Predation risk drives long-term shifts in migratory behaviour and demography in a large herbivore population

Migration is an adaptive life-history strategy across taxa that helps individuals maximise fitness by obtaining forage and avoiding predation risk. The mechanisms driving migratory changes are poorly understood, and links between migratory behaviour, space use, and demographic consequences are rare. Here, we use a nearly 20-year record of individual-based monitoring of a large herbivore, elk (Cervus canadensis) to test hypotheses for changing patterns of migration in and adjacent to a large protected area in Banff National Park (BNP), Canada. We test whether bottom-up (forage quality) or top-down (predation risk) factors explained trends in (i) the proportion of individuals using 5 different migratory tactics, (ii) differences in survival rates of migratory tactics during migration and whilst on summer ranges, (iii) cause-specific mortality by wolves and grizzly bears, and (iv) population abundance. We found dramatic shifts in migration consistent with behavioural plasticity in individual choice of annual migratory routes. Shifts were inconsistent with exposure to the bottom-up benefits of migration. Instead, exposure to landscape gradients in predation risk caused by exploitation outside the protected area drove migratory shifts. Carnivore exploitation outside the protected area led to higher survival rates for female elk remaining resident or migrating outside the protected area. Cause-specific mortality aligned with exposure to predation risk along migratory routes and summer ranges. Wolf predation risk was higher on migratory routes than summer ranges of montane-migrant tactics, but wolf predation risk traded-off with heightened risk from grizzly bears on summer ranges. A novel eastern migrant tactic emerged following a large forest fire that enhanced forage in an area with lower predation risk outside of the protected area. The changes in migratory behaviour translated to population abundance, where abundance of the montane-migratory tactics declined over time. The presence of diverse migratory life histories maintained a higher total population abundance than would have been the case with only one migratory tactic in the population. Our study demonstrates the complex ways in which migratory populations change over time through behavioural plasticity and associated demographic consequences because of individuals balancing predation risk and forage trade-offs.

Integrating EM and Patch-seq data: Synaptic connectivity and target specificity of predicted Sst transcriptomic types

Neural circuit function is shaped both by the cell types that comprise the circuit and the connections between those cell types ¹ . Neural cell types have previously been defined by morphology ^{2, 3} , electrophysiology ^{4, 5} , transcriptomic expression ^6-8 , connectivity ^9-13 , or even a combination of such modalities ^14-16 . More recently, the Patch-seq technique has enabled the characterization of morphology (M), electrophysiology (E), and transcriptomic (T) properties from individual cells ^17-20 . Using this technique, these properties were integrated to define 28, inhibitory multimodal, MET-types in mouse primary visual cortex ²¹ . It is unknown how these MET-types connect within the broader cortical circuitry however. Here we show that we can predict the MET-type identity of inhibitory cells within a large-scale electron microscopy (EM) dataset and these MET-types have distinct ultrastructural features and synapse connectivity patterns. We found that EM Martinotti cells, a well defined morphological cell type ^{22, 23} known to be Somatostatin positive (Sst+) ^{24, 25} , were successfully predicted to belong to Sst+ MET-types. Each identified MET-type had distinct axon myelination patterns and synapsed onto specific excitatory targets. Our results demonstrate that morphological features can be used to link cell type identities across imaging modalities, which enables further comparison of connectivity in relation to transcriptomic or electrophysiological properties. Furthermore, our results show that MET-types have distinct connectivity patterns, supporting the use of MET-types and connectivity to meaningfully define cell types.

Longitudinal assessment of myocardial edema following experimental acute myocardial infarction using a comprehensive CMR protocol

Background

Preclinical and clinical data following acute myocardial infarction (MI) and reperfusion have shown a bimodal pattern of edematous myocardium at risk (MaR) on cardiovascular magnetic resonance (CMR) imaging during the first week [1,2]. In contrary, there have also been data demonstrating that MaR is stable during the first week in patients using contrast-enhanced steady-state free precession (CE-SSFP) imaging [3].

Purpose

To use a comprehensive CMR protocol to assess the dynamics of edematous MaR during the first week following acute experimental MI.

Methods

Acute myocardial ischemia was induced in seven pigs by endovascular balloon occlusion in the left anterior descending artery with reperfusion after 40 minutes. CMR was performed at baseline, at 120 minutes, 24 hours and seven days post-reperfusion on a 1.5T scanner. The CMR protocol comprised of a prototype T2-SSFP sequence where two experiments with 16 echo times (T2 mapping16) and with 10 echo times (T2 mapping10) [1] were performed. After contrast administration, a short-axis CE-SSFP stack and late gadolinium enhancement (LGE) images were acquired. T2-maps were acquired in a mid-apical ventricular short-axis slice corresponding to the same anatomical level at all time points. All image analysis was performed using designated software. Severity of MaR was measured by placing a region of interest in the ischemic area on T2 maps and extent of MaR was assessed by delineating hyperintense areas in CE-SSFP short-axis stacks. Data is presented as mean ± SD and one-way ANOVA was used followed by Tukey's multiple comparison test.

