Alterations in multi-layer strain in AL amyloidosis

BACKGROUND

Cardiac involvement in AL amyloidosis portends a poor prognosis. 2D-speckle tracking echocardiography (2D-STE) strain can identify subclinical cardiac involvement. This study performed multilayer and multiplanar 2D-STE myocardial strain analysis.

METHODS

We compared 75 AL amyloidosis patients to 49 hypertensive patients and 49 healthy controls. Longitudinal strain was obtained from epicardial, mid-myocardial and endocardial layers; segmental strain was measured from mid-myocardial basal, mid and apical segments.

RESULTS

Global longitudinal strain was reduced in epicardial (-14.3 ± -4.0% vs. -17.4 ± 2.2% vs. -17.5 ± -2.0%, p < .001), mid-myocardial (-16.3 ± -4.5% vs. -19.7 ± 2.5% vs. -19.7 ± -2.2%, p < .001) and endocardial layers (-18.7 ± -4.9% vs. -22.2 ± 3.0% vs. -22.3 ± -2.6%, p < .001) in amyloid patients compared to hypertensive and healthy controls. Segmental strain confirmed significant reduction in basal (-11.2 ± -3.9% vs. -17.6 ± 2.7% vs. -20.9 ± -3.4%, p < .001) and mid (-14.8 ± -4.3% vs. -19.2 ± 2.5% vs. -19.6 ± -2.2%, p < .001) LV segments in the AL amyloid group. Receiver operating curve analysis demonstrated that an optimal cut-off of -16% for basal segmental strain better differentiated AL amyloid from hypertensive group (sensitivity 96%, specificity 70%, AUC 0.93), compared to relative apical sparing (AUC of 0.85).

CONCLUSION

Strain demonstrated myocardial involvement in all layers in AL amyloidosis, with reduced basal segmental longitudinal strain a likely marker of early disease.

Correlation Between Quantitative Uptake of 99mTC-DPD and Echocardiographic Parameters in Cardiac ATTR: A Novel Follow-Up Strategy

Aims: There has been a paradigm shift in diagnosis of cardiac transthyretin amyloidosis (ATTR) with non-invasive techniques including technetium-99m 3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) bone scintigraphy. We evaluated structural and functional biventricular alterations by transthoracic echocardiography (TTE) and determined the correlation with 99mTc-DPD tracer uptake in ATTR. Materials and Methods: ATTR patients (wild-type, hereditary or asymptomatic transthyretin [TTR] variant carriers) with 99mTc-DPD and TTE were selected; 99mTc-DPD uptake was analyzed quantitatively. TTE assessment of left ventricle (LV) and right ventricle (RV) parameters was performed. Results: Forty ATTR patients (wild-type n = 17; hereditary ATTR and TTR variant carriers n = 23; median age 68.8 ± 22 years) were included. TTE parameters displaying good correlation with 99mTc-DPD tracer uptake included LV average wall thickness (r = 0.837), LV indexed mass (LVMI; r = 0.802), RV wall thickness (r = 0.610), average e' (r = -0.830), E/e' ratio (r = 0.786), LV global longitudinal strain (GLS; r = 0.714) and RV GLS (r = 0.632; p < 0.001 for all). Hereditary ATTR and TTR variant carriers without cardiac tracer uptake had normal echocardiographic parameters. Receiver operating characteristic curves demonstrated strong diagnostic accuracies for structural (LV wall thickness, LVMI and RV wall thickness; area under the curve (AUC) of 0.96 for all) and functional (LV and RV GLS; AUC of 0.86 and 0.88, respectively) parameters. Conclusion: Good correlations between TTE biventricular structural and functional parameters were demonstrated with quantitative 99mTc-DPD uptake. Echocardiography may potentially assume a significant role in longitudinal follow-up for monitoring disease progression and for evaluating treatment response.

New developments in cost modeling for the LHC computing

The increase in the scale of LHC computing during Run 3 and Run 4 (HL-LHC) will certainly require radical changes to the computing models and the data processing of the LHC experiments. The working group established by WLCG and the HEP Software Foundation to investigate all aspects of the cost of computing and how to optimise them has continued producing results and improving our understanding of this process. In particular, experiments have developed more sophisticated ways to calculate their resource needs, we have a much more detailed process to calculate infrastructure costs. This includes studies on the impact of HPC and GPU based resources on meeting the computing demands. We have also developed and perfected tools to quantitatively study the performance of experiments workloads and we are actively collaborating with other activities related to data access, benchmarking and technology cost evolution. In this contribution we expose our recent developments and results and outline the directions of future work.

