Short-term outcome after transcatheter aortic valve replacement with a novel balloon-expandable valve

OBJECTIVES

Transcatheter aortic valve replacement (TAVR) has been expanding rapidly with numerous transcatheter heart valve (THV) systems currently available. The Myval balloon-expandable (BE) valve (Meril Life Sciences Pvt. Ltd., India) is a novel THV system indicated for the treatment of patients with severe aortic stenosis. The primary objective of this study is to assess the safety and performance of the Myval BE valve.

METHODS

In this prospective single-centre study, 120 consecutive patients who underwent TAVR with the Myval BE valve were included. Clinical outcomes were evaluated at 30 days and 6 months using Valve Academic Research Consortium‑2 criteria. All-cause mortality, stroke, acute kidney injury, major vascular complications, moderate or severe paravalvular leakage (PVL) and need for a permanent pacemaker implantation (PPI) were investigated.

RESULTS

At 6‑month follow-up, all-cause death and cardiac death were seen in 5.8% and 0.8% of the patients respectively. Periprocedural stroke and need for PPI were both seen in 3.3% of the patients. Access-site-related vascular and bleeding complications were absent. Improved valve haemodynamics and no moderate to severe PVL could be seen at 30 days. An intermediate valve size was selected in 51% of the patients.

CONCLUSIONS

The Myval BE valve demonstrates improved valve haemodynamics, absence of moderate to severe PVL and good safety outcomes at 6‑month follow-up with low cardiac death rate and acceptable rates of permanent pacemaker implantation and periprocedural stroke. Future randomised controlled trials will further establish the clinical utility of the Myval BE valve.

The impact of alcohol use on the quality of cardiopulmonary resuscitation among festival attendees: A prespecified analysis of a randomised trial

BACKGROUND

Cardiac arrests often occur in public places, but despite the undisputed impact of bystander CPR, it is debated whether one should act as a rescuer after alcohol consumption due to the perceived adverse effects. We provide the first objective data on the impact of alcohol levels on CPR-skills.

METHODS

Pre-specified analysis of a randomised study at the Lowlands music festival (August 2019, the Netherlands) on virtual reality vs face-to-face CPR-training. Participants with an alcohol level ≥ 0.5‰ (WHO-endorsed cut-off for traffic participation) were eligible provided they successfully completed a tandem gait test. We studied alcohol levels (AL, ‰) in relation to CPR-quality (compression depth and rate) and CPR-scenario performance.

RESULTS

Median age of the 352 participants was 26 (22-31) years, 56% were female, with n = 214 in Group 1 (AL = 0‰), n = 85 in Group 2 (AL = 0-0.5‰) and n = 53 in Group 3 (AL ≥ 0.5‰). There were no significant differences in CPR-quality (depth: 57 [49-59] vs 57 [51-60] vs 55 mm [47-59], p = 0.16; rate: 115 [104-121] vs 114 [106-122] vs 111 min^-1 [95-120], p = 0.19). There were no significant correlations between alcohol level and compression depth (Spearman's rho -0.113, p = 0.19) or rate (Spearman's rho -0.073, p = 0.39). CPR-scenario performance scores (maximum 13) were not different between groups (12 (9-13) vs 12 (9-13) vs 11 (9-13), p = 0.80).

CONCLUSION

In this study on festival attendees, we found no association between alcohol levels and CPR-quality or scenario performance shortly after training.

TRIAL REGISTRATION

Lowlands Saves Lives is registered on https://www.

CLINICALTRIALS

gov (NCT04013633).

Left atrial strain at CMR is a strong independent prognostic predictor in DCM, superior to LV-GLS, LVEF and LAVI, and incremental to LGE

Background

The left atrium (LA) is an early sensor of left ventricular (LV) dysfunction. LA size and new-onset atrial fibrillation (AF) are associated with an increased risk of mortality and heart failure (HF) progression in patients with dilated cardiomyopathy (DCM). Whether abnormal LA strain measured at cardiac magnetic resonance (CMR) – a new technology to study atrial function – may predict overall outcome in DCM – either or not leading to new onset AF – remains completely unknown.

Purpose

To determine the prognostic value of CMR derived LA strain in DCM patients.

Methods

A total of 488 DCM patients (age 54 [46–62] years, 61% male) undergoing CMR were prospectively enrolled in the Maastricht Cardiomyopathy Registry between 2004 and 2018. Outcome consisted of the combination of sudden or cardiac death, HF hospitalization or life-threatening arrhythmias. LA reservoir (passive LA filling), conduit (passive LV filling), and booster strain (active LV filling) were measured using feature tracking strain analysis of the 2- and 4-chamber long-axis cines (Figure 1). Given the non-linearity of continuous variables, cubic spline analysis was performed to dichotomize.