Results

An example of all acquired CMR sequences is shown in Figure 1, with red arrows depicting the extent of edematous MaR. Figure 2 shows the severity of MaR by T2 values from T2 mapping16 where T2 values were significantly lower at 24 hours compared to 120 minutes post-reperfusion (P<0.05). However, no significant difference was seen at 120 minutes or at 24 hours compared to T2 values at seven days (P=0.46 and P=0.35). No difference at baseline (47±3 ms vs 49±3 ms, P=0.10) was observed when comparing T2 mapping16 against T2 mapping10 but a significant difference between the time points 120 min (80±8 ms vs 69±7 ms, P=0.02), 24 h, (69±9 ms vs 54±4 ms, P=0.03), and seven days (76±10 ms vs 67±5 ms, P=0.04) post-reperfusion. There was no statistically significant difference between T2 values post-reperfusion using T2 mapping10 (P=ns). The extent of myocardium at risk assessed by CE-SSFP did not show a bimodal pattern of edema, but rather a significantly lower extent at seven days compared to the extent at 120 minutes and 24 hours (P<0.05).

Conclusion

The severity and extent of edematous myocardium at risk does not follow a bimodal pattern over the course of one week. However, absolute T2 values differ between T2 mapping sequences and therefore a standardization of a CMR protocol for the assessment of MaR is of importance.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Swedish Heart-Lung Foundation and The Medical Faculty of Lund University (ALF)

Diagnostic value of electroanatomical mapping in patients with suspected arrhythmogenic cardiomyopathy

Background

Case series suggested that low voltage areas (LVA) on invasive electroanatomical mapping (EAM) could identify arrhythmogenic cardiomyopathy (ACM) at an earlier stage as compared to late gadolinium enhancement (LGE) and fatty infiltration on cardiac magnetic resonance (CMR). Data comparing LVA with structural abnormalities on CMR are lacking.

Purpose

To report the prevalence of substrate abnormalities identified by EAM vs. CMR in a cohort of patients with suspected ACM.

Methods

We retrospectively identified 66 consecutive patients with suspected ACM, who underwent EAM following clinical onset with ventricular arrhythmias. The cutoff value for EAM-defined LVA was <0.5 mV bipolar, <8 mV unipolar. Data from a prior CMR, performed no more than 12 months before, were used for comparison.

Results

The study cohort (mean age 47 years, range 21–76; 83% males; mean left ventricular ejection fraction 53%, range 28–70%) was composed of patients with suspected ACM involving either the right (n=62) or the left ventricle (n=4) following presentation with sustained monomorphic ventricular tachycardia. EAM was obtained by isolated endocardial, epicardial, or combined approach, respectively, in 11 (17%), 15 (23%) and 40 (61%) patients. Overall, 61 patients (92%) had documented LVA, of whom 89% showed an epicardial localization. In the same population, CMR identified a lower prevalence of substrate abnormalities (LGE 65%; fatty infiltration 50%). In particular, there were 27 patients (41%) with EAM-defined LVA and absent substrate abnormalities on CMR. Based on the 2010 Task Force Criteria and the 2021 Padua Criteria, a definite diagnosis of ACM was missing for a total of 19 patients (29%): due to the uniform identification of LVA in the absence of CMR abnormalities, EAM helped to establish the most likely diagnosis of ACM in all of them (19/19).

Conclusions

Our data suggest that EAM is capable of identifying substrate abnormalities in a consistent proportion of patients with suspected ACM and absent abnormalities on CMR. In this setting, the implementation of LVA to the current diagnostic criteria could improve the diagnostic yield for ACM.

Funding Acknowledgement

Type of funding sources: None.

High prevalence of malignant ventricular arrhythmias in patients with early-stage left ventricular noncompaction

Background

Early-stage left ventricular non compaction (LVNC) is a nonischemic cardiomyopathy characterized with nondilated phenotype and unpredictable risk of malignant ventricular arrhythmias (MVA).

Purpose

To report the occurrence of MVA in patients with early-stage LVNC.

Methods

Consecutive patients (n=63) diagnosed with LVNC according to recognized criteria either on transthoracic echocardiogram or cardiac magnetic resonance were retrospectively enrolled. Patients with late-stage LVNC, defined by a coexistent dilated cardiomyopathy phenotype, were excluded (n=49). Patient-tailored medical treatment, as well as ICD implantation strategies, were based on the updated ESC guidelines integrated by the experience of a referral center for arrhythmia management. The study endpoint was the occurrence of MVA (defined as sustained VT, VF, or appropriate ICD therapy) by 5-year follow-up.

