EADV Task Force Pruritus White Paper on chronic pruritus and chronic prurigo: Current challenges and future solutions

Chronic pruritus (CP) is frequent in general medicine and the most common complaint in general dermatology. The prevalence of CP is expected to rise in the future due to the ageing population. The clinical presentation, underlying aetiology and treatment strategy of CP are heterogeneous. Also, individual treatment aims and physical, psychic and economic burdens of patients might vary. Chronic prurigo (CPG) is the most severe disease in the chronic pruritus spectrum, being associated with long-standing scratch-induced skin lesions and a therapy refractory itch-scratch-cycle. It is thus important to raise disease awareness for CP and CPG in the general public and among decision-makers in the health system. Further, there is a need to support a rational clinical framework to optimize both diagnostics and therapeutics. Currently, there is still a shortcoming regarding approved therapies and understanding CP/CPG as severe medical conditions. Therefore, the EADV Task Force Pruritus decided to publish this white paper based on several consensus meetings. The group consented on the following goals: (a) ensure that CP is recognized as a serious condition, (b) increase public awareness and understanding of CP and CPG as chronic and burdensome diseases that can greatly affect a person's quality of life, (c) clarify that in most cases CP and CPG are non-communicable and not caused by a psychiatric disease, (d) improve the support and treatment given to patients with CP to help them manage their disease and (e) publicize existing therapies including current guidelines. We aim to point to necessary improvements in access and quality of care directed to decision-makers in health policy, among payers and administrations as well as in practical care.

An ECG-based machine learning model for predicting new-onset atrial fibrillation is superior to age and clinical features in identifying patients at high stroke risk

BACKGROUND

Several large trials have employed age or clinical features to select patients for atrial fibrillation (AF) screening to reduce strokes. We hypothesized that a machine learning (ML) model trained to predict AF risk from 12‑lead electrocardiogram (ECG) would be more efficient than criteria based on clinical variables in indicating a population for AF screening to potentially prevent AF-related stroke.

METHODS

We retrospectively included all patients with clinical encounters in Geisinger without a prior history of AF. Incidence of AF within 1 year and AF-related strokes within 3 years of the encounter were identified. AF-related stroke was defined as a stroke where AF was diagnosed at the time of stroke or within a year after the stroke. The efficiency of five methods was evaluated for selecting a cohort for AF screening. The methods were selected from four clinical trials (mSToPS, GUARD-AF, SCREEN-AF and STROKESTOP) and the ECG-based ML model. We simulated patient selection for the five methods between the years 2011 and 2014 and evaluated outcomes for 1 year intervals between 2012 and 2015, resulting in a total of twenty 1-year periods. Patients were considered eligible if they met the criteria before the start of the given 1-year period or within that period. The primary outcomes were numbers needed to screen (NNS) for AF and AF-associated stroke.

RESULTS

The clinical trial models indicated large proportions of the population with a prior ECG for AF screening (up to 31%), coinciding with NNS ranging from 14 to 18 for AF and 249-359 for AF-associated stroke. At comparable sensitivity, the ECG ML model indicated a modest number of patients for screening (14%) and had the highest efficiency in NNS for AF (7.3; up to 60% reduction) and AF-associated stroke (223; up to 38% reduction).

CONCLUSIONS

An ECG-based ML risk prediction model is more efficient than contemporary AF-screening criteria based on age alone or age and clinical features at indicating a population for AF screening to potentially prevent AF-related strokes.

[Tumor predisposition syndromes and nephroblastoma : Early diagnosis with imaging]

CLINICAL/METHODICAL ISSUE

The Beckwith-Wiedemann spectrum (BWSp) as well as the WT1-related syndromes, Denys-Drash syndrome (DDS) and WAGR spectrum (Wilms tumor, Aniridia, genitourinary anomalies and a range of developmental delays) are tumor predisposition syndromes (TPS) of Wilms tumor (WT). Patients with associated TPS are at higher risk of developing chronic kidney disease and bilateral and metachronous tumors as well as nephrogenic rests.

STANDARD RADIOLOGICAL METHODS

Standard imaging diagnostics for WT include renal ultrasound and magnetic resonance imaging (MRI). In the current renal tumor studies Umbrella SIOP-RTSG 2016 and Randomet 2017, thoracic computed tomography (CT) is also recommended as standard. Positron emission tomography (PET)-CT and whole-body MRI, on the other hand, are not part of routine diagnostics.

METHODOLOGICAL INNOVATIONS

In recent publications, renal ultrasound is recommended every 3 months until the age of 7 years in cases of clinical suspicion or molecularly proven TPS.

PERFORMANCE

Patients with TPS and regular renal ultrasounds have smaller tumor volumes and lower tumor stages at WT diagnosis than patients without such a screening. This allows a reduction of therapy intensity and facilitates the performance of nephron sparing surgery, which is prognostically relevant especially in bilateral WT.

ACHIEVEMENTS

Early diagnosis of WT in the context of TPS ensures the greatest possible preservation of healthy and functional renal tissue. Standardized screening by regular renal ultrasounds should therefore be firmly established in clinical practice.

PRACTICAL RECOMMENDATIONS

The initial diagnosis of TPS is clinical and requires a skilled and attentive examiner in the presence of sometimes subtle clinical manifestations, especially in the case of BWSp. Clinical diagnosis should be followed by genetic testing, which should then be followed by sonographic screening.

