Homozygous MTHFR C677T carriers develop idiopathic portal vein thrombosis 20 years earlier than wild type

The aim of this study was to evaluate the impact of methylene tetrahydrofolate reductase (MTHFR) rs1801133 (C→T667 transition) on age at first idiopathic portal vein thrombosis (PVT) and to identify clinical and/or laboratory variables influencing age at first PVT, including plasma homocysteine and the prothrombin rs1799963 PT (G→A transition at position 20210) (PT) mutation. A retrospective cross-sectional cohort, including 15 MTHFR TT, 32 MTHFR TC and 22 MTHFR CC idiopathic PVT participants contributing demographics, age at PVT, plasma concentrations of homocysteine and of natural anticoagulants. MTHFR TT carriers presented with a lower age at PVT than heterozygous or wild-type genotypes (31 ± 8 vs. 48 ± 15 vs. 52 ± 13 years, P  = 0.001) and were more likely to have a plasma HC concentration above the cut-off (73.3 vs. 32 vs. 50%, P  = 0.04). MTHFR TT and protein C predicted age at PVT ( P  < 0.0001 and P  = 0.06); MTHFR TT predicted plasma homocysteine ( P  = 0.05). In the MTHFR TT group, plasma homocysteine inversely related to protein C ( P  = 0.03). Plasma homocysteine predicted the extent of PVT ( P  = 0.03). Compound MTHFR TT + PT GA did not lower age at first PVT compared to MTHFR TT alone (35 ± 9 vs. 30 ± 8 years). MTHFR TT is associated with a 20-year earlier PVT presentation than heterozygous and wild-type MTHFR genotypes. The inverse relation between plasma homocysteine and protein C contributes to the prematurity of PVT in the MTHFR TT group, whereas plasma homocysteine contributes to the extent of PVT. The recent exclusion of MTHFR genotyping from the thrombophilia screen needs revisiting in this setting.

Homozygous MTHFR C667T carriers ≤45 years old develop central retinal vein occlusion five years earlier than wild type

PURPOSE

To assess age at 1st central retinal vein occlusion (CRVO) in carriers ≤ 45 years old of the methylenetetrahydrofolate reductase (MTHFR) C667T genotype compared to heterozygous and wild type, and to identify predictors of age at CRVO.

METHODS

Retrospective cohort study consisting of 18 MTHFR TT, 23 MTHFR TC and 28 MTHFR CC participants; information regarding age, sex, age at CRVO, history of dyslipidaemia, hypertension, smoking and plasma HC measured by immunoassay were collected.

RESULTS

Age at CRVO was lower in MTHFR TT than MTHFR TC and CC (32 ± 6 vs 38 ± 5 vs 37 ± 6 years, respectively, p = 0.005); plasma HC was higher in MTHFR TT than in the other genotypes [14.4 (10.8, 19.6) vs 10.4 ((8.6,12.5) vs 8.5 ((7.5,9.8) μmol/l, p = 0.0002). Smoking (cigarettes/day) independently predicted age at CRVO (p = 0.039) and plasma HC (p = 0.005); smoking status (yes/no) predicted ischemic CRVO (p = 0.01) that was more common in the MTHFR TT group (p = 0.006).

CONCLUSIONS

Carriers of the MTHFR TT genotype ≤ 45 years old develop their 1st CRVO on average 5 years earlier than the MTHFR CC genotype; smoking contributes to the prematurity and severity of CRVO in MTHFR TT carriers.

Subclinical atherosclerosis in Behcet's disease and its inverse relation to azathioprine use: an updated meta-analysis

To evaluate the intima media thickness of carotid arteries (IMT) and its clinical, laboratory and treatment correlates in Behcet's disease (BD). Systematic search of EMBASE and PubMed databases from January 2016 to October 2022; we employed random effect meta-analyses for continuous outcomes and Peto's odds ratio for rare events. The meta-analysis included 36 case control studies: the IMT was greater in BD (n = 1103) than in controls (n = 832) (p < 0.0001) with wide heterogeneity (I2 = 86.9%); a sensitivity analysis that included mean age of BD participants, gender, disease duration and activity, atherogenic index of plasma, blood pressure, C-reactive protein, ethnicity, smoking status, anti-inflammatory and immune suppressive agents, revealed that male gender, mean age of participants and azathioprine use (the latter two in inverse fashion) partly explained the heterogeneity variance (p = 0.02, p = 0.005, and p = 0.01). The IMT was greater in vascular (n = 114) than in non-vascular BD (n = 214) (p = 0.006). BD patients (n = 782) had a greater pooled prevalence of carotid plaques than controls (n = 537) (13.1% vs. 2.97%, p < 0.0001). Subclinical carotid artery atherosclerosis represents a vascular feature of BD, independently of the traditional cardiovascular risk factors. The inverse correlations between IMT, age and azathioprine use suggest that thicker carotid arteries at disease onset eventually regress with immune suppressive treatment: this assumption needs verification on adequately designed clinical trials.

The effective enhancement of information in 3D small-world networks of biological neuronal cells

The cardiovascular system, the kidney, or the brain, are examples of complex systems - where the properties of the systems arise because of the layout of cells in those systems. One way to characterize systems is using networks, where elements and interactions of the systems are represented as nodes and links of a graph. Network's topology can be, in turn, measured by the small-world coefficient. Small world networks feature increased clustering and shorter paths compared to random or periodic networks of the same size. This suggests that systems with small world attributes can also efficiently transport signals, nutrients, or information within their body. While several reports in literature have illustrated that real biological systems are small-world, yet little is known about how information varies as a function of the small-world-ness (sw) of three dimensional graphs. Here, we used a model of the brain to estimate quantitatively the information processed in 3D networks. In the model, nodes of the graph are neuronal units capable to receive, integrate and transmit signals to other neurons of the system in parallel. The information encoded in the signals was then extracted using the techniques of information theory. In simulations where the topology of networks of400nodes was varied over large intervals, we found that in the0-9swrange information scales linearly with the small world coefficient, with a five-fold increase. Results of the paper and review of the existing literature on model organisms suggest that a small-world architecture may offer an evolutionary advantage to biological systems.

Surely you are joking, Mr Docking!

In the wake of recent COVID-19 pandemics scientists around the world rushed to deliver numerous CADD (Computer-Aided Drug Discovery) methods and tools that could be reliably used to discover novel drug candidates against the SARS-CoV-2 virus. With that, there emerged a trend of a significant democratization of CADD that contributed to the rapid development of various COVID-19 drug candidates currently undergoing different stages of validation. On the other hand, this democratization also inadvertently led to the surge rapidly performed molecular docking studies to nominate multiple scores of novel drug candidates supported by computational arguments only. Albeit driven by best intentions, most of such studies also did not follow best practices in the field that require experience and expertise learned through multiple rigorously designed benchmarking studies and rigorous experimental validation. In this Viewpoint we reflect on recent disbalance between small number of rigorous and comprehensive studies and the proliferation of purely computational studies enabled by the ease of docking software availability. We further elaborate on the hyped oversale of CADD methods' ability to rapidly yield viable drug candidates and reiterate the critical importance of rigor and adherence to the best practices of CADD in view of recent emergence of AI and Big Data in the field.

A review of modeling pesticides in freshwaters: Current status, progress achieved and desirable improvements

This study comprises a critical review of modeling of pesticides in surface waters. The aim was to update the status of the use of models to simulate the fate of pesticides from diffuse sources. ISI papers were selected on Scopus and the information concerning the study areas, type of pesticides (herbicides, fungicides and insecticides), the model, and the methodology adopted (i.e., calibration and/or validation, spatial and temporal scales) were analyzed. The studies were carried out in Europe (55.5%), North America (22.3%), Asia (13.9%) and South America (8.3%). The Soil and Water Assessment Tool proved to be the most used model (45.95%). Herbicides were the most modeled pesticides (71.4%), followed by insecticides (18.2%) and fungicides (10.4%). The main herbicides modeled were atrazine, metolachlor, isoproturon, glyphosate, and acetochlor. Insecticides such as chlorpyrifos and metaldehyde. Chlorothalonil, and fungicides (i.e., tebuconazole) were the most widely investigated. Based on published studies, it was found that modeling approaches for assessing the fate of pesticides are constantly evolving and the model algorithms work well with diverse watershed conditions, management strategies, and pesticide properties. Several papers reported concentrations of pesticides exceeding ecotoxicological thresholds revealing that water contamination with pesticides used in agriculture and urban areas is a priority issue of current global concern.

Thrombocytopenia in antiphospholipid syndrome: a free radical perspective

Thrombosis associated with thrombocytopenia is an apparent paradox that is present across a wide spectrum of disorders. While thrombocytopenia has been a controversial clinical classification criterion for antiphospholipid syndrome because initial reports failed to demonstrate a relation between low platelet count with other clinical or laboratory manifestations of the syndrome, recent data highlight the association between mild to moderate thrombocytopaenia and the risk of thrombosis. Although antiphospholipid antibodies may induce platelet activation in vitro, additional stimuli may contribute to their activation in vivo, amongst which reactive oxygen and nitrogen species and lipid peroxidation products, elevated in patients with the antiphospholipid syndrome: an excess of the same stimuli may induce megakaryocyte and platelet apoptosis that leads to decreased platelet production and increased destruction, exposure resulting ultimately in thrombocytopaenia. Herein we provide a novel plausible framework involving free radicals that could add to the understanding of the thrombocytopenia/thrombosis paradox in the antiphospholipid syndrome.