Results

The study cohort consisted of 14 patients (mean age 37±17 y, 64% males), presenting with palpitation (n=4), syncope (n=4), or dyspnea on effort (n=6). LVNC was diagnosed by echocardiogram and cardiac magnetic resonance in 13 and 1 patients, respectively. Because of nonmalignant VA, seven patients (50%) underwent ICD implant before discharge. By 5-year follow-up, 5 patients (36%) experienced MVA, including VF or appropriate ICD shocks for fast VT. Left ventricular ejection fraction (LVEF) ≥45% was the only factor associated with the occurrence of MVA (5/11 event in cases with LVEF ≥45% vs. 0/3 events in controls with LVEF <45%; p=0.145). Baseline features, including age, gender, NC/C ratio, and clinical presentation were comparable between cases with LVEF ≥45% and controls, all p>0.05. Drug treatment, including RAAS inhibitors, betablockers and antiarrhythmics was also comparable.

Conclusions

Our preliminary data show that in early-stage LVNC the occurrence of MVA is higher for patients with LVEF ≥45%. Efforts are needed to identify earlier predictors of arrhythmic risk, to improve patient selection for ICD implant.

Funding Acknowledgement

Type of funding sources: None.

Hypothermia yields favourable cardiac energetics in experimental ischemia/reperfusion – insights from non-invasive pressure-volume loops by CMR

Background/Introduction

In experimental studies, mild hypothermia (<35°C) has reduced infarct size [1], potentially through reduced reperfusion injury [2], but human trials have been ambiguous [3]. Furthermore, a pressure-volume (PV) loop framework is the gold standard for assessing cardiac performance, but the invasive approach limits its clinical use. Therefore, we used a porcine model of ischemia/reperfusion with cardiovascular magnetic resonance (CMR) imaging throughout one week to acquire non-invasive PV loops.

Purpose

To quantify the cardioprotective effects of hypothermia at reperfusion by serial CMR imaging in a perspective of cardiac energy and mechanics.

Methods

Normothermia and Hypothermia groups (n=7+7 pigs) were imaged with CMR at baseline and subjected to 40 minutes of normothermic ischemia by catheter intervention. Thereafter, the Hypothermia group was rapidly cooled (<35°C) for 5 minutes before reperfusion. Additional imaging at two hours, 24 hours, and seven days were used to assess ventricular volumes and ischemic injuries. Infarct size was determined by high-resolution ex-vivo T1-weighted images.

Results

Figure 1 shows that stroke volume (SV: p=0.029; Friedmans test) and ejection fraction (EF: p=0.068) were notably reduced post-reperfusion in the Normothermia group. In contrast, the decreases were ameliorated in the Hypothermia group (SV: p=0.77; EF: p=0.13). Mean arterial pressure (MAP) was stable in the Normothermia group (p=0.77) but dropped two hours post-reperfusion in hypothermic animals (p=0.007). Over one week, both groups experienced the same decrease and partial recovery pattern for stroke work, external power, and ventricular-arterial coupling. Still, the adverse effects from ischemia were generally attenuated in the Hypothermia group. Although not significant, ischemia/reperfusion caused smaller infarcts in the Hypothermia group (10±8% vs 15±8%; p=0.32). The change in PV loop variables from baseline to 24 hours was compared with infarct size for each group. Though statistical power was limited, the general trend in analyses of covariance indicated that hypothermia has cardioprotective properties incremental to reducing infarct sizes (Figure 2), such as higher external power (p=0.061) and lower arterial elastance (p=0.015).

Conclusion

Using non-invasive PV loops by CMR, we observed that mild hypothermia before reperfusion results in favourable cardiac energetics that alleviates the heart's work after an ischemia/reperfusion injury during the first week. This study suggests that hypothermia has cardioprotective properties, incremental to reducing infarct size. The primary cardioprotective mechanism was likely an afterload reduction unloading the injured left ventricle.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Swedish Heart-Lung FoundationThe Medical Faculty of Lund University (ALF)

Analysis of rare disruptive germline mutations in 2,135 enriched BRCA-negative breast cancers excludes additional high-impact susceptibility genes

BACKGROUND

Breast cancer has a significant heritable basis, of which approximately 60% remains unexplained. Testing for BRCA1/BRCA2 offers useful discrimination of breast cancer risk within families, and identification of additional breast cancer susceptibility genes could offer clinical utility.

PATIENTS AND METHODS

We included 2,135 invasive breast cancer cases recruited via the BOCS study, a retrospective UK study of familial breast cancer.

ELIGIBILITY CRITERIA

female, BRCA-negative, white European ethnicity, and one of: i) breast cancer family history, ii) bilateral disease, iii) young age of onset (<30 years), iv) concomitant ovarian cancer. We undertook exome sequencing of cases and performed gene-level burden testing of rare damaging variants against those from 51,377 ethnicity-matched population controls from gnomAD.