P309 The use of echocardiographic parameters to predict clinical outcomes in AL-amyloidosis cardiomyopathy

Background

AL-amyloidosis has a rapid clinical progression, with cardiac involvement associated with a particularly poor prognosis. Cardiac amyloidosis is diagnosed by either invasive biopsy or conventional echocardiographic parameters such as increased wall thickness, in the absence of other causes. More recently, novel parameters including 2D longitudinal strain have demonstrated diagnostic utility in a range of infiltrative cardiomyopathies including cardiac amyloidosis.

Aim/Method: We sought to evaluate traditional and novel echocardiographic parameters in their ability to predict adverse outcomes in a cohort of AL-amyloid patients. 80 patients who had transthoracic echocardiograms at a single centre were included. Comprehensive echocardiographic assessment was performed, including left ventricular ejection fraction (LVEF), LV Global Longitudinal Strain (GLS), LV mass (indexed to BSA). The primary endpoint was a composite of of major adverse cardiac events (MACE) and all-cause mortality, that was assessed by interrogation of the medical records on a specified censor date.

Results

At a mean follow-up (time from echo to censor date) of 5.4 ± 2.6years, 38/80 (47.5%) of patients experienced the primary endpoint of MACE or death, of which 25/80 (31%) were deaths. LVEF (59 ± 5.6%vs56 ± 6.4%, p = 0.04), GLS (17.4 ± 3.9%vs14.8 ± 4.9%, p = 0.01) basal longitudinal strain (12.3 ± 3.2%vs9.6 ± 3.9%, p = 0.002), indexed LV mass (107 ± 36g/m2vs130 ± 34g/m2, p = 0.06) and E/E’ (13.7 ± 4.9vs20.6 ± 9.6, p &lt; 0.001) were all significantly different between patients who experienced the primary endpoint and those that didn’t. The strongest predictors of outcome were E/E’ (AUC 0.74), LV mass (AUC 0.73) and the ratio GLS:LV mass (AUC 0.73). An E/E’ of 15 had a sensitivity of 71% and specificity of 69%, while an indexed LV mass of 108 had a sensitivity and specificity of 74% and 67% respectively. GLS to LV mass as a cutoff of 0.16 had a sensitivity and specificity of 70% and 69% respectively.

Conclusion

In a cohort of 80 patients with AL-amyloid cardiomyopathy, almost half (47.5%) reached the primary composite endpoint. Diastolic dysfunction as expressed as E/E’, and LV mass were the most powerful predictors of outcome, while global longitudinal strain and LV basal strain were also reduced, and showed superiority over LV ejection fraction in predicting prognosis.

P1543 The assessment of regional myocardial strain in classifying amyloid cardiomyopathy

Background

An infiltrative cardiomyopathy is a common manifestation of AL-amyloidosis, with cardiac involvement associated with a poor prognosis. Wild-type transthyretin amyloidosis (wt-TTR), is a distinct clinical entity occurring predominantly in men &gt; 65 yrs, that has gained interest recently due to novel treatment options. Regional strain analysis has been shown to discriminate both forms of cardiac amyloidosis from other causes of concentric left ventricular hypertrophy, with a characteristic pattern of ‘apical sparing’. Due to the significant difference in both the course of the disease and treatment options between groups, a non-invasive echocardiographic method of determining subtype would be valuable.

Aim/Method: We sought to compare traditional and novel echocardiographic parameters in a cohort of AL ( n = 80) and wild type (wt-TTR) amyloid ( n = 32) patients. All amyloid patients underwent comprehensive transthoracic echocardiography, including both conventional parameters and LV longitudinal strain. Further novel parameters were computed including the ratio of global longitudinal strain (GLS) to LV ejection fraction (LVEF), as well as GLS to indexed LV mass.