Prognostic impact of echocardiographic derived precapillary wedge pressure and pulmonary vascular resistances in patients with heart failure

Background

A reliable echocardiographic algorithm for the estimation of precapillary wedge pressure (PCWP) and pulmonary vascular resistances (PVR) has been recently validated by our group in a large cohort of patients undergoing right heart catheterization (RHC) (1). Those metrics may add relevant clinical and prognostic information in patients with heart failure (HF).

Objective

To assess the clinical/prognostic significance of echocardiographic derived PCWP and PVR in a large cohort of chronic HF patients on modern treatments.

Methods

Outpatients with chronic HF with either reduced (≤40%) or mildly reduced LVEF (41–49%) underwent a thorough clinical multiparametric assessment and were followed-up for a composite endpoint of cardiac death, appropriate ICD shock, or first HF hospitalization.

Results

Out of 1,483 patients prospectively enrolled (70±12 years, 73% males, 42% ischemic etiology, LVEF 35±8%), PCWP (16.4±5.8 mmHg) was elevated (&gt;15 mmHg) in 53% of cases, while PVR (1.7±0.7) was elevated (&gt;3 WU) in 6% of cases. Of the latter group, most (92%) had also elevated PCWP. Patients with increased PCWP were older, had a higher heart rate and lower cardiac output, showed a higher degree of left and right chamber remodeling, had a higher neurohormonal activation, worse renal function, worse functional capacity and ventilatory efficiency on effort (all p&lt;0.001). Those patients with high PCWP and PVR showed higher heart rate and pulmonary pressures, lower cardiac output, and right ventricular function, higher neurohormonal activation, lower functional capacity and ventilatory efficiency on effort compared to patients with high PCWP but normal PVR (all p&lt;0.01). The optimal prognostic cut-point was identified for both PCWP (16.2 mmHg) and PVR (2 WU) by log-rank maximal likelihood ratio. Over a median follow-up of 22 (8–37) months, both measures significantly stratified patients for the risk of the primary endpoint at Kaplan-Meier analysis (log-rank 92.9, p&lt;0.001 for PCWP; log-rank 17.3, p&lt;0.001 for PVR). At multivariable Cox regression analysis (adjusted for age, sex, ischemic HF etiology, renal function, LVEF, and NT-proBNP), PCWP (hazard ratio, HR 1.77 [95% CI 1.30–2.40], p&lt;0.001) but not PVR (HR 1.15 [95% CI 0.88–1.51], p=0.31) remained an independent predictor of the primary outcome.

Conclusion

The estimation of PCWP and PVR by echocardiography add relevant clinical and prognostic information and may help in the decision making in patients with HF.

Funding Acknowledgement

Type of funding sources: None.

Clinical and prognostic significance of left ventricular outflow tract velocity time integral (LVOT-VTI) in patients with chronic heart failure

Background

The echocardiographic evaluation of cardiac output relies on the product of the flow across the left ventricular outflow tract (LVOT), estimated through its velocity time integral (LVOT-VTI), and its cross-sectional area, estimated through the formula πr2. Considering the geometrical assumption behind such formula, LVOT-VTI has been proposed as a more reproducible surrogate of cardiac systolic function and showed prognostic value in the critical care setting. However, the role of such measure in patients with chronic heart failure (HF) remains unexplored.

Objective

To assess the clinical and prognostic significance of LVOT-VTI in a contemporary cohort of patients with chronic HF.

Methods

Outpatients with chronic HF with a LV ejection fraction &lt;50% were prospectively enrolled to undergo a clinical, echocardiographic, and biohumoral assessment, and were followed-up for the endpoint of all-cause death.

Results

Finally, 971 patients were enrolled (71±12 years, 72% men, 50% ischemic etiology, LVEF 35±9%). Most patients showed a NYHA class I-II (74%) and were treated with ACE-inhibitors/ARBs or ARNI (81%), beta-blockers (95%), and mineralocorticoid receptor antagonists (71%). Patients were distinguished in three subgroups according to LVOT-VTI tertiles &lt;19 (n=324), 19–24 (n=324), or ≥24 (n=323). Compared with the other two subgroups, patients with LVOT-VTI &lt;19 showed worse NYHA class, lower LVEF and tricuspid annular plane systolic excursion (TAPSE), and higher E/e', left atrial volume index (LAVi), estimated systolic pulmonary arterial pressure (sPAP), and NT-proBNP concentration (all p&lt;0.001). No differences were observed as for patients' age, HF etiology, and therapies (all p&gt;0.05). Over a median follow-up of 22 (9–34) months, 103 (11%) patients met the primary endpoint. LVOT-VTI significantly stratified the risk of death, observing 65 (20%), 21 (7%), and 17 (5%) events across the subgroups with values &lt;19, 19–24, or ≥24 (log-rank 33, p&lt;0.001). At multivariable regression analysis, LVOT-VTI &lt;19 (HR 2.06 [95% 1.21–3.49], p=0.008), but not LVEF &lt;30% (p=0.614) was an independent predictor of all-cause death in a model adjusted for age, sex, ischemic etiology, renal function, hemoglobin, E/e', LAVi, TAPSE, sPAP, and NT-proBNP.

Conclusion

LVOT-VTI is associated with disease severity and is a strong predictor of all-cause death in patients with chronic HF.

Funding Acknowledgement

Type of funding sources: None.

Prevalence of amyloid transthyretin cardiomyopathy in elderly subjects from the general population: first results from the CATCH study

Background

Amyloid transthyretin cardiomyopathy (ATTR-CM) has become treatable. Wild-type ATTR-CM is an age-related disorder. Establishing the exact prevalence of ATTR-CM in elderly subjects from the general population may be useful for healthcare providers and policy makers alike.

Methods

The Characterizing the burden of Amyloid Transthyretin CardiomyopatHy in the elderly (CATCH) study is a population screening on all subjects aged ≥65 years followed by general practitioners working in a part of Tuscany (Italy) where there is no cluster of variant ATTR. The study started on March 12, 2021 and is ongoing. The first step of the evaluation includes clinical history and physical examination, electrocardiogram, transthoracic echocardiogram, and blood sampling with measurement of N-terminal pro-B-type natriuretic peptide and high-sensitivity (hs) troponin T. The following elements are searched: 1) any clinical red flag of amyloidosis (history of carpal tunnel syndrome, lumbar spine stenosis, etc.), 2) interventricular septal thickness ≥12 mm or other echocardiographic red flags, 3) hs-troponin T higher than the upper reference limit (14 ng/L). Patients with any of these elements are referred to a second step including diphosphonate scintigraphy and the search for a monoclonal protein in the serum and urine. The standard diagnostic workup for CA is then followed until the diagnosis is confirmed or discarded.

Results

As of October 13, 2021, 514 subjects ≥65 years have been evaluated for possible participation. Among them, 135 (26%) could not be contacted, were reluctant to enter the study, died before being contacted, or were bedridden. Out of the other 379 subjects, 329 (87%) have already undergone the first step. Forty percent of individuals (n=132) have been referred to the second step. Thirteen subjects have declined (10%); 69 patients have undergone diphosphonate scintigraphy and the search for a monoclonal protein (while the other 50 are awaiting these exams). Two subjects showed an intense myocardial uptake of the diphosphonate tracer (Perugini score 2–3) and no monoclonal protein, and were then diagnosed with ATTR-CM. They were both women, aged 83 and 78 years, both mildly symptomatic for dyspnea (New York Heart Association II) and with unexplained hypertrophy. The search for TTR gene mutation was negative in the first case and is still ongoing in the second. Based on these preliminary data, the prevalence of ATTR-CM in the elderly population can be calculated as 2/266=0.8% (Figure 1).

Conclusions

The CATCH study is expected to enroll at least 1,000 subjects and will provide the first data on the epidemiology of ATTR-CM in elderly subjects. Based on an interim analysis, almost 1 in 100 individuals ≥65 years has ATTR-CM.

Funding Acknowledgement

Type of funding sources: None.

Comparison of the efficacy and safety between different oral P2Y12 receptor inhibitors in patients with acute coronary syndrome: a systematic review and meta-analysis

Introduction

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor for at least 1 month is the mainstay of therapy after an acute coronary syndrome (ACS). Despite several randomized controlled trials (RCTs) having compared different DAPT regimens after an ACS, the choice of the optimal P2Y12 receptor inhibitor is still debated.

Purpose

We aimed to compare the efficacy and safety profiles of the new P2Y12 receptor inhibitors (prasugrel and ticagrelor) versus clopidogrel in patients with ACS through a meta-analysis of RCTs.

Methods

We performed an extensive literature search, from January 1970 to December 2021 using PubMed database. Studies were eligible if they were RCTs directly comparing different oral P2Y12 receptor inhibitors in patients with ACS. Data on study methods, patient characteristics, and outcomes of interest (all-cause and cardiovascular death, recurrent myocardial infarction, stroke, major and non-major bleeding) were extracted from the original publications. We performed a meta-analysis using a random-effects model with the Mantel–Haenszel method. The effect measures of each study included were calculated and reported as odds ratio (OR) with 95% confidence interval (CI), visually presented in forest plots. A two-sided p-value &lt;0.05 was considered statistically significant. Heterogeneity was tested using the I2-statistic.