RESULTS

159/2135 (7.4%) cases had a qualifying variant in an established breast cancer susceptibility gene, with minimal evidence of signal in other cancer susceptibility genes. Known breast cancer susceptibility genes PALB2, CHEK2 and ATM were the only genes to retain statistical significance after correcting for multiple testing. Due to the enrichment of hereditary cases in the series, we had good power (>80%) to detect a gene of BRCA1-like risk (odds ratio = 10.6) down to a population minor allele frequency of 4.6 x 10^-5 (1 in 10,799, less than one tenth that of BRCA1)and of PALB2-like risk (odds ratio = 5.0) down to a population minor allele frequency of 2.8 x 10^-4 (1 in 1,779, less than half that of PALB2). Power was lower for identification of novel moderate penetrance genes (odds ratio = 2-3) like CHEK2 and ATM.

CONCLUSIONS

This is the largest case-control whole-exome analysis of enriched breast cancer published to date. Whilst additional breast cancer susceptibility genes likely exist, those of high penetrance are likely to be of very low mutational frequency. Contention exists regarding the clinical utility of such genes.

Safety hazards in clinical practice of seclusion in psychiatric care

Introduction

Seclusion is part of the clinical practice in European psychiatric hospital care with the aim to maintain the safety of patients and staff. Adverse events and harm have been reported for patients and staff resulting from seclusion. Safety hazards, which are the prerequisite of adverse events, can be identified using video observation methods. Identifying safety hazards can be used to prevent adverse events and improve the quality of psychiatric care.

Objectives

To identify safety hazards during seclusion in psychiatric hospital care.

Methods

Descriptive design with non-participant video-observation of seclusion care practice. Data consisted of video recordings (n = 36) from six wards of one psychiatric hospital in Finland. The data were analysed with inductive thematic analysis.

Results

Clinical practice of seclusion included safety hazards stemming from the actions of patients and staff. Patients’ actions were as follows: aggressive behaviour, attempting to escape, precarious movements, preventing the visibility of staff, exposing themselves to contamination, and falls during seclusion. Staff actions included: leaving dangerous items to seclusion, issues in the administration of medication, performing physical and mechanical restraints in unsecure way, and precarious movements and postures.

Conclusions

According to our results, the use of seclusion has safety hazards that can result in harm for patients and staff. To improve the quality and safety of seclusion in clinical practice, the guidelines, practices, and staff training need to consider the various safety hazards. While the work in Europe to abolish the use of seclusion is still in progress, this topic requires attention in clinical practice, education, and policymaking.

Disclosure

No significant relationships.

Ventricular longitudinal shortening is an independent predictor of death in heart failure patients with reduced ejection fraction

Reduced ventricular longitudinal shortening measured by atrioventricular plane displacement (AVPD) and global longitudinal strain (GLS) are prognostic markers in heart disease. This study aims to determine if AVPD and GLS with cardiovascular magnetic resonance (CMR) are independent predictors of cardiovascular (CV) and all-cause death also in heart failure with reduced ejection fraction (HFrEF). Patients (n = 287) were examined with CMR and AVPD, GLS, ventricular volumes, myocardial fibrosis/scar were measured. Follow-up was 5 years with cause of death retrieved from a national registry. Forty CV and 60 all-cause deaths occurred and CV non-survivors had a lower AVPD (6.4 ± 2.0 vs 8.0 ± 2.4 mm, p < 0.001) and worse GLS (− 6.1 ± 2.2 vs − 7.7 ± 3.1%, p = 0.001). Kaplan–Meier analyses displayed increased survival for patients in the highest AVPD- and GLS-tertiles vs. the lowest tertiles (AVPD: p = 0.001, GLS: p = 0.013). AVPD and GLS showed in univariate analysis a hazard ratio (HR) of 1.30 (per-mm-decrease) and 1.19 (per-%-decrease) for CV death. Mean AVPD and GLS were independent predictors of all-cause death (HR = 1.24 per-mm-decrease and 1.15 per-%-decrease), but only AVPD showed incremental value over age, sex, body-mass-index, EF, etiology and fibrosis/scar for CV death (HR = 1.33 per-mm-decrease, p < 0.001). Ventricular longitudinal shortening remains independently prognostic for death in HFrEF even after adjusting for well-known clinical risk factors.

Phenotypic characterization of PIGN-associated paroxysmal dyskinesia in Soft-coated wheaten terriers and preliminary response to acetazolamide therapy