Results

wt-TTR patients had significantly greater LV mass (176 ± 59g/m2vs118 ± 37g/m2, p &lt; 0.001), and worse diastolic dysfunction as expressed as E/E’ (21.5 ± 11vs17 ± 8, p = 0.04). LVEF was significantly lower in wt-TTR patients however remained in the normal range in both groups (53 ± 6%vs57 ± 6%, p = 0.001), whilst GLS was significantly reduced compared to AL-amyloid patients (11.5 ± 3.4%vs16.2 ± 4.6%, p &lt; 0.001). LVEF:GLS was significantly higher in wt-TTR patients (4.93 ± 1.4vs3.87 ± 1.3, p = 0.001) reflecting a more profound reduction in strain with a relatively preserved ejection fraction. Similarly, the ratio of GLS to LV mass was significantly lower in wt-TTR amyloidosis (0.078 ± 0.05vs0.155 ± 0.07, p &lt; 0.001), reflecting a more significant reduction in strain for a given wall thickness in wt-TTR patients. GLS:LV mass was the strongest discriminator between subtypes (AUC 0.82), with a cutoff of 0.09 giving a sensitivity and specificity of 71% and 80% respectively, for detecting wt-TTR.

Conclusion

In this cohort, patients with wt-TTR had significantly greater increase in LV wall thickness and diastolic dysfunction, which may in part reflect their increased age (77vs62). However, GLS was also significantly reduced compared to AL-amyloid, even when accounting for LV ejection fraction and LV mass, suggesting these composite parameters may have value in determining the subtype of cardiac amyloidosis.

Late referral of cancer patients with malnutrition to dietitians: a prospective study of clinical practice

PURPOSE

Malnutrition (MN) in cancer is common but underdiagnosed. Dietitian referrals may not occur until MN is established. We investigated cancer patient characteristics (demographics, nutritional status, and nutrition barriers) on referral to oncology dietitians. We also examined referral practices and prevalence of missed referral opportunities.

METHODS

This was a naturalistic multi-site study of clinical practice. Data from consecutive referrals were collected in inpatient and outpatient settings. Demographics, nutritional status (weight, body mass index (BMI), weight loss in the preceding 3-6 months, oral intake, nutrition barriers), referral reasons, and use of screening were recorded. Missed opportunities for earlier referral were also noted.

RESULTS

Two hundred patients were included (60% male, 51% inpatients). Half had gastrointestinal and hepatobiliary cancers. The majority were on antitumor treatment. Two-thirds had lost ≥ 5% body weight. Forty percent were overweight or obese. Seventy percent had ≥ 2 nutritional barriers. Most common nutrition barriers were anorexia, nausea, and early satiety. Greater weight loss and lower food intake were associated with ≥ 2 barriers. Weight loss was the most common referral reason. Screening was used in 35%. Referrals should have occurred sooner in nearly half (45%, n = 89).

CONCLUSIONS

Cancer patients were referred late to a dietitian, with multiple nutritional barriers. Most referrals were for established weight loss (WL). WL may be masked by pre-existing obesity. Almost half had missed earlier referral opportunities; screening was infrequent. Over one-quarter should have been re-referred sooner. There is a clear need for clinician education. Future research should investigate the optimal timing of dietitian referral and the best nutrition screening tools for use in cancer.

System Performance and Cost Modelling in LHC computing

The increase in the scale of LHC computing expected for Run 3 and even more so for Run 4 (HL-LHC) over the next ten years will certainly require radical changes to the computing models and the data processing of the LHC experiments. Translating the requirements of the physics programmes into computing resource needs is a complicated process and subject to significant uncertainties. For this reason, WLCG has established a working group to develop methodologies and tools intended tocharacterise the LHC workloads, better understand their interaction with the computing infrastructure, calculate their cost in terms of resources and expenditure and assist experiments, sites and the WLCG project in the evaluation of their future choices. This working group started in November 2017 and has about 30 active participants representing experiments and sites. In this contribution we expose the activities, the results achieved and the future directions.

Low-Frequency and Rare-Coding Variation Contributes to Multiple Sclerosis Risk

Multiple sclerosis is a complex neurological disease, with ∼20% of risk heritability attributable to common genetic variants, including >230 identified by genome-wide association studies. Multiple strands of evidence suggest that much of the remaining heritability is also due to additive effects of common variants rather than epistasis between these variants or mutations exclusive to individual families. Here, we show in 68,379 cases and controls that up to 5% of this heritability is explained by low-frequency variation in gene coding sequence. We identify four novel genes driving MS risk independently of common-variant signals, highlighting key pathogenic roles for regulatory T cell homeostasis and regulation, IFNγ biology, and NFκB signaling. As low-frequency variants do not show substantial linkage disequilibrium with other variants, and as coding variants are more interpretable and experimentally tractable than non-coding variation, our discoveries constitute a rich resource for dissecting the pathobiology of MS.