Results

A total of 117 studies were available for the analysis; after full reading 11 studies were eligible to be analyzed. The 11 studies reported data on 50,722 patients: 25,424 [50.1%] taking a new oral P2Y12 receptor inhibitor and 25,298 [49.9%] taking clopidogrel. Patients receiving ticagrelor or prasugrel showed a lower risk of all-cause mortality (OR 0.88, 95% confidence interval [CI] 0.80–0.97, I2=8%), cardiovascular mortality (OR 0.88, 95% CI 0.81–0.95, I2=0%), and recurrent myocardial infarction (OR 0.86, 95% CI 0.76–0.97, I2=43%) compared to those receiving clopidogrel. The two groups did not differ significantly concerning the risk of stroke (OR 0.98, 95% CI 0.82–1.17, I2=0%), major bleeding (OR 1.05, 95% CI 0.97–1.15, I2=0%), or non-major bleeding (OR 1.36, 95% CI 0.85–2.20, I2=67%). By restricting the analysis to the studies comparing ticagrelor versus clopidogrel, the ticagrelor group showed a lower risk of all-cause mortality (OR 0.79, 95% CI 0.70–0.90, I2=0%), but a higher risk of non-major bleeding (OR 1.67, 95% CI 1.05–2.66, I2=30%). There was no significant difference between ticagrelor and clopidogrel in terms of cardiovascular death (OR 0.87, 95% CI 0.73–1.05, I2=0%), stroke (OR 1.06, 95% CI 0.85–1.13, I2=0%), or major bleeding (OR 1.02, 95% CI 0.93–1.12, I2=0%).

Conclusions

In patients with an ACS, a DAPT strategy with aspirin plus either prasugrel or ticagrelor is associated with a reduced risk of all-cause and cardiovascular mortality as well as of recurrent myocardial infarction compared to aspirin plus clopidogrel, without an increased risk of bleeding.

Funding Acknowledgement

Type of funding sources: None.

Feasibility and long-term outcomes of leadless pacemaker implant after transvenous lead extraction

Funding Acknowledgements

Type of funding sources: None.

Background

Infections and malfunction are major indications to transvenous lead extraction. Managing extracted patients represents a clinical and interventional challenge, since this population may be at higher risk for mechanical, vascular or infective complications.

The use of leadless pacing systems has been described as a potentially useful technology that could tackle the obstacles that affect this peculiar population.

The study aimed to investigate feasibility and long-term outcomes of M-TPS implant in a specific patient population, like post transvenous lead extraction patients, which represent a challenge for conventional cardiac pacing.

Methods

Between May 2014 and November 2021, 155 patients (120 males, 77.42%, mean age 78 ± 9 y) underwent M-TPS implantation in our Center, targeting a non-apical site of delivery when feasible. A subgroup of 48 patients (39 males, 81.25%) had undergone transvenous lead extraction. All patients fulfilled standard criteria for pacemaker implantation with specific indication to receive VVI pacing. The outcome evaluation included electrical performance (capture threshold, pacing impedance, R wave amplitude) before hospital discharge and then followed at 1, 6, and 12 months and then annually. Major complications were defined as life-threatening events, required surgical intervention or any event causing significant hemodynamic instability or resulting in death. High pacing threshold (HPT) was defined as 1.0 V/0.24 ms.

Results

In 48/155 cases (39 males, 81,25%) M-TPS was implanted after successful transvenous lead extraction. There were no statistically significant differences between groups for demographics characteristics, and PM implant indications. The implant procedure was successful in all cases and no device-related events were registered during follow-up. In particular, no device infection and/or malfunction were reported. Patients were followed-up for an average of 24 months (median 18 months). No differences were observed between groups in procedure duration, single device delivery (group 1 vs group 2: 63.21% vs 73.91%, p=0.20), fluoroscopy time (group 1 vs group 2: 11.79 ± 7.53 vs 10.49 ± 6.19 minutes, p=0.64), electrical performance at implant (group 1 vs group 2: pacing threshold 0.54 ± 0.35 V/0.24 ms vs 0.62 ± 0.32 V/0.24 ms, p=0.09; impedance 758.02 ± 227.89 Ohm vs 724.26 ± 178.14 Ohm, p=0.36; R wave amplitude 10.1 ± 4.73 mV vs 9.59 ± 5.30 mV, p=0.50) and at 18 month F-U (group 1 vs group 2: pacing threshold 0.50 ± 0.10 V/0.24 ms vs 0.85 ± 0.9 V/0.24 ms, p=0.45; impedance 559.58 ± 94.43 Ohm vs 543.34 ± 64.39 Ohm, p=0.69; R wave amplitude 12.00 ± 5.06 mV vs 13.42 ± 5.77 mV, p=0.55).

Conclusions

Leadless pacemaker implant is a feasible, safe and effective option for patients treated with transvenous lead extraction, with electrical performance and outcomes comparable to a cohort of naïve patients at long-term follow up.

Left atrial thrombus and smoke resolution in patients with atrial fibrillation or flutter under chronic oral anticoagulation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Data on left atrial/left atrial appendage (LA/LAA) thrombus resolution after non–vitamin K antagonist (VKA) oral anticoagulant treatment (OAT) are scarce.

Purpose

The aim of this study was to explore retrospectively the resolution of LA/LAA spontaneous echo-contrast or thrombus in patients with nonvalvular atrial fibrillation (AF) or atrial flutter (AFL) after OAT in a real-world single center practice.

Methods

A single center retrospective analysis of patients with AF/AFL who underwent a transesophageal echocardiography (TEE) for an electrical cardioversion and/or atrial fibrillation ablation was performed. Patients showing LA/LAA echo-contrast or thrombus and with at least one TEE follow up to detect the resolution of LA/LAA echo-contrast/thrombus were included and analyzed.

Results

Among 277 TEE performed, 73 cases (26%) of LA/LAA echo-contrast or thrombus were detected in our hospital. Among them, a total of 53 patients showed LAA/LA echo-contrast (19%) and 20 (7%) patients showed a thrombus. Patients with echo-contrast or thrombus were usually male (78% vs 72%, p=0.05) with more comorbidities, as hypertension (90% vs 72%, p=0.03) and congestive heart failure (36% vs 17%, p=0.007) and with an overall higher CHA2DS2-Vasc score (3.5±1.5 vs 3±1, p=0.0001). All they were under chronic anticoagulation with a VKA (65%) or with a NOAC (35%), without differences between groups. (p=NS). At the TTE/TEE analysis, they showed a comparable ejection fraction (55±11 vs 55±22%, p=NS), a trend for an increased LA dilatation (27±8 vs 26±6 cm2, p=0.07) and a low LAA peak velocity (94% vs 19%, p=0.0001). The Echo-contrast Group maintained the same OAT strategy in 49 patients (93%), switching from VKA to NOAC in 3 cases (6%) and from NOAC to NOAC in 1 (1%). The Thrombus Group kept the same OAT strategy with a NOAC in 6 cases (30%) and changed the strategy in 14 patients (70%). Particularly, they titrated NOAC dose in 1 (5%) and the VKA dose in 4 (20%), switched from NOAC to VKA in 5 (25%), from VKA to NOAC in 3(15%) and from NOAC to NOAC in 1 (5%). Smoke resolution was observed in LA/LAA smoke group in 1/10 cases (10%) after a median time of 52 days (20-135) and LA/LAA thrombus resolution 8/15 (53%) after a median time of 45 days (25-180). Patients with the thrombus resolution had a lower CHA2DS2-Vasc score (3.5±2 vs 4±1, p=0.05), and showed a trend for a more frequent use of a NOAC (37.5 vs 28%, p=0.07) and a longer overall anticoagulation time (7.5 vs 4 months, p=0.08). At one-year follow-up, 1 ischemic stroke (1.9%) and 2 deaths (3.8%) were observed only in the Echo-contrast group.

Conclusion(s)

In OAT patients with an LA/LAA thrombus changing the OAT strategy is associated with thrombus resolution in more than 50% of cases, after an appropriate anticoagulation period and in lower CHAD2S2Vasc patients. Chronic OAT strategy confirmation, also with NOAC, is rarely effective, also in case of echo-contrast resolution.

P288 PREVALENCE OF AMYLOID TRANSTHYRETIN CARDIOMYOPATHY IN ELDERLY SUBJECTS FROM THE GENERAL POPULATION: FIRST RESULTS FROM THE CATCH STUDY

Background

Amyloid transthyretin cardiomyopathy (ATTR–CM) has become treatable. Wild–type ATTR–CM is an age–related disorder. Establishing the exact prevalence of ATTR–CM in elderly subjects from the general population may be useful for healthcare providers and policy makers.

Methods

The Characterizing the burden of Amyloid Transthyretin CardiomyopatHy in the elderly (CATCH) study is a population screening on all subjects aged ≥65 years followed by general practitioners in a part of Tuscany (Italy) where there is no cluster of variant ATTR. The study started on March 12, 2021 and is ongoing. Patients with 1) any clinical red flag of amyloidosis, 2) interventricular septal thickness ≥12 mm or other echocardiographic red flags, and/or 3) hs–troponin T &gt; 14 ng/L are referred to diphosphonate scintigraphy and search for a monoclonal protein.

Results

As of October 13, 2021, 514 subjects ≥65 years have been evaluated for possible participation. Among them, 135 (26%) could not be contacted, were reluctant to enter the study, died before being contacted, or were bedridden. Out of the other 379 subjects, 329 (87%) have already undergone the first step. Forty percent of individuals (n = 132) have been referred to the second step. Thirteen subjects have declined (10%); 69 patients have undergone diphosphonate scintigraphy and the search for a monoclonal protein (while the other 50 are awaiting these exams). Two subjects showed an intense myocardial uptake of the diphosphonate tracer (Perugini score 2–3) and no monoclonal protein, and were then diagnosed with ATTR–CM. They were both women, aged 83 and 78 years, both mildly symptomatic for dyspnea (New York Heart Association II) and with unexplained hypertrophy. The search for TTR gene mutation was negative in the first case and is still ongoing in the second. Based on these preliminary data, the prevalence of ATTR–CM in the elderly population can be calculated as 2/266=0.8%.