X-ray Fourier transform holography with beam shaping optical elements

Holography is a powerful method for achieving 3D images of objects. Extending this method to short wavelengths potentially offers significantly higher resolution than visible light holography. However, current X-ray holography setups employ nanoscale pinholes to form the reference wave. This approach is relatively inefficient and limited to very small sample size. Here, we propose a new setup for X-ray holography based on a binary diffractive optical element (DOE), which forms at the same time the object illumination and the reference wave. This optic is located separately from the sample plane, which permits investigation of larger sample areas. Using an extended test sample, we demonstrate a resolution of 90 nm (half-pitch) at an undulator beamline at BESSY II. The new holography setup can be directly transferred to free electron laser sources enabling time-resolved nanoscale imaging for ultra-fast processes.

Reflection on the proposed changes to dose quantities-an industrial perspective

In 2021, the ICRP initiated the revision of the general recommendations of the system of radiation protection, and part of it will focus on dose quantities. The recently published ICRP Publication 147 and ICRU Report 95 have described the extent of the proposed modifications and paved the way for the strategy to be adopted. These revisions would seek to simplify, improve the accuracy and extend the field of use of dose quantities. While the Radiological Protection Working Group of the World Nuclear Association recognises the notable improvement in the estimation of the protection quantities and the usefulness of such changes for the medical and research sector, the benefits of the proposed new system seem very limited for the nuclear industry and industries involving naturally occurring radioactive materials. The complexity associated with changing a long-standing and robust system and the risk incurred by the human factor seem unjustified, bearing in mind the likely cost.

Reflections on low-dose radiation, the misconceptions, reality and moving forward

Low dose radiation has been widely accepted by the radiation protection community as presenting a very low risk to human health, if any. Over-conservatism in optimisation principles and regulations have resulted in a disproportionate fear of radiation amongst the general public and government authorities alike, overlooking the great benefits nuclear science and techniques have brought to society as a whole. As such, the World Nuclear Association advocates for a recontextualisation of the radiation hazards with regards to low dose radiation, and a greater awareness as to the absence of any discernible effects associated with it.

POS0091 OFF-TARGET PROFILING OF JANUS KINASE (JAK) INHIBITORS IN RHEUMATOID ARTHRITIS: A COMPUTER-BASED APPROACH FOR DRUG SAFETY STUDIES AND REPURPOSING

Background:

The JAK inhibitors (JAKi’s) tofacitinib and baricitinib are new alternatives for treating rheumatoid arthritis. Safety concerns associated with JAKi’s, such as the increased risk for thrombosis and viral infections, have emerged worldwide. The underlying explanatory mechanisms remain unknown, suggesting the elevated risk is likely due to underlying confounding or an off-target binding effect. Computational approaches can explore the potential for a small molecule drug to interact with previously unknown biological targets and identify potential safety-related concerns, and open doors for potential drug repurposing.

Objectives:

To identify and characterize the off-target binding effects of baricitinib and tofacitinib, with a focus on targets related to thrombosis and viral infection

Methods:

Potential targets of baricitinib and tofacitinib were predicted using two neural-network-based systems (TIGER[1] and SPiDER[2]). Targets were considered relevant if they had (1) a SPiDER confidence with p<0.05, or (2) a TIGER score >1. Selected targets related to the outcome of interest were experimentally evaluated at Eurofins Cerep (France-Celle L’Evescault, www.eurofins.com) if commercial available. Compounds were tested at (1) single concentration (30 µM) with technical replicates, using radioligand or enzymatic assays, or (2) multiple concentrations (30 µM highest concentration; dilution factor in a log-scale) with technical replicates, using calcium flux or inhibition of [cAMP] assays. Observed activity of ≥50% inhibition or stimulation on the target was considered active, between 25 to 50% inhibition (or a dissociation constant [Kd] from 1 to 10 µM) was considered as moderate activity, and lower than 25% was considered inactive. Dose-response curve were performed on active and moderate targets for IC50 / EC50 (half maximal inhibitory / effective concentration) determination.

Results:

TIGER and SPiDER suggested a total of 99 off-target binding effects (baricitinib n=41; tofacitinib n=58), of which 17 targets had potential impact on thrombosis or viral infection (baricitinib n=5 and 4, respectively; tofacitinib n=5 and 3, respectively). Commercial testing was available on 11 targets (Adenosine Receptor A2A [AA2AR], Epidermal growth factor receptor, induclible NOS, PI3 Kinase (p110b/p85a), Phosphodiesterase 10A2 [PDE10A2] and Protein Kinase N2 [PKN2] for baricitinib; and Adenosine receptor A3, 15-Lipoxygenase [15-LO], PKN2, Transient receptor potential cation channel [TRPM6] and AA2AR for tofacitinib). Of these, 5 targets showed active or moderately active binding activity (baricitinib n=2; tofacitinib n=3), and were tested for dose-response curves. Test results confirmed ligand-binding activity with IC50 on nanomolar (PKN2), and micromolar ranges (PDE10A2 and TRPM6).