A hereditary movement disorder in Soft coated wheaten terriers (SCWT) has been associated with a mutation in PIGN which encodes an enzyme involved in synthesis of glycosylphosphatidylinositol (GPI). The objective of this study was to describe and classify the clinical phenotype and assess therapeutic response. Twenty-five SCWT and related dogs homozygous for PIGN:c.398C>T with paroxysmal dyskinesia were available for inclusion. Medical records and video recordings of 17 dogs were evaluated in a retrospective case series. Affected dogs had episodes of involuntary, hyperkinetic movements and dystonia. Median age of onset was 2.5 years. A typical episode consisted of rapid, irregular hyperflexion and extension of the pelvic limbs with some degree of truncal dystonia. A mild episode consisted of spontaneous flexion of one pelvic limb while walking which could resemble a lameness. Episodes lasted several minutes to several hours and occurred up to 10 times/day or more. They were not associated with exercise or fasting but were sometimes triggered by excitement or stress. Acetazolamide therapy improved nine of 11 dogs, in seven cases abolishing episodes. Five of 17 dogs treated with other agents had mild improvement with clonazepam (n = 2), levetiracetam (n = 1), or phenobarbital (n = 2). Paroxysmal dyskinesias must be differentiated from seizure disorders since they often respond to different therapies. The SCWT phenotype consisted predominantly of hyperkinesia, and can respond dramatically to acetazolamide. GPI anchors proteins to the cell surface including carbonic anhydrase IV which modulates synaptic pH in the brain. Altered activity of this enzyme may be the target of acetazolamide therapy.

A Prospective Pilot Study to Identify a Myocarditis Cohort who may Safely Resume Sports Activities 3 Months after Diagnosis

International cardiovascular society recommendations to return to sports activities following acute myocarditis are based on expert consensus in the absence of prospective studies. We prospectively enrolled 30 patients with newly diagnosed myocarditis based on clinical parameters, laboratory measurements and cardiac magnetic resonance imaging with mildly reduced or preserved left ventricular ejection fraction (LVEF) with a follow-up of 12 months. Cessation of physical activity was recommended for 3 months. The average age was 35 (19-80) years with 73% male patients. One case of non-sustained ventricular tachycardia was recorded during 48-h-Holter electrocardiogram. Except for this case, all patients were allowed to resume physical exercise after 3 months. At 6- (n = 26) and 12-month (n = 19) follow-up neither cardiac events nor worsening LVEF were recorded. The risk of cardiac events at 1 year after diagnosis of myocarditis appears to be low after resumption of exercise after 3 months among patients who recover from acute myocarditis.

[Epithelioid trophoblastic tumour with pulmonary metastasis]

Epithelioid trophoblastic tumours are rare kind of gestational trophoblastic disease. Their detection is made by repetitive measurement of ?HCG after any gestational period (including spontaneous abortion). Epithelioid trophoblastic tumour can cause pulmonary metastasis. We describe the clinical case of a 44-year old woman with a cystic lesion of the right pulmonary apex following a miscarriage which was an epithelioid trophoblastic tumour. She's still in complete remission after surgery and careful follow up.

Increased Consumption of Plant Foods Is Associated with Increased Bone Mineral Density

OBJECTIVES

To determine the relationship between plant food consumption and bone mineral density (BMD) in a healthy population when age, gender, BMI and physical activity are accounted for.

DESIGN

Cross-sectional study.

SETTING

Participants were recruited from the Sydney Adventist hospital and the University of New South Wales, Sydney, Australia.

PARTICIPANTS

33 males and 40 females (total n=73) participated in this study. The mean age was 56.1 ± 8.5 years. All participants were non-diabetic and in general good health.

MEASUREMENTS

A principle component analysis (PCA) was performed on 12 month self-report food intake data, gathered using the Cancer Council Victoria Dietary Questionnaire for Epidemiological Studies Version 2. Dual-energy X-ray absorptiometry was used to measure total BMD. Fasting plasma total protein, calcium and 25-Hydroxy Vitamin D levels were analysed by the Sydney Adventist Hospital pathology laboratory. Anthropometric measures were obtained using a standardized protocol. Self-reported physical activity levels were assessed using the International Physical Activity Questionnaire.

RESULTS

The PCA revealed three principle components. These were termed 'Meat Based', 'Junk Food' and 'Plant Based.' After controlling for age, gender, physical activity and BMI, the Plant Based component correlated positively with BMD (p=0.054, R2=0.439) and T-score (p=0.053, R2=0.221). Using a similar model no association between the Meat Based component and BMD or T-score was found. However, when the Plant Based component was included the Meat Based component correlated positively with BMD (p=0.046, R2=0.474) and T-score (p=0.046, R2=0.279). There was no significant association between the Junk Food component and BMD or T-score. People in the third Plant (927 ± 339 vs 751 ± 255 g/day, p=0.025) and Meat Based (921 ± 270 vs 676 ± 241 g/day, p=0.002) tertile had higher calcium intakes than those in the first. People in the second Plant Based tertile had higher plasma Vitamin D levels than those in the first (63.5 ± 16.8 vs. 52.3 ± 22.1 nmol/L, p=0.053) while those in the third Junk Food tertile had lower levels than those in the first (52.4 ± 18.5 vs. 65.4 ± 19.8 nmol/L, p=0.027). No association between Plant Based tertiles and protein intake was observed, however those in the third Meat Based (99.7 ± 25.1 vs. 50.9 ± 13.8 g/day, p=0.000) and Junk Food (87.4 ± 30.7 vs. 56.6 ± 22.2 g/day, p=0.000) tertile had higher protein intake compared to those in the first tertile.