Conclusions

The CATCH study is expected to enroll at least 1,000 subjects and will provide the first data on the epidemiology of ATTR–CM in elderly subjects. Based on an interim analysis, almost 1 in 100 individuals ≥65 years has ATTR–CM.

C8 THE CEREBRAL PERFORMANCE CATEGORY IN THE DECISION–MAKING PROCESS OF IMPLANTING AN ICD IN OUT–OF–HOSPITAL CARDIAC ARREST SURVIVORS WITH BAD NEUROLOGICAL OUTCOME

Introduction

According to the European Society of Cardiology guidelines secondary prevention ICD implantation is a class I indication only for those patients with an estimated survival &gt; 1 year with a good functional status. However, it is not specified how to assess the functional status and its evaluation could be quite difficult in the case of out–of–hospital cardiac arrest (OHCA) survivors with major neurological outcomes. Cerebral Performance Category (CPC) is the most widespread scale to define the neurological and functional outcome of OHCA survivors, but it is not known if it can be used to guide ICD implantation.

Objective

To evaluate whether the presence of a bad neurological outcome (CPC &gt; 2) at discharged could be used as a prognostic index in order to evaluate the implantation of an ICD in OHCA survivors. Materials and Methods. We considered all the patients who had a cardiac arrest from 01/10/2014 to 30/09/2019 presenting a CPC&gt; 2 at discharge. The territory included was that of the Province of Pavia (550000 inhabitants) from 2014 to 2018 and of the Provinces of Pavia, Lodi, Cremona and Mantua (1550000 inhabitants) from 2019. We assessed the survival and the neurological status variation at 1–year.

Results

In the study period, CPR was attempted in 2998 confirmed OHCAs. 227 patients (7.6%) were discharged alive and in 218 of these, CPC was available. 51 patients (23.4%) had a CPC&gt;2 at discharge (22 CPC = 3, 24 CPC = 4 and 5 CPC = A). 1–year follow–up was available in 200 patients: among 158 alive, 12 (7.6%) had CPC&gt;2 (7 CPC = 3 and 5 CPC = 4). 1–year survival of patients with CPC&gt;2 at discharge was significantly lower those discharged with CPC≤2 (39.6% vs 91.6% p &lt; 0.001). Only 19/48 patients discharged with CPC&gt;2 survived at 1 year: a good cerebral performance was recovered in 6 patients (31.6%), while CPC&gt;2 persisted in 11 (58%) and the CPC value was unknown in 2 of them.

Conclusions

Our results highlight that 1–year survival is quite low in patients with CPC&gt;2 at discharge and that an improvement in cerebral performance occurs only in a minority of them. This evidence suggests the need for clinical re–evaluation after the event in order to carefully evaluate whether to implant an ICD in this kind of patients.

C1 THE ROLE OF ATRIAL ELECTRO–MECHANICAL COUPLING AS PREDICTOR OF CATHETER ABLATION EFFICIENCY

Background

Atrial fibrillation (AF) results in electrical and structural remodeling of the atria, and the extent of remodeling has already been found to be associated with higher AF recurrence rate after catheter ablation (CA). Recently, a novel echocardiographic parameter derived from tissue Doppler imaging (TDI), called PA–TDI, has been introduced to assess the total atrial activation time, as a non–invasive surrogate of fibrosis and atrial cardiomyopathy. The aim of the study was to investigate the role of PA–TDI interval as predictor of AF ablation efficacy.

Methods

Consecutive patients with persistent or paroxysmal symptomatic AF referred to our Center to perform radiofrequency ablation or cryoablation procedures were prospectively enrolled. In these patients, a complete transthoracic echocardiographic examination was performed before and after the ablation procedure, including assessment of the PA–TDI interval.

Results

From October 2018 to May 2020, 221 consecutive patients (mean age 61 ± 9 years, 74% male, mean BMI 26.5 ± 3.6, mean Ejection Fraction 61 ± 6%) symptomatic for AF, undergoing the procedure ablation (first procedure or re–do) were enrolled. Out of the blanking period, 25% of patients experienced recurrence of arrhythmia during follow–up (mean 16 months). Compared to patients who did not relapse, patients with AF recurrence have a generally longer post–procedural PA–TDI interval (139.6 ± 22.1 msec vs 153.9 ± 33 msec, respectively). In the multivariable analysis only post–procedure PA–TDI and re–do interventions were found to be independent predictors of AF recurrence. A PA–TDI cut–off&gt; 144msec identifies patients at risk of post ablation AF recurrence with sensitivity 58.7% and specificity 73.5% (AUC 0.697).

Conclusions

The PA–TDI interval is an independent predictor of AF recurrence after catheter ablation. This echocardiographic parameter is easily obtainable, low–cost, reproducible, and accessible even in peripheral centers.

C26 COMPLETE REVASCULARISATION IMPROVES SURVIVAL OF PATIENTS RESUSCITATED AFTER AN OUT–OF–HOSPITAL CARDIAC ARREST

Background

Sudden cardiac death is a major issue in industrialised countries and survival of patients after out–of–hospital cardiac arrest (OHCA) remains low. Acute myocardial infarction (AMI) is the principal cause of OHCA and myocardial revascularisation plays a positive role on survival. In this setting little is known about the role of complete (CR) versus culprit–only revascularisation (IR) on survival.

Purpose

The aim of this study was to assess whether CR could lead to a better one–year survival as compared to IR. Methods. Among patients prospectively enrolled in the Lombardia CARe OHCA registry from January 1 2015 to May 1 2021, who underwent a coronary angiography (CAG) at the Fondazione IRCCS Policlinico San Matteo were enrolled in this study. CAGs were retrospectively reviewed by two interventional cardiologists. Prehospital and survival data were retrieved from the registry.

Results

We enrolled 239 patients [mean age 63.7±12.4 years; male 79.9%; shockable presenting rhythm 84.1%; AMI at post ROSC ECG 67.9%; ejection fraction 37% (30–45), circulatory support with ECMO 10.9%]. Among the 119 (50%) patients with multi–vessel disease, 82 (69%) received IR whereas 37 (31%) received CR [8 during the first procedure, 29 in a second procedure with a median time after OHCA of 5 (2.5–10) days]. This latter group showed significantly higher one–year survival (54.9% vs 16.2%, p &lt; 0.001). At univariable logistic regression only a shockable presenting rhythm and the presence of chronic total occlusion (CTO) were significantly associated with the probability of receiving a CR [OR 5.1 (95%CI 1.1–22), p = 0.03; OR 0.37 (95%CI 0.16–0.85), p = 0.02 respectively]. However, at multivariable regression analysis only CTO was significantly associated with the probability of receiving a CR [OR 0.36 (95%CI 0.15–0.9), p = 0.007]. At Cox multivariable regression model cardiac arrest duration (longer that the median value of 24 min) and CR were independently associated with the probability of death [HR 3.6 (95%CI 1.9–6.9), p &lt; 0.001; HR 0.2 (95%CI 0.1–0.9), p = 0.02]. Similarly, cardiac arrest duration, CR and a shockable presenting rhythm were associated with the probability of death or poor neurologic outcome [HR 3.3 (95%CI 1.8–6), p &lt; 0.001; HR 0.5 (95%CI 0.3–0.9), p = 0.03 and HR 0.2 (95%CI 0.1–0.5), p &lt; 0.001].

Conclusions

Complete revascularisation is independently associated with a better one–year survival in patients resuscitated from an out–of–hospital cardiac arrest.

C60 12–LEAD POST–ROSC ELECTROCARDIOGRAM DISCRIMINATES SURVIVAL TO HOSPITAL DISCHARGE. A SUB–ANALYSIS OF THE PEACE STUDY

Background

Once the return of spontaneous circulation (ROSC) after an out–of–hospital cardiac arrest (OHCA) is achieved in patients with an ST–elevation myocardial infarction, the acquisition of a 12–lead electrocardiogram (ECG) is strongly recommended in order to determine candidates for urgent coronary angiography. However, little is known so far about the association of ECG features and survival to hospital discharge in OHCA patients.

Methods

We analysed all the post–ROSC ECGs collected from January 2015 to December 2018 in three European centres (Pavia, Lugano and Vienna). For every ECG, the main features were analysed and filed in the database together with the pre–hospital data collected for every patient according to the Utstein style.