Conclusion:

The results suggest both baricitinib and tofacitinib are promiscuous binders with effects on several families. Although it may lead to side effects, off-target binding also represents a potential opportunity for drug repurposing. Besides on-target effects, both drugs are under clinical investigation for the treatment of COVID-19 due to off-target interactions. The proposed pharmacological off-target effects of those with active binding include attenuation of pulmonary vascular remodeling, anti-fibrotic and anti-psychotic activities (PDE10A2), modulation of viral response (PKN2), and hypomagnesaemia (TRPM6), which is involved in cardiovascular diseases. This study supports tofacitinib and baricitinib as candidates for drug repurposing (e.g., in COVID-19, Hepatitis C virus, and pulmonary hypertension). We did not identify active off-target interactions linked to thrombosis to explain the elevated risk observed in clinical practice. Further research is required to elucidate the underlying patient-specific factors (confounders) that could explain this safety concern.

References:

[1]Schneider P et al. Angew Chem Int Ed 2017;56:11520–4.

[2]Reker D et al. PNAS 2014;111:4067–72.

Disclosure of Interests:

None declared

Deep Neural Networks Can Predict New-Onset Atrial Fibrillation From the 12-Lead ECG and Help Identify Those at Risk of Atrial Fibrillation-Related Stroke

Supplemental Digital Content is available in the text.

Atrial fibrillation (AF) is associated with substantial morbidity, especially when it goes undetected. If new-onset AF could be predicted, targeted screening could be used to find it early. We hypothesized that a deep neural network could predict new-onset AF from the resting 12-lead ECG and that this prediction may help identify those at risk of AF-related stroke.

The burden in chronic prurigo: patients with chronic prurigo suffer more than patients with chronic pruritus on non-lesional skin: A comparative, retrospective, explorative statistical analysis of 4,484 patients in a real-world cohort

BACKGROUND

Chronic prurigo (CPG) is known as a high burdensome disease characterized by severe pruritus and multiple pruriginous lesions. Interestingly, the disease-specific burden is not well established and there are no data which compare the impact of CPG with chronic pruritus (CP) on non-lesional skin (CP-NL).

OBJECTIVES

To address this issue, we analysed datasets from 4484 patients with either CPG or CP-NL.

METHODS

Demographic medical data and additional information collected by validated patient reported outcome tools were analysed. The visual analogue scale and numerical rating scale (NRS) were used for assessing the pruritus intensity, the ItchyQoL for patients' quality of life, the Hospital Anxiety and Depression Scale and the Patient Needs Questionnaire' as a part of Patient Benefit Index for Pruritus for measuring the importance of 27 patient needs in terms of treatment goals. The Neuroderm questionnaire was used to assess the history of pruritus characteristics and the impact on sleep.

RESULTS

Patients with CPG suffered longer and with a higher intensity from pruritus [NRS worst the last 24 h, CPG 6.0 (4.0;8.0) vs. CP-NL 3.0 (5.0;7.0), P < 0.001]. In them, pruritus occurred more often and the whole day and night which led to more loss in sleeping hours [CPG 3.0 h (2.0;4.0) vs. CP-NL 2.0 h (1.0;4.0), P < 0.001]. Patients with CPG showed higher scores for depression [HADS-D, CPG 6.0 (3.0;10.0) vs. CP-NL 5.0 (2.0;8.0), P < 0.001], more impaired quality of life [ItchyQol; CPG: 72.6 (61.6;83.6) vs. CP-NL 59.4 (48.4;70.4), P < 0.001] and higher weighted needs in the predefined treatment goals.

DISCUSSION

Not only the presence of severe pruritus and pruriginous lesions but also sleep disorders and other mental symptoms may contribute to a higher burden in patients with CPG when compared with patients with CP-NL.

Central hemodynamic effects in patients with chronic coronary syndrome after long-term ivabradine therapy

Objectives

We sought to assess central hemodynamic effects in 23 patients (18 male, 5 female) with a resting heart rate (HR) of ≥70 beats per minute (bpm) and chronic coronary syndrome after long-term ivabradine therapy (6 months) by cardiac magnetic resonance (CMR).

Methods and results

In a cross-over design, all patients were treated with ivabradine (Iva, 7.5 mg bid) and placebo for 6 months each. CMR was performed three times (at baseline, after 6 and 12 months) to determine left ventricular (LV) function parameters, including end-diastolic and end-systolic volumes (EDVi, ESVi), stroke volume (SVi) and ejection fraction (EF) as well as volume-time curve (VTC) parameters, including peak ejection rate (PER), peak ejection time (PET), peak filling rate (PFR), peak filling time from ES (PFT), peak ejection rate normalized to EDV (PER/EDV) and peak filling rate normalized to EDV (PFR/EDV) for global LV function (systolic and diastolic) assessment. Flow measurements of the ascending aorta were performed with phase-contrast velocity imaging.

Treatment with Iva led to a HR reduction of 11.4 bpm (Iva 58.8±8.2 bpm vs placebo 70.2±8.3 bpm, p&lt;0.0001).There was no difference in LVEF (%) (Iva 57.4±11.2 vs placebo 53.0±10.9, p=0.18), EDVi or ESVi. SVi (ml/m2) remained comparatively unchanged after long-term treatment with Iva (Iva 40.6±9.6 vs placebo 35.7±8.8, p=0.08). VTC parameters reflecting systolic LV function (PER, PET) were unaffected by Iva, while both PFR and PFR/EDV were significantly increased (PFR/EDV (s-1) Iva 2.4±0.4 vs placebo 2.1±0.4, p=0.03). There was a trend to longer PFT during treatment with Iva, though not reaching statistical significance. Medium and maximum aortic flow were not affected by treatment with Iva, while mean velocity (cm/s) was significantly reduced (Iva 6.7±2.7 vs placebo 9.0±3.4, p=0.01). Aortic flow parameters were correlated to aortic distensibility (AD), as surrogate parameter for arterial stiffness. AD was significantly correlated to both aortic flow and flow velocity, whereby mean velocity showed the strongest correlation to AD (r=0.74 [0.61 to 0.83], p&lt;0.0001).