CONCLUSION

In a healthy middle aged population with normal BMD, an increase in plant food consumption, either alone or in combination with a diet containing meat, is associated with improved bone mineralisation markers. This positive relationship is most likely due to the extensive range of micronutrients and phytochemicals packaged within plants.

Decreased atrioventricular plane displacement after acute myocardial infarction yields a concomitant decrease in stroke volume

Acute myocardial infarction (AMI) can progress to heart failure, which has a poor prognosis. Normally, 60% of stroke volume (SV) is attributed to the longitudinal ventricular shortening and lengthening evident in the atrioventricular plane displacement (AVPD) during the cardiac cycle, but there is no information on how the relationship changes between SV and AVPD before and after AMI. Therefore, the aim of this study was to determine how SV depends on AVPD before and after AMI in two swine models. Serial cardiac magnetic resonance imaging was carried out before and 1–2 h after AMI in a microembolization model (n = 12) and an ischemia-reperfusion model (n = 14). A subset of pigs (n = 7) were additionally imaged at 24 h and at 7 days. Cine and late gadolinium enhancement images were analyzed for cardiac function, AVPD measurements and infarct size estimation, respectively. AVPD decreased (P < 0.05) in all myocardial regions after AMI, with a concomitant SV decrease (P < 0.001). The ischemia-reperfusion model affected SV to a higher degree and had a larger AVPD decrease than the microembolization model (−29 ± 14% vs. −15 ± 18%; P < 0.05). Wall thickening decreased in infarcted areas (P < 0.001), and A-wave AVPD remained unchanged (P = 0.93) whereas E-wave AVPD decreased (P < 0.001) after AMI. We conclude that AVPD is coupled to SV independent of infarct type but likely to a greater degree in ischemia-reperfusion infarcts compared with microembolization infarcts. AMI reduces diastolic early filling AVPD but not AVPD from atrial contraction. These findings shed light on the physiological significance of atrioventricular plane motion when assessing acute and subacute myocardial infarction.

NEW & NOTEWORTHY The link between cardiac longitudinal motion, measured as atrioventricular plane displacement (AVPD), and stroke volume (SV) is investigated in swine after acute myocardial infarction (AMI). This cardiac magnetic resonance study demonstrates a close coupling between AVPD and SV before and after AMI in an experimental setting and demonstrates that this connection is present in ischemia-reperfusion and microembolization infarcts, acutely and during the first week. Furthermore, AVPD is equally and persistently depressed in infarcted and remote myocardium after AMI.

P6505Urinary desmosine, an elastin-specific degradation product is associated with maximum aortic root size and aortic z-scores in patients with bicuspid aortic valve

Background

Bicuspid aortic valve (BAV) is the commonest congenital cardiac abnormality affecting up to 2% of the general population. BAV is highly diverse in phenotype however a common feature is its inherent risk of morbidity and mortality from aortic root dilatation and dissection. Aortic dilatation involves elastin degradation and desmosine is an amino acid cross-link that is released into the bloodstream and urine following elastin degradation. It is known from an earlier pilot study (DESMA) of desmosine in Marfan Syndrome (MFS) patients that plasma desmosine among patients with MFS is significantly elevated and correlates with aortic size however whether this same observation is seen in other forms of inherited aortopathies such as BAV is unclear.

Objectives

1. To investigate whether patients with BAV have higher elastin degradation as indicated by plasma desmosine and urinary desmosine levels.

2. To explore the relationship between plasma and urinary desmosine levels with aortic root size in patients with BAV.

Methods

We measured urinary (ng/mg creatinine) and plasma desmosine (ng/mL) in 20 patients with BAV and healthy control subjects using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Aortic root size and corresponding Z-scores were measured on echocardiogram. Correlation was analysed with Spearman's rank test.

Results

The patients with BAV were predominantly male (n=15, 75%) with a mean age of 50.5 years ± 17.6 [SD]. All the BAV patients had normal LV systolic function and none had prior aortic root surgery or were current smokers. Nine BAV patients had treated hypertension. Compared to controls, both plasma desmosine (0.30±0.10 vs 0.26±0.075 ng/mL, p=0.01) and urinary desmosine (15.9±4.6 vs 7.2±2.8 ng/mg creatinine, p<0.001) were significantly elevated in patients with BAV. Urinary and plasma desmosine (Figure 1) were also significantly correlated (r=0.55, p=0.01). There was a significant association between urinary desmosine and maximal aortic root size and Z-scores in the BAV cohort (Figure 2) compared to controls (p=0.02), however this was not seen with plasma desmosine.

Conclusions

Urinary and plasma desmosine levels are significantly higher in patients with BAV compared to controls. Urinary desmosine is also significantly associated with maximal aortic root size, reflecting higher elastin degradation. This suggests a potential use of desmosine as a biomarker to monitor disease progression in patients with BAV.