Results

We collected 370 ECGs: 287 males (77.6%); median age 62 years old (IQR 53–70 years); 121 from Pavia (32.7%), 38 from Lugano (10.3%) and 211 from Vienna (57.0%). In Cox univariable regression, age older than 62 years [HR 1.7 (95% IC 1.1–2.4), p = 0.007], QRS wider than 120 msec [HR 1.87 (95% IC 1.3–2.7), p &lt; 0.001], ST elevation in more than one segment [HR 1.7(95% IC 1.2–2.5),p=0.003], the presence of left bundle branch block (LBBB) [HR 1.7 (95% IC 1.1–2.9), p = 0.03] and a right bundle branch block [HR 1.8 (95% IC 1.1–2.8), p = 0.01] were all associated with death before hospital discharge. In multivariable Cox regression, adjusted for the ROSC–to–ECG time, age older than 62 years [HR 1.6 (95% IC 1.1–2.3), p = 0.01], QRS wider than 120 msec [HR 1.7 (95%IC 1.2–2.5), p = 0.004] and the presence of ST elevation in more than one segment [HR 1.7 (95%IC 1.2–2.5), p = 0.004] were independently associated with death before hospital discharge. By considering these latter three risk factors, the rate of survival to hospital discharge was significantly influenced by their number [no risk factor: 80.8%; 1 factor: 71.2%; 2 factors: 61.9%; 3 factors: 34.4%; p &lt; 0.001, p for trend &lt;0.001]. With a Cox regression model, considering the absence of risk factor as a reference, we confirmed that having 2 or 3 risk factors was significantly associated with death before hospital discharge [HR 1.9 (95%IC 1–3.5), p = 0.037 e HR 5.1(95%IC 2.6–10.1), p &lt; 0.001 respectively].

Conclusions

Our study confirms the central role of ECG in STEMI patients resuscitated after an OHCA and proves that post–ROSC ECG features can be used for both the selection of patients who may benefit from urgent coronary angiography as well as for prognostic stratifications.

P30 CARDIAC ARRESTS IN SPORTS: WHAT IS DIFFERENT COMPARED TO OTHER PUBLIC PLACES?

Introduction

Cardiac arrests in sports can involve professional athletes, amateurs, but also spectators of sports competitions. Sports facilities are the only ones for which the current law provides for the presence of an automatic external defibrillator (AED) and trained personnel, unlike other public places (schools, work, street, station, general public buildings) where it is only recommended.

Objective

To compare patient characteristics, presentation rhythm, bystander cardiopulmonary resuscitation (CPR), AED use before emergency medical services (EMS) arrival, and return of spontaneous circulation (ROSC) longer than 30 seconds in the Utstein category of out–of–hospital cardiac arrests (OHCAs) in sports compared to events in other public places.

Materials and Methods

We considered all the OHCAs occurred from 01/01/2015 to 31/12/2020 in the provinces of Pavia, Lodi, Cremona, Mantua and Varese (2400000 inhabitants), excluding the OHCAs occurred at home, in long–term care facilities and witnessed by the EMS.

Results

During the study period, 22 OHCAs occurred in sports and 552 in other public places (school, work, street, station, public buildings). The age is similar in the two groups [sport 59 years (IQR 53.5–66.7) vs other 63 years (IQR 51–75), p = 0.2]. In sports, there is a trend in favor of shockable rhythms (13/22=59% vs 185/552=33%, p = 0.1). The percentage of CPR performed by bystanders in sports is significantly higher than in other public places (20/22=91% vs 299/552=54%, p = 0.003), as the bystander AED use (11/22=50% vs 64/552=12%, p &lt; 0.001) and bystander AED shock (7/22=31% vs 27/552=5%, p &lt; 0.001) before EMS arrival. A ROSC greater than 30 seconds was obtained in 59% of OHCAs in sports, with a statistically significant difference compared to events in other public places (13/22=59% vs 166/552=30%, p = 0.015).

Conclusions

During sports competitions there is a greater ability to intervene in case of cardiac arrest, which determines a higher probability of obtaining ROSC, although in terms of age or presentation rhythm the patients are comparable to OHCA victims in other places public. These results suggest the need for an AED and trained personnel in other public places as well.

Earlier onset of peripheral arterial thrombosis in homozygous MTHFR C677T carriers than in other MTHFR genotypes: a cohort study

To investigate whether age at first presentation of pure peripheral arterial thrombosis (PAT) in lower and upper limbs and in the splanchnic circulation occurs earlier in carriers of the methylenetetrahydrofolate reductase (MTHFR) T677T genotype compared to the heterozygous and wild type and to identify predictors of a possible earlier onset. Retrospective cohort study on 27 MTHFR TT, 29 MTHFR TC and 29 MTHFR CC participants; data regarding age, sex, age at PAT, clinical history (dyslipidaemia, hypertension, smoking, obesity) and homocysteine (HC) measured by immunoassay were collected. Age at PAT was lower in MTHFR TT than MTHFR TC and CC (43 ± 9 vs 47 ± 9 vs 51 ± 4 years, respectively, p = 0.02); plasma HC was higher in MTHFR TT than in the other groups (25 ± 19 vs 12.7 ± 6.7 vs 11.3 ± 3.3 μmol/l, respectively, p < 0.001) while the activated partial thromboplastin ratio (aPTTr) was lower in MTHFR TT than in other genotypes (0.90 ± 0.10 vs 0.97 ± 0.12 vs 0.97 ± 0.08 μmol/L p < 0.001). Among categorical variables, MTHFR TT and dyslipidaemia independently predicted age at AT (p = 0.01 & p = 0.03, respectively) whereas among the continuous variables HC independently predicted age at PAT (p = 0.02) as well as the aPTTr (p = 0.001); smoking predicted lower limb PAT (p = 0.005). MTHFR TT carriers develop their first PAT an average of 4 and 8 years earlier than MTHF CT and CC genotypes; MTHFR TT, dyslipidaemia and plasma HC contribute to the prematurity of the PAT while the interplay between elevated HC and smoking may affect type of arterial district occlusion.

The small world coefficient 4.8 ± 1 optimizes information processing in 2D neuronal networks

Small world networks have recently attracted much attention because of their unique properties. Mounting evidence suggests that communication is optimized in networks with a small world topology. However, despite the relevance of the argument, little is known about the effective enhancement of information in similar graphs. Here, we provide a quantitative estimate of the efficiency of small world networks. We used a model of the brain in which neurons are described as agents that integrate the signals from other neurons and generate an output that spreads in the system. 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Plasma Homocysteine in Behcet's Disease: A Systematic Review and Meta-Analysis

AIM

 To evaluate the relevance of plasma homocysteine (HC) in Behcet's disease (BD) and its clinical manifestations.

METHODS

 Systematic review of EMBASE and PubMed databases according to PRISMA guidelines from inception to July 2021; random-effects meta-analyses for continuous outcomes.

RESULTS

 The search strategy retrieved 48 case-control (2,669 BD and 2,245 control participants) and 5 cohort studies (708 BD participants). Plasma HC was higher in BD than in controls (p < 0.0001) with wide heterogeneity (I2  = 89.7%) that remained unchanged after sensitivity analysis according to year of article publication, age of BD participants, study size, study quality, method of HC determination, and male/female ratio >1.5; some pooled ethnicities explained a small part of the heterogeneity (I2  = 16.3%). Active BD participants had higher HC than inactive ones (p < 0.0001), with moderate heterogeneity (I2  = 49.2%) that disappeared after removal of an outlier study with very high disease activity. BD participants with any vascular involvement had higher HC than those without (p < 0.0001) with wide heterogeneity (I2  = 89.7%); subgroup analysis on venous thrombosis only changed neither effect size (p < 0.0001) nor heterogeneity (I2  = 72.7%). BD participants with ocular involvement had higher HC than those without (p < 0.0001) with moderate heterogeneity (I2  = 40.3%).

CONCLUSION

 Although causality cannot be inferred, the consistency of the elevation of plasma HC in BD, particularly in patients with active disease, with vascular and ocular involvement suggests an intrinsic involvement of HC in these clinical manifestations.

Time dependent adhesion of cells on nanorough surfaces

Understanding and controlling the mechanisms of cell adhesion to nanomaterials is essential in tissue engineering, regenerative medicine, the development of experimental models for the study of neurodegenerative diseases. Nonetheless, despite the great many of studies that have examined how cells interact with nanoscale surfaces, little is known about the temporal dimension of the process of adhesion. In a previous work, Decuzzi and Ferrari, by examining how the energy of a cell changes while binding to a nanoscale surface, determined a criterion to decide whether nanoroughness can either enhance or retard cell adhesion. While accurate, however their model template disregards the time variable. Here, starting from the work of Decuzzi and Ferrari, we have developed a mathematical model based on chemotaxis that describes how cells adhere to a nanorough surface over time. Relaxing the originating constraint of a fixed density of ligand molecules expressed by the cell membrane, we show that the strength of adhesion depends on time and that, for certain values of the model parameters, a cell can arrive to establish a stable adhesion to a substrate even if the process of binding is initially energetically unfavourable. We show that, for a cell-membrane stiffness of 10kPa, an initial density of receptors of 500bonds/μm², a specific and non-specific energy density of adhesion of 10^-5J/m² and 10^-7J/m², and roughness in the low nanometer range, cell adhesion forces can be completely activated from few seconds to some tens of minutes from the initial contact with the surface.

Antiphospholipid Antibodies in Sickle Cell Disease: A Systematic Review and Exploratory Meta-Analysis

The relationship between antiphospholipid antibodies (aPL) and sickle cell disease (SCD) has never been systematically addressed. Our aim was to evaluate potential links between SCD and aPL in all age groups. EMBASE/PubMed was screened from inception to May 2020 and Peto odds ratios for rare events were calculated. The pooled prevalence (PP) of IgG anticardiolipin antibodies (aCL) was higher in individuals with SCD than in controls (27.9% vs 8.7%, P < 0.0001), that of IgM aCL was similar in the two groups (2.9% vs 2.7%); only individuals with SCD were positive for lupus anticoagulant (LA) (7.7% vs 0%, P < 0.0001). The PP of leg ulcers was similar between aPL positive and negative individuals (44% vs 53%) and between patients in acute crisis and stable patients (5.6% vs 7.3%). Reporting of aPL as a binary outcome and not as a titer precluded further interpretation. The results indicate that a prospective case-control study with serial measurements of a panel of aPL in SCD patients might be warranted, in order to understand further the possible pathogenic role of aPL in SCD.