Conclusion

Systolic LV function was unaffected by treatment with Iva, while the filling during diastole was significantly improved. While medium and maximum aortic flow were not affected by Iva, mean velocity was significantly reduced. Aortic distensibility as surrogate parameter for arterial stiffness was significantly correlated to aortic mean velocity. This study confirms the underlying physiological principle of the If-current inhibitor Ivabradine.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): This work was supported by the Deutsche Herzstiftung (German Heart Foundation) (F/14/11 to F.C.) and the Deutsche Forschungsgemeinschaft (DFG KFO 196 to U.L., S.H.S and M.B. and SFB TTR 219, S-01 to M.B.). The Saarland University Medical Center has received an unrestricted grant from Servier (France).

Scanning acoustic microscopy investigation of weld lines in injection-molded parts manufactured from industrial thermoplastic polymer

Scanning acoustic microscopy (SAM) is used to characterize welds in a thermoplastic polymer (ABS) manufactured by injection-molding, particularly at the locations of weld-lines known to form as unavoidable significant defects. Acoustic micrographs obtained at 420 MHz clearly resolve the weld lines with morphological deformations and microelastic heterogenity. This is also where terahertz (THz) measurements, carried out in support of the SAM study, reveal enhanced birefringence corresponding to the location of these lines enabling verification of the SAM results. Rayleigh surface acoustic waves (RSAW), quantified by V(z) curves (with defocusing distance of 85 μm), are found to propagate slower in regions close to the weld lines than in regions distant from these lines. The discrepancy of about 100 m/s in the velocity of RSAW indicates a large variation in the micro-elastic properties between areas close to and distant from the weld lines. The spatial variations in velocity (V_R) of RSAWs indicate anisotropic propagation of the differently polarized ultrasonic waves.

A Machine Learning Approach to Management of Heart Failure Populations

BACKGROUND

Heart failure is a prevalent, costly disease for which new value-based payment models demand optimized population management strategies.

OBJECTIVES

This study sought to generate a strategy for managing populations of patients with heart failure by leveraging large clinical datasets and machine learning.

METHODS

Geisinger electronic health record data were used to train machine learning models to predict 1-year all-cause mortality in 26,971 patients with heart failure who underwent 276,819 clinical episodes. There were 26 clinical variables (demographics, laboratory test results, medications), 90 diagnostic codes, 41 electrocardiogram measurements and patterns, 44 echocardiographic measurements, and 8 evidence-based "care gaps": flu vaccine, blood pressure of <130/80 mm Hg, A_1c of <8%, cardiac resynchronization therapy, and active medications (active angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker/angiotensin receptor-neprilysin inhibitor, aldosterone receptor antagonist, hydralazine, and evidence-based beta-blocker) were collected. Care gaps represented actionable variables for which associations with all-cause mortality were modeled from retrospective data and then used to predict the benefit of prospective interventions in 13,238 currently living patients.

RESULTS

Machine learning models achieved areas under the receiver-operating characteristic curve (AUCs) of 0.74 to 0.77 in a split-by-year training/test scheme, with the nonlinear XGBoost model (AUC: 0.77) outperforming linear logistic regression (AUC: 0.74). Out of 13,238 currently living patients, 2,844 were predicted to die within a year, and closing all care gaps was predicted to save 231 of these lives. Prioritizing patients for intervention by using the predicted reduction in 1-year mortality risk outperformed all other priority rankings (e.g., random selection or Seattle Heart Failure risk score).

CONCLUSIONS

Machine learning can be used to priority-rank patients most likely to benefit from interventions to optimize evidence-based therapies. This approach may prove useful for optimizing heart failure population health management teams within value-based payment models.

Introducing the CSP Analyzer: A novel Machine Learning-based application for automated analysis of two-dimensional NMR spectra in NMR fragment-based screening

NMR-based screening, especially fragment-based drug discovery is a valuable approach in early-stage drug discovery. Monitoring fragment-binding in protein-detected 2D NMR experiments requires analysis of hundreds of spectra to detect chemical shift perturbations (CSPs) in the presence of ligands screened. Computational tools are available that simplify the tracking of CSPs in 2D NMR spectra. However, to the best of our knowledge, an efficient automated tool for the assessment and binning of multiple spectra for ligand binding has not yet been described. We present a novel and fast approach for analysis of multiple 2D HSQC spectra based on machine-learning-driven statistical discrimination. The CSP Analyzer features a C# frontend interfaced to a Python ML classifier. The software allows rapid evaluation of 2D screening data from large number of spectra, reducing user-introduced bias in the evaluation. The CSP Analyzer software package is available on GitHub https://github.com/rubbs14/CSP-Analyzer/releases/tag/v1.0 under the GPL license 3.0 and is free to use for academic and commercial uses.