Secukinumab for treatment of psoriasis: does secukinumab precipitate or promote the presentation of cutaneous T-cell lymphoma?

Secukinumab is an interleukin (IL)-17 monoclonal antibody inhibiting T-helper (Th)1-mediated immune response. It has proven high efficacy for moderate to severe psoriasis but data on its long-term toxicities are limited. We describe two patients who received secukinumab for clinically presumed psoriasis, but were subsequently diagnosed with mycosis fungoides (MF) following skin biopsies triggered by skin deterioration while on secukinumab. Previous studies suggested decreased numbers of regulatory T cells (Tregs) with increasing stage of MF, which may lead to the shift in the Treg/Th17 balance towards the Th17 pathway. Theoretically, the use of IL-17 monoclonal antibodies to inhibit Th17 pathway may lead to further immunosuppression and disease progression in cutaneous T-cell lymphoma (CTCL) by shifting the balance towards Tregs, although this hypothesis has not been proven. With uncertainty over the role of IL-17 and Treg/Th17 as well as diagnostic challenges in CTCL, we recommend that patients should have a confirmatory skin biopsy prior to the commencement of biologic therapy.

Delayed asymptomatic progressive intraventricular pneumocephalus in a dog following craniotomy

Delayed pneumocephalus developed in a 9-year-old dog following transfrontal craniotomy and implantation of an experimental local chemotherapy into a partially resected oligodendroglioma, but the animal appeared to be asymptomatic. MRI evidence of increasing intracranial pressure, including progressive ventricular dilatation and compression of periventricular parenchyma, led to the recommendation for exploratory craniotomy. The barrier between the intracranial cavity and frontal sinus was enhanced, and pneumocephalus resolved on MRI at both 1 and 3 months following the repair.

Psychiatric features of new variant Creutzfeldt-Jakob disease

Aims and method

New variant Creutzfeldt–Jakob disease is a novel prion disease of humans that may be causally linked to bovine spongiform encephalopathy. Psychiatric symptoms occur in the early stages of the illness and may be difficult to distinguish from the symptoms of more common psychiatric disorders. Cases of new variant Creutzfeldt–Jakob disease are identified through the national surveillance system. Information on psychiatric features has been obtained by review of case notes and, in the majority of cases, by interview of relatives by a member of the surveillance staff.

Results

Thirty-five cases of new variant Creutzfeldt–Jakob disease have been identified in the UK and detailed information on the clinical features and investigations is currently available in 33 of these cases. All but one of the cases exhibited prominent early psychiatric symptomatology, but the diagnosis of an underlying neurological disease was not possible in the majority of cases until the development of neurological symptoms and signs. Early indications of an underlying neurological disorder included cognitive impairment, persistent sensory symptoms or limb pain and, in a minority, gait imbalance, dysarthria or visual symptoms. Limited evidence suggests that investigations such as electroencephalogram or brain imaging are unlikely to provde useful diagnostic information during the ‘psychiatric’ phase of the illness.

Clinical implications

The early recognition of an underlying neurological disorder may be impossible in the early psychiatric phase of new variant Creutzfeldt–Jakob disease, but the suspicion of this diagnosis may be raised by the occurrence of associated neurological symptoms. The development of early diagnostic markers is an important objective.

Development of competency based standards An application of the Delphi research technique

This paper, by Ann Bonner and Glenn Stewart, describes the benefits and limitations of using the Delphi technique research method. The technique was applied to a study in Australia that sought to identify advanced practice competency standards within a nursing speciality.

ICSH guidelines for the laboratory diagnosis of nonimmune hereditary red cell membrane disorders

INTRODUCTION

Hereditary spherocytosis (HS), hereditary elliptocytosis (HE), and hereditary stomatocytosis (HSt) are inherited red cell disorders caused by defects in various membrane proteins. The heterogeneous clinical presentation, biochemical and genetic abnormalities in HS and HE have been well documented. The need to raise the awareness of HSt, albeit its much lower prevalence than HS, is due to the undesirable outcome of splenectomy in these patients.