Cell aggregation on nanorough surfaces

The ability to control adhesion and the spatial organization of cells over nanoscale surfaces is essential in tissue engineering, regenerative medicine, the growth of organoids and spheroids as an in-vitro-model of human development and disease. Nonetheless, despite the several different works that have explored the influence of nanotopography on cell adhesion and clustering, little is known about how the forces arising from membrane conformational change developing during cell adaptation to a nanorough surface, and the cell-cell adhesion forces, interact to guide cell assembly. Here, starting from the works of Decuzzi and Ferrari, who examined how the energy of a cell varies while adhering to a nanoscale surface, and of Armstrong and collaborators, who developed a continuous model of cell-cell adhesion and morphogenesis, we provide a description of how nanotopography can modulate cellular clustering. In simulations where the parameters of the model were varied over large intervals, we found that nanoroughness may induce cell aggregation from a homogenous, uniform state, also for weak cell-cell adhesion. Results of the model are relevant in bio-engineering and biomedical nanotechnology, and may be of interest for those involved in the design and fabrication of biomaterials and scaffolds for tissue formation and repair.

Prognostic value of NT-proBNP and best cut-offs for risk prediction in obese patients with chronic systolic heart failure

Background

N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP) is a strong predictor of outcome in chronic systolic heart failure (CHF). Although plasma NT-proBNP has been reported to display an inverse correlation with body-mass-index (BMI), its prognostic value in obese patients has been poorly investigated so far.

Objectives

To evaluate the prognostic value and the best cut-offs for risk prediction of NT-proBNP in obese individuals from a multinational cohort of patients with systolic CHF.

Methods

We analyzed data from the BIOS (Biomarkers In Heart Failure Outpatient Study) Consortium. Patients with left ventricular ejection fraction (LVEF) ≤50% were selected and classified as nonobese (BMI &lt;30 kg/m2), mildly obese (BMI 30–35 kg/m2), moderately obese (BMI 35–40 kg/m2), or severely obese (BMI ≥40 kg/m2), according to standard nomenclature. Clinical and bio-humoral data, including NT-proBNP testing, were retrieved, and 5-year cardiac and all-cause mortality status were considered as primary and secondary outcome, respectively. The independent prognostic role of NT-proBNP was evaluated through Cox regression analysis, adjusting the model for age, gender, New York Heart Association class, ischaemic aetiology, LVEF, and estimated glomerular filtration rate (eGFR).

Results

The study population included 11,574 patients (age 65±12 years, LVEF 30±9%, males 78%). Most of patients were nonobese (n=8,937, 77%), while mildly, moderately, and severely obese patients were 1,887 (16%), 499 (4%), and 251 (3%), respectively. Median values of plasma NT-proBNP were progressively lower from nonobese to mildly, moderately, and severely obese patients (1455 ng/L, 903 ng/L, 767 ng/L, 660 ng/L, respectively) and BMI was predictive of NT-proBNP independently from age, LVEF, and eGFR (r=−0.152, p&lt;0.001). The best NT-proBNP cut-offs to predict 5-year cardiac mortality were significantly lower in mildly [1044 ng/L; AUC 0.663 (Sen 66%; Spe 59%), p&lt;0.001] moderately [736 ng/L; AUC 0.670 (Sen 76%; Spe 52%), p&lt;0.001]), and severely [1060 ng/L; AUC 0.635 (Sen 57%; Spe 69%), p=0.021] obese patients compared to nonobese individuals [2034 ng/L; AUC 0.714 (Sens. 65%; Spec. 66%), p&lt;0.001]. Further, NT-proBNP independently predicted 5-year cardiac death in nonobese, mildly and moderately obese patients (all p&lt;0.001), but not in severely obese patients (p=0.457). Similar findings were observed for the secondary endpoint of 5-year all-cause mortality.

Conclusions

Compared to nonobese CHF patients, obese patients have lower circulating NT-proBNP levels, which retain independent prognostic significance for cardiac and all-cause mortality across most categories of obesity. BMI-adjusted NT-proBNP cut-offs might be considered for prognostic stratification in obese patients with CHF.

Funding Acknowledgement

Type of funding source: None

Central and obstructive apneas prevalence in heart failure with reduced, mid-range and preserved ejection fraction

Background

Central apneas (CA) and obstructive apneas (OA) are highly prevalent in heart failure (HF) both with reduced and preserved systolic function. However, a comprehensive evaluation of apnea prevalence across HF according to ejection fraction (i.e HF with patients with reduced, mid-range and preserved ejection fraction- HFrEf, HFmrEF and HFpEF, respectively) throughout the 24 hours has never been done before.

Materials and methods

700 HF patients were prospectively enrolled and then divided according to left ventricular EF (408 HFrEF, 117 HFmrEF, 175 HFpEF). All patients underwent a thorough evaluation including: 2D echocardiography; 24-h Holter-ECG monitoring; cardiopulmonary exercise testing; neuro-hormonal assessment and 24-h cardiorespiratory monitoring.

Results

In the whole population, prevalence of normal breathing (NB), CA and OA at daytime was 40%, 51%, and 9%, respectively, while at nighttime 15%, 55%, and 30%, respectively.

When stratified according to left ventricular EF, CA prevalence decreased from HFrEF to HFmrEF and HFpEF: (daytime CA: 57% vs. 43% vs. 42%, respectively, p=0.001; nighttime CA: 66% vs. 48% vs. 34%, respectively, p&lt;0.0001), while OA prevalence increased (daytime OA: 5% vs. 8% vs. 18%, respectively, p&lt;0.0001; nighttime OA: 20 vs. 29 vs. 53%, respectively, p&lt;0.0001).

When assessing moderte-severe apneas, defined with an apnea/hypopnea index &gt;15 events/hour, prevalence of CA was again higher in HFrEF than HFmrEF and HFpEF both at daytime (daytime moderate-severe CA: 28% vs. 19% and 23%, respectively, p&lt;0.05) and at nighttime (nighttime moderate-severe CA: 50% vs. 39% and 28%, respectively, p&lt;0.05). Conversely, moderate-severe OA decreased from HFrEF to HFmrEF to HFpEF both at daytime (daytime moderate-severe OA: 1% vs. 3% and 8%, respectively, p&lt;0.05) and nighttime (noghttime moderate-severe OA: 10% vs. 11% and 30%, respectively, p&lt;0.05).

Conclusions

Daytime and nighttime apneas, both central and obstructive in nature, are highly prevalent in HF regardless of EF. Across the whole spectrum of HF, CA prevalence increases and OA decreases as left ventricular systolic dysfunction progresses, both during daytime and nighttime.

Funding Acknowledgement

Type of funding source: None

Central apneas and Ticagrelor related dyspnea in patients with acute coronary syndrome

Background

Patients treated with ticagrelor often develop dyspnea of unknown origin. We aim to explore the contribution of central apneas to ticagrelor-related dyspnea in patients with acute coronary syndrome (ACS).

Methods

We consecutively enrolled patients with ACS, preserved left ventricular ejection fraction and no history of obstructive sleep apnea, treated either with ticagrelor 90 mg bid (n=30) or prasugrel 10 mg od (n=24). One week after ACS onset, all patients underwent, beyond thorough cardiovascular and respiratory assessment, 24-hour cardiorespiratory monitoring and assessment of chemosensitivity to hypercapnia.

Results

Patients treated with ticagrelor reported more frequently dyspnea than patients treated with prasugrel (43% versus 4%, p=0.001), despite no difference in demographic, clinical, echocardiographic and pulmonary data. Patients with dyspnea induced by ticagrelor showed higher apnea-hypopnea and central apnea index both at daytime and at nighttime compared to patients treated with ticagrelor but without dyspnea and patients treated with prasugrel (daytime AHI: 26 [7–34] vs 6 [4–14] and 6 [0–11] events/hour; nighttime AHI: 65 [17–72] vs 22 [8–37] and vs 11 [4–23] events/hour; daytime CAI: 5 [1–15] vs 1 [0–6] and 0 [0–1) events/hour; nighttime CAI 34 [2–55] vs 3 [0–9] and 0 [0–1], all p&lt;0.05). Likewise, they also presented with higher hypercapnic ventilatory response (2.4 [1.9–2.7] vs 1.3 [1.1–1.9] and 0.9 [0.5–2.1] L/min/mmHg, all p&lt;0.05).

Conclusions

Central apneas should be considered a likely mechanism of dyspnea in ACS patients treated with ticagrelor. A drug-related sensitization of the chemoreflex may be the cause of ventilatory instability in this setting.

Funding Acknowledgement

Type of funding source: None

Sacubitril/valsartan improves ventilation stability in patients with chronic heart failure

Background

Sacubitril/valsartan (SV) ameliorates symptoms and prognosis in patients with heart failure and reduced ejection fraction (HFrEF), but the reasons for such effects are unclear. The impact of SV on ventilation has never been investigated. In HFrEF, apneas are highly prevalent both at daytime and nighttime and are associated with increased mortality.

Purpose

We hypothesize that treatment with SV could favourably stabilize ventilation by reducing the severity of central apneas in patients with HFrEF.