[Is the discipline associated with self-confidence in handling rational antibiotic prescription? : Results from the MR2 study in German hospitals]

BACKGROUND

Besides public awareness and specialist knowledge and training of physicians, their self-confidence plays a key role for clinical decision-making in the respective area.

OBJECTIVE

This exploratory study investigated the influence of the discipline on differences in self-confidence in dealing with antibiotics and in the self-rated knowledge.

METHODS

In 2015 the multi-institutional reconnaissance of practice with multiresistant bacteria (MR2) questionnaire containing items on antibiotic prescription and multiresistant pathogens was sent out to 1061 physicians working in departments for internal medicine, general surgery, gynecology and obstetrics and urology. In 2017 a similar MR2 survey was sent to 1268 specialist and assistant physicians in anesthesiology in Germany. Besides demographic data 4 items on self-confidence in the use of antibiotic treatment and 11 items concerning self-rated knowledge about rational antibiotic therapy and multiresistant pathogens were included in the present analysis. Logistic regression analysis, the χ²-test and the Kruskal-Wallis test were used for statistical analysis of the influence of the discipline on these items.

RESULTS

The response rates were 43% (456 out of 1061) from the non-anesthetists and 56% (705 out of 1268) from the anesthetists. Of the non-anesthetists 44% and 57% of the anesthetists had had no advanced training on antibiotic stewardship during the year before the study. In the overall analysis anesthetists (mean±SD: 2.53±0.54) were significantly less self-confident about antibiotics than colleagues from other departments (internal medicine: 3.10±0.50, general surgery: 2.97±0.44, gynecology and obstetrics: 3.12±0.42 and urology: 3.15±0.44) in the unadjusted (all p<0.001) and adjusted comparison. The analysis of self-rated knowledge about rational antibiotic prescription showed similar results. Senior consultant status and advanced training in infectiology were significantly associated with self-confidence and self-rated knowledge about antibiotics.

CONCLUSION

Anesthetists showed significantly less self-confidence in dealing with antibiotics than colleagues from other disciplines. Advanced training on a rational prescription of antibiotics was associated with a greater self-confidence, so that the implementation of compulsory courses on rational antibiotic stewardship in the respective residency curriculum needs to be considered.

Risk detection in patients with obstructive sleep apnea syndrome based on cardiovascular time series analysis

Obstructive sleep apnea represents the most common form of sleep-disordered breathing and has a high prevalence in patients with cardiovascular disease. Disturbed sleep is a potential risk factor for cardiovascular disorders such as arterial hypertension, cardiac ischemia, sudden cardiac death, and stroke. In this study we investigated polysomnographic records and analyzed the ECG, plethysmogram, respiration and SpO2 time series during wakefulness (WK), NREM, and REM sleep stages applying variability and coupling analyses methods. We enrolled 55 patients with obstructive sleep apnea syndrome (OSAS) and 29 healthy control subjects (CON: 45.9±14.9 years, 21 male) in this study. OSAS patients were subdivided into a low- and high-risk group (LR: 50.8±14.1 years, n=29, 21 male; HR: 57.2±13.4 years, n=26, 19 male) based on the Apnea-Hypopnea Index (AHI) (CON: 0-5 AHI, LR: 5-15 AHI, HR: >15 AHI). We could demonstrate the presence of an altered autonomic function in OSAS patients, differing from healthy controls. This altered autonomic function was mainly based on heart rate-, respiratory-, SpO2- and plethysmogram variability and their couplings. The discriminant analysis showed that the optimal set consisting of two autonomic indices revealed a high classification power (ACC=86.7%, AUC=90.3%, SENS=89.5% and SPEC=84.6%) when comparing low-risk and high-risk OSAS patients during WK. These results were slightly improved when analyzing REM sleep stages. Based on these results it seems to be possible to perform optimal risk stratification for OSAS patients based on autonomic indices. Based on our findings it is possible to differentiate between high-risk OSAS patient and low-risk OSAS patient at an early stage and in a promising manner allowing to set up therapy strategies for those patients in an early stage.

The German version of the Critical-Care Pain Observation Tool for critically ill adults : A prospective validation study

BACKGROUND

The implementation of the Critical-Care Pain Observation tool (CPOT) in intensive care units (ICU) has been associated with more frequent pain assessments, a reduced number of complications, and improved administration of analgesics and sedatives. So far no German translation exists. Translating this tool into foreign languages requires further validation testing.

OBJECTIVE

The aim of this prospective observational validation study was to translate the original version of the CPOT according to scientific principles for translation and to establish the validity and reliability of the German translation of CPOT for critically ill adult patients.

MATERIAL AND METHODS

A total of 292 cardiac surgery patients from 2 ICUs of 2 German university teaching hospitals were included (114 patients at center 1 and 178 patients at center 2). Of the included patients 22.6% were female and 76.4% were male with a mean age of 68.5 years ±9.3 SD. Pain was evaluated with the CPOT, the Bhavioral Pain Scale (BPS) and with the Numeric Rating scale (NRS) at three time points (1. intubated + sedated, 2. intubated + awake, 3. extubated + awake) at rest and during nociceptive stimulus (positioning). Assessments were made separately by trained physicians and nursing staff.