METHODS

The scope of this guideline is to identify the characteristic clinical features, the red cell parameters (including red cell morphology) for these red cell disorders associated, respectively, with defective cytoskeleton (HS and HE) and abnormal cation permeability in the lipid bilayer (HSt) of the red cell. The current screening tests for HS are described, and their limitations are highlighted.

RESULTS

An appropriate diagnosis can often be made when the screening test result(s) is reviewed together with the patient's clinical/family history, blood count results, reticulocyte count, red cell morphology, and chemistry results. SDS-polyacrylamide gel electrophoresis of erythrocyte membrane proteins, monovalent cation flux measurement, and molecular analysis of membrane protein genes are specialist tests for further investigation.

CONCLUSION

Specialist tests provide additional evidence in supporting the diagnosis and that will facilitate the management of the patient. In the case of a patient's clinical phenotype being more severe than the affected members within the immediate family, molecular testing of all family members is useful for confirming the diagnosis and allows an insight into the molecular basis of the abnormality such as a recessive mode of inheritance or a de novo mutation.

Impact of US Brown Swiss genetics on milk quality from low-input herds in Switzerland: interactions with grazing intake and pasture type

This study investigated the effect of, and interactions between, contrasting crossbreed genetics (US Brown Swiss [BS] × Improved Braunvieh [BV] × Original Braunvieh [OB]) and feeding regimes (especially grazing intake and pasture type) on milk fatty acid (FA) profiles. Concentrations of total polyunsaturated FAs, total omega-3 FAs and trans palmitoleic, vaccenic, α-linolenic, eicosapentaenoic and docosapentaenoic acids were higher in cows with a low proportion of BS genetics. Highest concentrations of the nutritionally desirable FAs, trans palmitoleic, vaccenic and eicosapentaenoic acids were found for cows with a low proportion of BS genetics (0-24% and/or 25-49%) on high grazing intake (75-100% of dry matter intake) diets. Multivariate analysis indicated that the proportion of OB genetics is a positive driver for nutritionally desirable monounsaturated and polyunsaturated FAs while BS genetics proportion was positive driver for total and undesirable individual saturated FAs. Significant genetics × feeding regime interactions were also detected for a range of FAs.

Antibodies to myelin oligodendrocyte glycoprotein in bilateral and recurrent optic neuritis

Objective:

We examined a cohort of adults with aquaporin-4 (AQP4) antibody–negative neuromyelitis optica/neuromyelitis optica spectrum disorder (NMO/NMOSD) for antibodies to myelin oligodendrocyte glycoprotein (MOG).

Methods:

We performed a flow cytometry cell-based assay using live human lentivirus–transduced cells expressing full-length surface MOG. Serum was tested in 23 AQP4 antibody–negative NMO/NMOSD patients with bilateral and/or recurrent optic neuritis (BON, n = 11), longitudinally extensive transverse myelitis (LETM, n = 10), and sequential BON and LETM (n = 2), as well as in patients with multiple sclerosis (MS, n = 76) and controls (n = 52).

Results:

MOG antibodies were detected in 9/23 AQP4 antibody–negative patients with NMO/NMOSD, compared to 1/76 patients with MS and 0/52 controls (p < 0.001). MOG antibodies were detected in 8/11 patients with BON, 0/10 patients with LETM, and 1/2 patients with sequential BON and LETM. Six of 9 MOG antibody–positive patients had a relapsing course. MOG antibody–positive patients had prominent optic disc swelling and were more likely to have a rapid response to steroid therapy and relapse on steroid cessation than MOG antibody–negative patients (p = 0.034 and p = 0.029, respectively). While 8/9 MOG antibody–positive patients had good follow-up visual acuity, one experienced sustained visual impairment, 3 had retinal nerve fiber layer thinning, and one had residual spinal disability.

Conclusions:

MOG antibodies have a strong association with BON and may be a useful clinical biomarker. MOG antibody–associated BON is a relapsing disorder that is frequently steroid responsive and often steroid dependent. Failure to recognize the disorder early and institute immunotherapy promptly may be associated with sustained impairment.

Classification of evidence:

This study provides Class II evidence that MOG antibodies are associated with AQP4 antibody–negative BON (sensitivity 69%, 95% confidence interval [CI] 42%–87%; specificity 99%, 95% CI 93.7%–99.8%).