Methods

51 patients with HFrEF (mean age 67±9 years, mean left ventricular ejection fraction, LVEF 27±7%) and apneas defined by an apnea-hypopnea index, AHI≥5 (median 16, interquartile range 8–28) events/hour, eligible to treatment with SV and previously on optimal medical therapy for HFrEF, were enrolled. An extensive evaluation including cardiac ultrasound and a 24-hour cardiorespiratory monitoring was performed.

Results

After six months of treatment with SV, left ventricle systolic and diastolic function, mitral regurgitation (MR), left atrial volume (LAVI) and systolic pulmonary artery pressure (sPAP) were improved. Severity of apneas was reduced by 50%, 65% and 36% throughout the 24-hour, at daytime and nighttime, respectively.

Conclusion

Besides its known efficacy on cardiac remodeling, SV positively decreases the apneic burden in patients with HFrEF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics unrestricted grant

Contrast induced acute kidney injury prevention during angiographic procedure with early renal replacement therapy

Background and purpose

Post-angiography renal replacement therapy (RRT) has shown protective effects from Ci-AKI (contrast induced acute kidney injury) in patients with pre-existing advanced renal disfunction. We analysed a series of 1095 continuative patients who undergone coronary or peripheral angiography in our center. In non-haemodialyzed patients with eGFR &lt;20ml/min/1.73m2 or with poor renal reserve we performed an “early” RRT, starting during angiography procedure and applied for at least 6 h after procedure, thus diverging from previous literature data based only on post-procedure hours delayed RRT application. The RRT modality chosen was CVVHDF (continous veno-venous hemodiafiltration).

Methods

We considered following subjects variability: age, sex, weight, presence of hypertension, dyslipidaemia, diabetes, smoking habitude, left ventricular ejection fraction, amount of contrast media given and shock or infection occurrence during hospital stay. We evaluate statistic significative of serum creatine (SCr) variation in patients receiving RRT from pre-procedure time (T0), at 24h (T1), 48h (T2), 72h (T3) after procedure and at 3–8 weeks follow-up (T4). Quantitative data were compared with Student T test, qualitative data with Chi Square test, considering statistically significant p value &lt;0.05 with two tails. Ci-AKI was defined as serum creatinine rise ≥0.3 mg/dL at 48h from contrast media administration, following KDIGO (kidney disease improving global outcomes) guidelines definition.

Results

26 patients received RRT. Medium SCr at T0 was 3.37 mg/dl and showed a significative reduction (see figure) at T1 (−0.88mg/dl = −20.6%, p=0.003) and T2 (−0.96mg/dl = −18.33%, p=0.029) and a trend towards reduction at T3 (−0.78mg/dl, p=0.174) and at T4 (−0.28mg/dl, p=0.568).

Between 26 pts, 6 pts (23%) developed Ci-AKI. Only contrast media amount significatively diverge between two groups (183 ml in the group with Ci-AKI vs 162 ml in pts with no Ci-AKI, p=0.03), showing also a trend towards significance for infection occurrence (83.3% pts Ci-AKI vs 40% pts no Ci-AKI, p=0.06) and shock onset (33.3%pts Ci-AKI vs 5% pts no Ci-AKI, p=0.06).

Average SCr diverge at T2 (3.18mg/dl Ci-AKI vs 2.04mg/dl no Ci-AKI, p=0.01) and at T3 (3.33mg/dl CI-AKI vs 2.31mg/dl no CI-AKI, p=0.06); we also found a trend towards progressive increase of SCr for Ci-AKI pts (T0-T1: +0.17mg/dl, p=ns; T0-T2: +0.41mg/dl, p=ns; T0-T3: +0.57mg/dl, p=ns; T0-T4: +1.35mg/dl, p=ns) and a significative reduction in SCr for no Ci-AKI pts (T0-T1: −1.23mg/dl = −29.32% p=0.001; T0-T2: −1.46mg/dl = −30.78%, p=0.01; T0-T4: −0.41mg/dl = −15.5%, p=0.05).

Conclusions

Early RRT with CVVHDF modality results effective in 77% of patients in avoiding Ci-AKI, with a significative SCr reduction at 24 and 48h. An increased amount of contrast media is significatively related to Ci-AKI incidence. Ci-AKI development could also possibly be related to shock and infection occurrence.

Figure 1

Funding Acknowledgement

Type of funding source: None

Autoimmune haemolytic anaemia and antiphospholipid antibodies in paediatrics: a systematic review and meta-analysis

INTRODUCTION/OBJECTIVE

The relationship between autoimmune haemolytic anaemia (AIHA) and antiphospholipid antibodies (aPL) has never been addressed via a meta-analysis in the paediatric age group. We evaluated the link between AIHA and aPL in childhood systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS).

METHODS

EMBASE and PubMed were screened from inception to May 2020 and Peto's odds ratio for rare events was employed for the between group comparisons.

RESULTS

The meta-analysis included 11 articles for a total of 575 children: the pooled prevalence of AIHA was greater in (1) IgG aCL-positive than IgG aCL-negative children (39.7% vs 20.9%, p = 0.005); (2) in APS-positive than APS-negative SLE children (36.8% vs 13.2%, p = 0.01); and (3) in SLE-related APS than in primary APS children (53% vs 16.2%, p = 0.008).

CONCLUSIONS

The pooled prevalence of AIHA is greatest in SLE with aPL/APS, low-moderate in SLE without aPL/APS, and lowest in primary APS. Key Points • Antiphospholipid antibodies strongly relate to autoimmune haemolytic anaemia. • Autoimmune haemolytic anaemia is more common in systemic lupus erythematosus with antiphospholipid antibodies.

Cardiogenic shock and acute kidney injury: the rule rather than the exception

Cardiogenic shock (CS) is a life-threatening condition of poor end-organ perfusion, caused by any cardiovascular disease resulting in a severe depression of cardiac output. Despite recent advances in replacement therapies, the outcome of CS is still poor, and its management depends more on empirical decisions rather than on evidence-based strategies. By its side, acute kidney injury (AKI) is a frequent complication of CS, resulting in the onset of a cardiorenal syndrome. The combination of CS with AKI depicts a worse clinical scenario and holds a worse prognosis. Many factors can lead to acute renal impairment in the setting of CS, either for natural disease progression or for iatrogenic causes. This review aims at collecting the current evidence-based acknowledgments in epidemiology, pathophysiology, clinical features, diagnosis, and management of CS with AKI. We also attempted to highlight the major gaps in evidence as well as to point out possible strategies to improve the outcome.

Antiphospholipid antibodies and lower extremity peripheral artery disease: A systematic review and meta-analysis

AIM

To evaluate the clinical relevance of antiphospholipid antibodies (aPL) in patients with lower extremity peripheral artery disease (PAD).

DATA SOURCES

EMBASE and MEDLINE databases were searched from inception to March 2020 for clinical studies reporting on the association between of aPL [IgG/IgM anticardiolipin (aCL) and lupus anticoagulant (LA)] and PAD.

METHODS

We determined the pooled prevalence (PP) of patients positive for aPL in PAD or the PP of PAD in patients positive for aPL; we employed Peto's odds ratio with random effect for the meta-analysis.

RESULTS

Twenty-one studies comprising 6,057 patients were evaluated: in patients with PAD, the PP of IgG aCL was 12% vs 4.1% in those without, IgM aCL was 13.2% vs 2.1%, and LA 13.3% vs 3.3%, respectively. The PP of patients with LA was greater in critical limb ischemia than in the control group (19.3% vs 4.2%). Also, the PP of patients with LA was greater in the failed than in the successful revascularisation group (35.8% vs 15.8%). The PP of post-procedural revascularisation failures was similar in the groups given or not given oral anticoagulation (59.2% vs 61.9%).

CONCLUSION

All the aPL related to PAD regardless of diagnostic definition used, whereas LA related also to critical limb ischaemia and failed revascularisation. Data expressed as percentage of participants positive for aPL limit the interpretation of these relationships.

Antiphospholipid antibodies in end-stage renal disease: A systematic review and meta-analysis

INTRODUCTION

The relationship between autoimmune hemolytic anemia and antiphospholipid antibodies (aPL) and/or antiphospholipid syndrome has never been systematically addressed.

METHODS

Systematic review of EMBASE and PubMed databases performed according to PRISMA guidelines from inception to March 2020; meta-analysis performed by Peto's odds ratio for rare events.

FINDINGS

Forty-five studies with different outcomes met the inclusion/exclusion criteria. The pooled prevalence (PP) of IgG anticardiolipin antibodies (aCL) positivity was greater in end-stage renal disease (ESRD) than controls (20.2% vs. 2.6%, P = 0.001, I²  >80%; I² = heterogeneity), particularly in hemodialysis patients (18.3% vs. 8%, I² = 0%). The PP of lupus anticoagulant was greater in ESRD than controls (8.7% vs. 0.2%, P < 0.0001, I² = 0%). The standardized mean difference of IgG aCL favored ESRD rather than controls (P < 0.0001, I² =97%). The PP of fistula occlusion was greater in IgG aCL-positive patients than negative patients (39% vs. 27%, I² =97%); the PP of IgG aCL positivity was greater in patients with fistula occlusion than without fistula occlusion (26.9% vs. 23.2%, P = 0.01, I² =72%); the same applied to the PP of lupus anticoagulant positivity (23% vs. 0.3%, P < 0.0001, I² = 0%). The standardized mean difference of IgG aCL favored fistula occlusion (P = 0.004, I² = 91%).