RESULTS

Good results for interrater reliability and internal consistency could be demonstrated (weighted Cohen's kappa of 0.73, Cronbach's coefficient alpha of 0.8). Spearman correlation between CPOT and NRS was moderate but significant. The receiver operating characteristic (ROC) analysis to obtain optimal thresholds of CPOT to detect pain revealed different results during rest and stimulus and in intubated and extubated patients.

CONCLUSION

The validated German CPOT translation is a reliable tool for pain assessment in cardiac ICU patients in the absence of patients' ability for self-reporting. The use of this German version of CPOT now allows a better international comparability of corresponding data in future studies.

Position Statement: Linear prurigo is a subtype of chronic prurigo

BACKGROUND

Chronic prurigo (CPG) is a distinct disease characterized by chronic pruritus, history and/or signs of prolonged scratching and multiple pruriginous lesions. It may present with various clinical manifestations, including papules, nodules, plaques or umbilicated lesions. Some patients with chronic pruritus show pruriginous linear and scaring scratch lesions (LSSL) and it is unclear whether these lesions belong to the spectrum of CPG.

OBJECTIVE

To achieve a consensus on the classification of pruriginous LSSL and establish criteria to differentiate them from similar appearing conditions of different nature.

METHODS

Members of the Task Force Pruritus (TFP) of the European Academy of Dermatology and Venereology participated in the consensus conference, discussing representative clinical cases. Using the Delphi method, consensus was reached when ≥75% of members agreed on a statement.

RESULTS

Twenty-one members of the TFP with voting rights participated in the meeting. It was consented that LSSL occurs due to chronic pruritus and prolonged scratching, and share common pathophysiological mechanisms with CPG. LSSL were thus considered as belonging to the spectrum of CPG and the term 'linear prurigo' was chosen to describe this manifestation.

CONCLUSION

Considering linear prurigo as belonging to the spectrum of CPG has important clinical implications, since both the diagnostic and therapeutic approach of these patients should be performed as recommended for CPG. Importantly, linear prurigo should be differentiated from self-inflicted skin lesions as factitious disorders or skin picking syndromes. In the latter, artificial manipulation rather than pruritus itself leads to the development of cutaneous lesions, which can show clinical similarities to linear prurigo.

Relations between a standardized experimental stressor and cutaneous sensory function in patients with chronic pruritus and healthy controls: an experimental case-control study

Background

While chronic pruritus (CP) is a frequent symptom, many aspects of its underlying pathophysiological mechanisms still need elucidation. Research on sensory cutaneous function and on the influence of stress has been conducted mainly in patients with atopic dermatitis but is lacking for patients with CP.

Objective

To assess whether a standardized social stressor influences cutaneous sensory function in patients with CP in comparison with healthy controls (HC).

Methods

Case–control study; 33 CP and 30 HC were submitted to the standardized quantitative sensory testing protocol before and after the Trier Social Stress Test and 1 h later. Intraepidermal nerve fibre density (IENFD) was determined.

Results

Mechanical pain sensitivity and mechanical detection thresholds were significantly higher in CP than in HC, and mechanical detection thresholds increased more in CP than in HC over the three measurements. In both groups, cold pain threshold increased and heat pain threshold decreased from before to after the stress test and remained constant 1 h later. Only in CP, almost all QST tests induced at least a small amount of pruritus, which was not significantly altered by the stress test. IENFD in pruritic skin was significantly reduced in CP when compared to healthy controls.

Conclusion

Peripheral thermal sensory function was not altered in CP despite reduced IENFD in lesional skin, but we could demonstrate central sensitization processes specifically in CP and influences of an acute stressor inducing more sensitivity to thermal pain in both groups.

Identifying Asthma Exacerbation-Related Emergency Department Visit Using Electronic Medical Record and Claims Data

Background  Asthma exacerbation leading to emergency department (ED) visit is prevalent, an indicator of poor control of asthma, and is a potentially preventable clinical outcome.

Objective  We propose to utilize multiple data elements available in electronic medical records (EMRs) and claims database to create separate algorithms with high validity for clinical and research purposes to identify asthma exacerbation-related ED visit among the general population.

Methods  We performed a retrospective study with inclusion criteria of patients aged 4 to 40 years, a visit to Geisinger ED from January 1, 2006, to October 28, 2013, with asthma on their problem list. Different electronic data elements including chief complaints, vitals, season, smoking, medication use, and discharge diagnoses were obtained to create the algorithm. A stratified random sample was generated to select the charts for review. Chart review was performed to classify patients with asthma-related ED visit, that is, the gold standard. Two reviewers performed the chart review and validation was done on a small subset.

Results  There were 966 eligible ED visits in the EMR sample and 731 in the claims sample. Agreement between reviewers was 95.45% and kappa statistic was 0.91. Mean age of the EMR sample was 22 years, and mostly white (93%). Multiple models conventionally used in studies were evaluated and the final model chosen included principal diagnosis, bronchodilator, and steroid use for both algorithms, chief complaints for EMR, and secondary diagnosis for claims. Area under the curve was 0.93 (95% confidence interval: 0.91–0.94) and 0.94 (0.93–0.96), respectively, for EMR and claims data, with positive predictive value of > 94%. The algorithms are visually presented using nomograms.

Conclusion  We were able to develop two separate algorithms for EMR and claims to identify asthma exacerbation-related ED visit with excellent diagnostic ability and varying discrimination threshold for clinical and research purposes.