Acknowledgement/Funding

Anonymous Trust

The contribution of comorbidities to mortality in hospitalized patients with heart failure

BACKGROUND

Heart failure (HF) with reduced ejection fraction (HFrEF) has a worse prognosis than HF with preserved EF (HFpEF). The study aimed to evaluate whether different comorbidity profiles of HFrEF- and HFpEF-patients or HF-specific mechanisms contribute to a greater extent to this difference.

METHODS

We linked data from two health insurances to data from a cardiology clinic hospital information system. Patients with a hospitalization with HF in 2005-2011, categorized as HFrEF (EF < 45%) or HFpEF (EF ≥ 45%), were propensity score (PS) matched to controls without HF on comorbidites and medication to assure similar comorbidity profiles of patients and their respective controls. The balance of the covariates in patients and controls was compared via the standardized difference (SDiff). Age-standardized 1-year mortality rates (MR) with 95% confidence intervals (CI) were calculated.

RESULTS

777 HFrEF-patients (1135 HFpEF-patients) were PS-matched to 3446 (4832) controls. Balance between patients and controls was largely achieved with a SDiff < 0.1 on most variables considered. The age-standardized 1-year MRs per 1000 persons in HFrEF-patients and controls were 267.8 (95% CI 175.9-359.8) and 86.1 (95% CI 70.0-102.3). MRs in HFpEF-patients and controls were 166.2 (95% CI 101.5-230.9) and 61.5 (95% CI 52.9-70.1). Thus, differences in MRs between patients and their controls were higher for HFrEF (181.7) than for HFpEF (104.7).

CONCLUSIONS

Given the similar comorbidity profiles between HF-patients and controls, the higher difference in mortality rates between HFrEF-patients and controls points more to HF-specific mechanisms for these patients, whereas for HFpEF-patients a higher contribution of comorbidity is suggested by our results.

Baraitser-Winter cerebrofrontofacial syndrome

Baraitser-Winter cerebrofrontofacial syndrome (BWCFF) (BRWS; MIM #243310, 614583) is a rare developmental disorder affecting multiple organ systems. It is characterised by intellectual disability (mild to severe) and distinctive facial appearance (metopic ridging/trigonocephaly, bilateral ptosis, hypertelorism). The additional presence of cortical malformations (pachygyria/lissencephaly) and ocular colobomata are also suggestive of this syndrome. Other features include moderate short stature, contractures, congenital cardiac disease and genitourinary malformations. BWCFF is caused by missense mutations in the cytoplasmic beta- and gamma-actin genes ACTB and ACTG1. We provide an overview of the clinical characteristics (including some novel findings in four recently diagnosed patients), diagnosis, management, mutation spectrum and genetic counselling.

Danish guidelines on management of otitis media in preschool children

INTRODUCTION

Otitis media is one of the most common diseases in small children. This underlines the importance of optimizing diagnostics and treatment of the condition. Recent literature points toward a stricter approach to diagnosing acute otitis media (AOM). Moreover, ventilating tube treatment for recurrent AOM (RAOM) and chronic otitis media with effusion (COME) has become the most frequently performed surgical procedure in pre-school children. Therefore, the Danish Health and Medicines Authority and the Danish Society of Otorhinolaryngology, Head and Neck Surgery deemed it necessary to update the Danish guidelines regarding the diagnostic criteria for acute otitis media and surgical treatment of RAOM and COME.

METHODS

The GRADE system (The Grading of Recommendations Assessment, Development and Evaluation) was used in order to comply with current standards of evidence assessment in formulation of recommendations. An extensive literature search was conducted between July and December 2014. The quality of the existing literature was assessed using AGREE II (Appraisal of Guidelines for Research & Evaluation), AMSTAR (assessing the Methodological Quality of Systematic Reviews), QUADAS-2 (Quality of Diagnostic Accuracy Studies), Cochrane Risk of Bias Tool for randomized trials and ACROBAT-NRSI (A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies). The working group consisted of otolaryngologists, general practitioners, pediatricians, microbiologists and epidemiologists.

CONCLUSION

Recommendations for AOM diagnosis, surgical management for RAOM and COME, including the role of adenoidectomy and treatment of ventilating tube otorrhea, are proposed in the guideline.

A case of denosumab-induced hypocalcaemia in a patient with non-metastatic prostate cancer and renal impairment

Denosumab is an emerging new treatment for osteoporosis in postmenopausal women and men with non-metastatic prostate cancer. It is largely used by specialists as an alternative treatment in patients with contraindications to traditional, more commonly used drugs such as bisphosphonates. One important side effect is hypocalcaemia, which may be life threatening. The risk of this is increased in renal impairment, mainly if eGFR < 30 ml/min/1.73m(2), and is exacerbated by vitamin D insufficiency. This is a case study of prolonged symptomatic hypocalcaemia after a single dose of denosumab in a patient with non-metastatic prostate cancer and moderate renal impairment (eGFR 40 ml/min/1.73m(2)). The patient presented with acute confusion, muscle cramps and myoclonic jerks 5 weeks after treatment. This case demonstrates the need to be aware of adverse effects of denosumab in mild-moderate renal impairment and the need to monitor calcium levels pre- and post-treatment.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

[Comparison between chylothorax and pseudochylothorax]

We report two cases of lipidic pleural effusion: an arthritis-associated pseudochylothorax and a chylous pleural effusion in a HIV seropositive patient. The incidence of lipidic pleural effusions is low, especially for pseudochylothorax. We review their clinical characteristics and management.

