma/mouse). Immunization did not reduce tumor incidence in mice treated with phorbol myristate acetate alone. The results suggest that, when mice are exposed to a carcinogen at doses low enough to approach environmental levels, immunization against the carcinogen can provide specific protection.

Behaviour of the different oxidation states of As, Sb, Se an Sn using dithiocarbamates for their separation from environmental, food and drug samples

The mentioned elements are known to occur in the environment in different oxydation states with different biological activities. Speciation of the oxydation state by selective enrichment can lead to relevant information for the toxicologist. A sample treatment procedure is described that --allows to discriminate between the oxidation states of the mentioned elements --converts the elements to the optimum oxydation state for enrichment from the sample --brings the elements in an ideal form for their determination by x-ray fluorescence analysis using coprecipitation with the dibenzyl-ammoniumsalt of dibenzyldithiocarbamic acid. An outline of the method, instrumentation used and applications to organic, biological and environmental samples is given.

Formation of adherent monolayers of murine lymphocytes in vitro: the use of serum-free medium and concanavalin A-coated surfaces to promote adherence

Murine thymus and spleen cells formed adherent monolayers in polystyrene tissue culture flasks when plated in serum-free medium. In the presence of 2% serum, thymus cells adhered poorly, but adherence was greatly enhanced if the flasks had been coated noncovalently with the lectin, concanavalin A. Adherence of leukemic lymphocytes (L1210) required both serum-free medium and concanavalin A-coated flasks; the extent of attachment was proportional to the concentration of the lectin used to coat the flasks at concentrations up to 0.1 mg/ml. Once L1210 cells had attached, they could not be removed by exposure to serum, ethylenediamine tetraacetic acid, trypsin, or alpha-methyl mannoside. Adherent L1210 cells remained capable of metabolism and proliferation during intervals of up to 7 days. The use of adherent monolayers for cytotoxicity assays was demonstrated by an assay for Pseudomonas aeruginosa toxin in EL4 murine leukemia cells.