Characterization of degeneration phenomena in lithium-ion batteries by combined microscopic techniques

The application of detector strategies in scanning electron microscopy (SEM) correlated with computer tomography (CT) and light microscopy (LM) delivered unique new insights in degeneration effects of lithium-ion batteries. There we exemplary studied reference, cycled and storage cells. High-resolution SEM permit to visualize a coating on top of the cathode material of the treated cells for the first time, which also connects the conductive additives and battery active material. This confirms the assumption of a solid permeable interface on top of the cathode. The detection of low-loss reflected backscattered electrons for energies beyond 3 keV increases the available spatial resolution for material contrast. This offered the opportunity to address the atomic number of precipitates in the nm range inside the coating to be above carbon and below Li_1-x(Ni_1/3Mn_1/3Co_1/3)O₂ (NMC). Applying voltage contrast enables to show the difference in electronic conductivity of plate-like features on top of the cycled cell anode, most likely lithium plating. Cross sectional images of the anode delivered a significant change of the surficial-area morphology for the treated cells with increasing porosity. Precipitates were detected on top of the separator foil. An increment in thickness of the entire treated cells by computer tomography was found, which can be explained by the alteration of the anode, separator and cathode.

[Imaging and biopsy of soft tissue tumors]

Soft tissue tumors represent a special challenge in interdisciplinary cooperation. Malignant tumors require a multimodal therapy concept so that patient treatment in a specialized tumor center is recommended. The task of the surgeon in close cooperation with the radiologist is the resection of the tumor in sano with the required safety margin. The aim of diagnostic imaging is to describe the primary expansion of the tumor size and a possible tumor infiltration of adjacent compartments. The most important diagnostic imaging for this purpose is magnetic resonance imaging (MRI), especially T1-weighted fat-suppressed gadolinium-enhanced sequences. Together with T2-weighted sequences a reliable differentiation between necrosis and vital tumor tissue is possible, which enables a targeted biopsy of vital tumor tissue. For the differentiation between benign and malignant soft tissue tumors and for determination of histological differentation a core needle biopsy, either computer tomography-guided or under sonographic control and increasingly more by MRI guidance, is currently the gold standard in most tumor centers. A representative biopsy from vital tumor tissue leads to the diagnosis with a very high degree of certainty.

Characterisation of anticancer peptides at the single-cell level

The development of efficacious anticancer therapeutics is difficult due to the heterogeneity of the cellular response to chemotherapy. Anticancer peptides (ACPs) are promising drug candidates that have been shown to be active against a range of cancer cells. However, few ACP studies focus on tumour single-cell heterogeneities. In order to address this need, we developed a microfluidic device and an imaging procedure that enable the capture, monitoring, and analysis of several hundred single cells for the study of drug response. MCF-7 human breast adenocarcinoma cells were captured in hydrodynamic traps and isolated in individual microchambers of less than 100 pL volume. With pneumatic valves, different sets of microchambers were actuated to expose the cells to various drugs. Here, the effect of three membranolytic ACPs - melittin, aurein 1.2 and aurein 2.2 - was investigated by monitoring the efflux of calcein from single MCF-7 cells. The loss of membrane integrity was observed with two different strategies that allow either focusing on one cell for mechanistic studies or parallel analysis of hundreds of individual cells. In general, the device is applicable to the analysis of the effect of various drugs on a large number of different cell types. The platform will enable us in the future to determine the origin of heterogeneous responses on pharmacological substances like ACPs within cell populations by combining it with other on-chip analytical methods.

[Conventional radiological diagnosis of benign none neoplasms]

BACKGROUND

Benign bone tumors are of special clinical importance because they might be confused with malignant bone tumors.

OBJECTIVES

The aim of this article it to present the characteristics of benign bone tumors. The focus is orientated towards conventional x‑ray as the essential pillar for primary diagnosis. Consequently, the description of signal intensities of benign bone tumors in magnetic resonance images or less helpful clues like male-female ratios are deliberately omitted.

RESULTS

The classification of bone tumors introduced by Lodwick allows the identification of benign growth patterns. Growth patterns will not help, for example, in case of dedifferentiation of benign chondroid tumors towards chondrosarcomas. Therefore, each diagnosis has to incorporate the patient's clinical scenario. Furthermore, benign bone tumors might also cause aggressive growth patterns. Tumors classified as Lodwick Ic or higher should not be automatically regarded as malignant. Naturally, further clarification is mandatory for these tumors.

CONCLUSIONS

Differentiation between definitely benign bone tumors and those which need further work up is a critical diagnostic step. In the majority of cases, this is possible based on the appearance in conventional x‑ray images. In case of possibly malignant lesions, both the patient's symptoms and the x‑ray morphology have to be considered by orthopedic surgeons, pathologists, and radiologists to determine the optimal diagnostic strategy.

[Update in neuroanesthesiology - key publications]

One of the aims of the Scientific Working Group Neuroanesthesia (WAKNA) of the German Society of Anesthesiology and Intensive Care Medicine is to disseminate new findings in the field of neuroscience and neuroanesthesia and to propagate novel therapeutic and diagnostic options into clinical practice. Once a year, the WAKNA displays and discusses recent noteworthy publications from the past 12 months at the German Anesthesia Meeting. In 2016, a new pharmacologic strategy with dexmedetomidine to prevent postoperative pain after craniotomy, the impact of the widely used anesthetic drug propofol on GABA receptor surface expression, a study highlighting the ultrasound-guided detection of increased intracranial pressure, and an article showing the interactions of neuromuscular blocking drugs on the BIS neuromonitoring were presented.