DISCUSSION

Lupus anticoagulant relates to ESRD regardless of management whereas IgG aCL relates specifically to ESRD on hemodialysis, but only lupus anticoagulant associates with fistula occlusion. The expression of aPL as patients positive for aPL rather than as titers precludes further assumptions on the relationship.

A nanomechanical model enables comprehensive characterization of biological tissues in ultrasound imaging

Sonography, elastography, sonoelastography are ultrasound imaging techniques commonly used in the clinical practice for the diagnosis of many pathological conditions. These highly reliable, non-invasive methods use high frequency, elastic pressure waves (ultrasounds) to interrogate the internal structure of biological tissues and organs, and the continuum mechanics hypothesis to reconstruct, from the output of the system, the biophysical characteristics of the samples. Nevertheless, continuum mechanics disregards the discrete nature of tissues and organs, resulting in an inability for the model to describe some important tissue biophysical characteristics such as the cell size and their spatial layout. Here, we used the theory of doublet mechanics - a discrete nano-mechanical field theory - to model the propagation of ultrasounds in a multilayered biological tissue. We found that the output of the model exhibits a very high sensitivity to the macro and micro characteristics of the tissue, including cell size. We used results from the model to correlate the internal structure of the samples to the reflection coefficient, i.e. the continuum level response of the system. This model, and its more sophisticated evolutions that will be developed over time, can complement traditional ultrasound imaging, and provide ways to analyze non-invasively living tissues with a resolution inaccessible to conventional techniques of analysis, including positron emission tomography, computer tomography, and magnetic resonance.

Validity of Coagulation Activation Markers in Antiphospholipid Syndrome: A Systematic Review and Meta-analysis with a Short Data Report

Prothrombin fragment F1 + 2 (F1 + 2) and thrombin–antithrombin (TAT) have been assessed in antiphospholipid syndrome (APS) but without evaluating a direct relationship with antiphospholipid (aPL) antibody titers. This article aims to investigate a direct relationship between aPL and F1 + 2 and perform a systematic review and meta-analysis of F1 + 2 and TAT in APS. Systematic search was performed using EMBASE and PubMed databases from January 1982 to December 2018 and random effects meta-analyses for continuous outcomes. This is a cross-sectional case–control study; immunoglobulin G/immunoglobulin M (IgG/IgM) anticardiolipin (aCL) anti-β2-glycoprotein-I, antiprothrombin (aPT) antibodies, F1 + 2, and lupus anticoagulants (LA) were measured in 25 thrombotic primary APS (PAPS), 9 nonthrombotic carriers of aPL, and 18 controls. The significant effect size (ES) for F1 + 2 between aPL +ve and aPL −ve systemic lupus erythematosus (SLE) and between aPL +ve SLE and control displayed high heterogeneity. The significant ES for F1 + 2 between aPL −ve SLE and controls displayed no heterogeneity. The ES for TAT between aPL +ve and aPL −ve SLE patients and between aPL −ve SLE and controls was low, without heterogeneity. Mean F1 + 2 was greater in PAPS (p < 0.0001), inversely correlated with IgG aCL, IgM aPT, and LA (p = 0.001, 0.03, and 0.01, respectively), though only IgG aCL negatively predicted F1 + 2 (p = 0.01). IgG aCL inversely predicts F1 + 2. IgG aCL positivity introduces heterogeneity in the F1 + 2 ES, whereas the lack of heterogeneity in the ES for TAT may indicate poor TAT formation in aPL +ve group. Thus, F1 + 2 measurements may be unfounded as already demonstrated for TAT in the 1990s.

Cortical-like mini-columns of neuronal cells on zinc oxide nanowire surfaces

A long-standing goal of neuroscience is a theory that explains the formation of the minicolumns in the cerebral cortex. Minicolumns are the elementary computational units of the mature neocortex. Here, we use zinc oxide nanowires with controlled topography as substrates for neural-cell growth. We observe that neuronal cells form networks where the networks characteristics exhibit a high sensitivity to the topography of the nanowires. For certain values of nanowires density and fractal dimension, neuronal networks express small world attributes, with enhanced information flows. We observe that neurons in these networks congregate in superclusters of approximately 200 neurons. We demonstrate that this number is not coincidental: the maximum number of cells in a supercluster is limited by the competition between the binding energy between cells, adhesion to the substrate, and the kinetic energy of the system. Since cortical minicolumns have similar size, similar anatomical and topological characteristics of neuronal superclusters on nanowires surfaces, we conjecture that the formation of cortical minicolumns is likewise guided by the interplay between energy minimization, information optimization and topology. For the first time, we provide a clear account of the mechanisms of formation of the minicolumns in the brain.

Relating the rate of growth of metal nanoparticles to cluster size distribution in electroless deposition

Electroless deposition on patterned silicon substrates enables the formation of metal nanomaterials with tight control over their size and shape. In the technique, metal ions are transported by diffusion from a solution to the active sites of an autocatalytic substrate where they are reduced as metals upon contact. Here, using diffusion limited aggregation models and numerical simulations, we derived relationships that correlate the cluster size distribution to the total mass of deposited particles. We found that the ratio ξ between the rates of growth of two different metals depends on the ratio γ between the rates of growth of clusters formed by those metals through the linearity law ξ = 14(γ - 1). We then validated the model using experiments. Different from other methods, the model derives k using as input the geometry of metal nanoparticle clusters, decoded by SEM or AFM images of samples, and a known reference.

Modelling soil erosion in a Mediterranean watershed: Comparison between SWAT and AnnAGNPS models

In this study, the simulations generated by two of the most widely used hydrological basin-scale models, the Annualized Agricultural Non-Point Source (AnnAGNPS) and the Soil and Water Assessment Tool (SWAT), were compared in a Mediterranean watershed, the Carapelle (Apulia, Southern Italy). Input data requirements, time and efforts needed for input preparation, strength and weakness points of each model, ease of use and limitations were evaluated in order to give information to users. Models were calibrated and validated at monthly time scale for hydrology and sediment load using a four year period of observations (streamflow and suspended sediment concentrations). In the driest year, the specific sediment load measured at the outlet was 0.89 t ha^-1 yr^-1, while the simulated values were 0.83 t ha^-1 yr^-1 and 1.99 t ha^-1 yr^-1 for SWAT and AnnAGNPS, respectively. In the wettest year, the specific measured sediment load was 7.45 t ha^-1 yr^-1, and the simulated values were 8.27 t ha^-1 yr^-1 and 6.23 t ha^-1 yr^-1 for SWAT and AnnAGNPS, respectively. Both models showed from fair to a very good correlation between observed and simulated streamflow and satisfactory for sediment load. Results showed that most of the basin is under moderate (1.4-10 t ha^-1 yr^-1) and high-risk erosion (> 10 t ha^-1 yr^-1). The sediment yield predicted by the SWAT and AnnAGNPS models were compared with estimates of soil erosion simulated by models for Europe (PESERA and RUSLE2015). The average gross erosion estimated by the RUSLE2015 model (12.5 t ha^-1 yr^-1) resulted comparable with the average specific sediment yield estimated by SWAT (8.8 t ha^-1 yr^-1) and AnnAGNPS (5.6 t ha^-1 yr^-1), while it was found that the average soil erosion estimated by PESERA is lower than the other estimates (1.2 t ha^-1 yr^-1).

Oxidative/nitrative stress in the pathogenesis of systemic sclerosis: are antioxidants beneficial?

Systemic sclerosis (SSc) is a multisystem autoimmune disease: characterised from the clinical side by progressive vasculopathy and fibrosis of the skin and different organs and from the biochemical side by fibroblast deregulation with excessive production of collagen and increased expression of nicotinamide adenine dinucleotide phosphate oxidase 4 (NOX4). The latter contributes to an overproduction of reactive oxygen species that through an autocrine loop maintains NOX4 in a state of activation. Reactive oxygen and nitrogen species are implicated in the origin and perpetuation of several clinical manifestations of SSc having vascular damage in common; attempts to dampen oxidative and nitrative stress through different agents with antioxidant properties have not translated into a sustained clinical benefit. Objective of this narrative review is to describe the origin and clinical implications of oxidative and nitrative stress in SSc, with particular focus on the central role of NOX4 and its interactions, to re-evaluate the antioxidant approaches so far used to limit disease progression, to appraise the complexity of antioxidant treatment and to touch on novel pathways elements of which may represent specific treatment targets in the not so distant future.

Silica diatom shells tailored with Au nanoparticles enable sensitive analysis of molecules for biological, safety and environment applications

Diatom shells are a natural, theoretically unlimited material composed of silicon dioxide, with regular patterns of pores penetrating through their surface. For their characteristics, diatom shells show promise to be used as low cost, highly efficient drug carriers, sensor devices or other micro-devices. Here, we demonstrate diatom shells functionalized with gold nanoparticles for the harvesting and detection of biological analytes (bovine serum albumin-BSA) and chemical pollutants (mineral oil) in low abundance ranges, for applications in bioengineering, medicine, safety, and pollution monitoring.

The effect of connectivity on information in neural networks

We present a mathematical model that quantifies the amount of information exchanged in bi-dimensional networks of nerve cells as a function of network connectivity Q. Upon varying Q over a significant range, we found that, from a certain cell density onwards, 90% of the maximal information transferred I(Q) in a random neuronal network is already reached with just 40% of the total possible connections Q among the cells. As a consequence, the system would not benefit from additional connections in terms of the amount of I(Q), in agreement with the tendency of brains to minimize Q because of its energetic costs. The model may reveal the circuits responsible for neurodegenerative disorders in that neurodegeneration can be regarded as a connective failure affecting information.