Sex-specific trends in 4-year survival in 37 276 men and women with acute myocardial infarction before the age of 55 years in Sweden, 1987-2006: a register-based cohort study

OBJECTIVE

To examine sex-specific trends in 4-year mortality among young patients with first acute myocardial infarction (AMI), 1987-2006.

DESIGN

Prospective cohort study.

SETTING

Sweden.

PARTICIPANTS

We identified 37 276 cases (19.4% women; age, 25-54 years) from the Swedish Inpatient Register, 1987-2006, who had survived 28 days after an AMI.

OUTCOME MEASURES

4-year mortality from all causes and standard mortality ratio (SMR).

RESULTS

From the first to last 5-year period, the absolute excess risk decreased from 1.38 to 0.50 and 1.53 to 0.59 per 100 person-years among men aged 25-44 and 45-54 years, respectively. Corresponding figures for women were a decrease from 2.26 to 1.17 and from 1.93 to 1.45 per 100 person-years, respectively. Trends for women were non-linear, decreasing to the same extent as those for men until the third period, then increasing. For the last 5-year period, the standardised mortality ratio for young survivors of AMI compared with the general population was 4.34 (95% CI 3.04 to 5.87) and 2.43 (95% CI 2.12 to 2.76) for men aged 25-44 and 45-54 years, respectively, and 13.53 (95% CI 8.36 to 19.93) and 6.42 (95% CI 5.24 to 7.73) for women, respectively. Deaths not associated with cardiovascular causes increased from 21.5% to 44.6% in men and 41.5% to 65.9% in women.

CONCLUSIONS

Young male survivors of AMI have low absolute long-term mortality rates, but these rates remain twofold to fourfold that of the general population. After favourable development until 2001, women now have higher absolute mortality than men and a 6-fold to 14-fold risk of death compared with women in the general population.

Should we reconsider lung transplantation through uncontrolled donation after circulatory death?

Lung transplantation through controlled donation after circulatory death (cDCD) has slowly gained universal acceptance with reports of equivalent outcomes to those through donation after brain death. In contrast, uncontrolled DCD (uDCD) lung use is controversial and requires ethical, legal and medical complexities to be addressed in a limited time. Consequently, uDCD lung use has not previously been reported in the United States. Despite these potential barriers, we present a case of a patient with multiple gunshot wounds to the head and the body who was unsuccessfully resuscitated and ultimately became an uDCD donor. A cytomegalovirus positive recipient who had previously consented for CDC high-risk, DCD and participation in the NOVEL trial was transplanted from this uDCD donor, following 3 h of ex vivo lung perfusion. The postoperative course was uneventful, and the recipient was discharged home on day 9. While this case represents a "best-case scenario," it illustrates a method for potential expansion of the lung allograft pool through uDCD after unsuccessful resuscitation in hospitalized patients.

Statistical mechanics approach to the sample deconvolution problem

In a multicellular organism different cell types express a gene in different amounts. Samples from which gene expression levels can be measured typically contain a mixture of different cell types; the resulting measurements thus give only averages over the different cell types present. Based on fluctuations in the mixture proportions from sample to sample it is in principle possible to reconstruct the underlying expression levels of each cell type: to deconvolute the sample. We use a statistical mechanics approach to the problem of deconvoluting such partial concentrations from mixed samples, explore this approach using Markov chain Monte Carlo simulations, and give analytical results for when and how well samples can be unmixed.

Genotypes and phenotypes of 162 families with a glomulin mutation

A decade ago, we identified a novel gene, glomulin (GLMN) in which mutations cause glomuvenous malformations (GVMs). GVMs are bluish-purple cutaneous vascular lesions with characteristic glomus cells in the walls of distended venous channels. The discovery of the genetic basis for GVMs allowed the definition of clinical features to distinguish GVMs from other venous anomalies. The variation in phenotype was also highlighted: from a single punctate blue dot to a large plaque-like lesion. In this study, we screened GLMN in a large cohort of patients to broaden the spectrum of mutations, define their frequency and search for possible genotype-phenotype correlations. Taking into account 6 families published by others, a mutation in GLMN has been found in 162 families. This represents 40 different mutations; the most frequent one being present in almost 45% of them. Expressivity varies largely, without a genotype/phenotype relationship. Among 381 individuals with a mutation, we discovered 37 unaffected carriers, implying a penetrance of 90%. As nonpenetrant individuals may transmit the disease to their descendants, knowledge on the mutational status is needed for appropriate genetic counseling.