Sixfold improved single particle measurement of the magnetic moment of the antiproton

Our current understanding of the Universe comes, among others, from particle physics and cosmology. In particle physics an almost perfect symmetry between matter and antimatter exists. On cosmological scales, however, a striking matter/antimatter imbalance is observed. This contradiction inspires comparisons of the fundamental properties of particles and antiparticles with high precision. Here we report on a measurement of the g-factor of the antiproton with a fractional precision of 0.8 parts per million at 95% confidence level. Our value /2=2.7928465(23) outperforms the previous best measurement by a factor of 6. The result is consistent with our proton g-factor measurement gp/2=2.792847350(9), and therefore agrees with the fundamental charge, parity, time (CPT) invariance of the Standard Model of particle physics. Additionally, our result improves coefficients of the standard model extension which discusses the sensitivity of experiments with respect to CPT violation by up to a factor of 20.

De-orphaning the marine natural product (±)-marinopyrrole A by computational target prediction and biochemical validation

A machine-learning method led to the discovery of the macromolecular targets of the natural anticancer compound marinopyrrol A.

Highly sensitive superconducting circuits at ∼700 kHz with tunable quality factors for image-current detection of single trapped antiprotons

We developed highly sensitive image-current detection systems based on superconducting toroidal coils and ultra-low noise amplifiers for non-destructive measurements of the axial frequencies (550-800 kHz) of single antiprotons stored in a cryogenic multi-Penning-trap system. The unloaded superconducting tuned circuits show quality factors of up to 500 000, which corresponds to a factor of 10 improvement compared to our previously used solenoidal designs. Connected to ultra-low noise amplifiers and the trap system, signal-to-noise-ratios of 30 dB at quality factors of >20 000 are achieved. In addition, we have developed a superconducting switch which allows continuous tuning of the detector's quality factor and to sensitively tune the particle-detector interaction. This allowed us to improve frequency resolution at constant averaging time, which is crucial for single antiproton spin-transition spectroscopy experiments, as well as improved measurements of the proton-to-antiproton charge-to-mass ratio.

Spotting and designing promiscuous ligands for drug discovery

The promiscuous binding behavior of bioactive compounds forms a mechanistic basis for understanding polypharmacological drug action. We present the development and prospective application of a computational tool for identifying potential promiscuous drug-like ligands. In combination with computational target prediction methods, the approach provides a working concept for rationally designing such molecular structures. We could confirm the multi-target binding of a de novo generated compound in a proof-of-concept study relying on the new method.

[Undesired awareness phenomena during general anesthesia: Evidence-based state of knowledge, current discussions and strategies for prevention and management]

Patient awareness during general anesthesia and the later recall of what happened during surgery can be experienced by patients as horrifying events that leave lasting mental trauma in the form of posttraumatic stress syndrome (PTSS). Awareness is related to a temporary insufficient depth of anesthesia. This phenomenon has been discussed for more than 20 years. According to randomized controlled studies, in the absence of risk factors awareness phenomena occur in 1-2 per 1000 operations involving general anesthesia (0.1-0.2%) and are classified as occasionally occurring critical events. An astonishing twist occurred elicited by the recent data from the 5th National Audit Project from Great Britain (NAP5) published in the British Journal of Anaesthesia and in Anaesthesia. The NAP5 evaluated patient reports of accidental awareness during general anesthesia (AAGA) in a multicenter manner in more than 2.7 million cases and indicated incidences of awareness of only 1:19,600, a frequency 20 times less than previously reported. These results gave rise to some controversy. It seems likely that, due to the absence of structured interviews, the NAP5 data only demonstrated the tip of the iceberg and may have vastly underestimated the real incidence of intraoperative awareness. The present overview summarizes the current knowledge about awareness. Furthermore, it addresses the question whether the awareness problem has been overestimated by evidence-based criteria or underestimated by the results of the NAP5. The responsibility for sufficient anesthesia in the clinical routine requires knowledge of awareness risks and potential sequelae. A formal recommendation from the German Society of Anesthesia and Intensive Care Medicine (DGAI) concerning awareness is not yet available; however, the recognition of evidence-based strategies in the management of anesthesia may minimize the occurrence of awareness and its sequelae.

Multi-objective active machine learning rapidly improves structure-activity models and reveals new protein-protein interaction inhibitors

Active machine learning puts artificial intelligence in charge of a sequential, feedback-driven discovery process. We present the application of a multi-objective active learning scheme for identifying small molecules that inhibit the protein-protein interaction between the anti-cancer target CXC chemokine receptor 4 (CXCR4) and its endogenous ligand CXCL-12 (SDF-1). Experimental design by active learning was used to retrieve informative active compounds that continuously improved the adaptive structure-activity model. The balanced character of the compound selection function rapidly delivered new molecular structures with the desired inhibitory activity and at the same time allowed us to focus on informative compounds for model adjustment. The results of our study validate active learning for prospective ligand finding by adaptive, focused screening of large compound repositories and virtual compound libraries.