Results

Seventy out of 488 DCM patients (14%) reached the endpoint (follow-up 6 [4–9] years). Age, NYHA class ≥3, late gadolinium enhancement (LGE) presence, LV ejection fraction (EF), LA volume index (LAVI), LV global longitudinal strain (GLS), and LA reservoir and conduit strain were univariably associated with worse outcome (all p-values <0.02). LA conduit strain was superior to reservoir strain to predict outcome. LA conduit strain, NYHA class ≥3 and LGE remained associated in the multivariable model (Figure 2A), while age, NTproBNP, LVEF, LA ejection fraction, LAVI and LV-GLS did not. Adding LA conduit strain to NYHA class and LGE significantly improved the calibration, accuracy, and reclassification of the prediction model (p<0.05). In patients without known AF and sinus rhythm (n=425) during CMR, 10% developed new-onset AF (paroxysmal or persistent) at long-term. Higher age, male sex, NYHA class ≥3, higher LAVI and impaired booster strain were all univariably associated with new-onset AF. Age and impaired booster strain remained as independent predictors of new-onset AF in the multivariable analysis (Figure 2B).

Conclusions

LA conduit strain on CMR is a strong independent prognostic predictor in DCM, superior to LV-GLS, LVEF and LAVI, and incremental to LGE. In addition, LA booster strain is an independent predictor of new-onset AF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Netherlands Cardiovascular Research Initiative, an initiative with support of the Dutch Heart Foundation

Peripheral microvascular function is linked to cardiac involvement on CMR in systemic sclerosis-related pulmonary arterial hypertension patients

Background

Systemic sclerosis (SSc) is characterized by vasculopathy, inflammation and fibrosis, and carries one of the worst prognosis in patients who also develop pulmonary arterial hypertension (PAH). Although PAH is a known prognosticator, SSc-PAH patients demonstrate disproportionately high morbidity and mortality, presumably due to cardiac involvement.

Purpose

To determine the pathophysiology of cardiac involvement in SSc, cardiovascular magnetic resonance (CMR) measures of perfusion, inflammation and fibrosis were compared between SSc-PAH and idiopathic PAH (IPAH) patients. In addition, the correlation between myocardial involvement on CMR and known markers of peripheral microvascular function was assessed.

Methods

Consecutive patients with SSc-PAH and IPAH of similar age and gender, consecutively underwent CMR imaging, and nailfold capillaroscopy (NC) with post-occlusive reactivity hyperaemia-test (PORH-test). CMR imaging included T2 mapping (inflammation), pre- and postcontrast T1 mapping to calculate the extracellular volume fraction (ECV, fibrosis), and adenosine-stress perfusion imaging to measure the relative myocardial upslope (microvascular perfusion), all measurements were performed on the left ventricle. These CMR markers were related to peripheral microvascular function by NC and PORH-test.

Results

Twenty SSc-PAH patients (71 [62–77] years, 14% male) and 5 IPAH patients (69 [47–77] years, 20% male) were included. SSc-PAH patients had higher ECV and T2 values than IPAH patients. NC showed lower average capillary density and reduced recruitment of capillaries after PORH in SSc-PAH patients, corresponding to impaired microvascular structure and function. Both higher ECV and T2 values correlated with lower average capillary density (r=−0.454 and −0.583, respectively, p<0.05 for both). Additionally, higher T2 values and lower relative myocardial upslope correlated with worse peripheral microvascular function measured by PORH-test (r=−0.471 and r=0.421, respectively, p<0.05 for both).

Conclusion

SSc-PAH patients showed higher markers of cardiac fibrosis and inflammation, compared to IPAH patients. These markers correlated well with worse peripheral microvascular function, suggesting that SSc-driven inflammation and vasculopathy concurrently affect peripheral microcirculation and the heart. This may have important therapeutic implications, for which future studies are warranted evaluating the role of anti-inflammatory/anti-fibrotic therapy.

Funding Acknowledgement

Type of funding sources: None.

CMR derived left ventricular intraventricular pressure gradients identify different patterns associated with prognosis in patients with dilated cardiomyopathy

Introduction

The direction of blood flow in the left ventricle (LV) is determined by intraventricular pressure gradients (IVPGs) between apex and base, which are altered when cardiac function declines. New cardiac magnetic resonance (CMR) post-processing software enables estimating LV-IVPGs. To date, the prognostic value of CMR derived IVPGs in patients with dilated cardiomyopathy (DCM) remains unknown.

Methods

DCM patients from the Maastricht Cardiomyopathy Registry, who underwent a CMR, were included. The software estimates the LV-IVPGs (between apex and base) by using the myocardial movement and velocity of a reconstructed 3D-LV model (derived from feature-tracking strain analysis of 2-, 3- and 4-chamber cine images). The primary outcome was a combined endpoint of heart failure (HF) hospitalisations, life-threatening arrhythmias and (sudden) cardiac death.

Results

In total, 447 DCM patients were included (age 55 interquartile range [46–63] years; 60% male). During a median follow-up of 6 [4–9] years, 66 patients (15%) reached the primary endpoint. In 168 patients (38%), a temporary pressure reversal from base-apex to apex-base during the systolic-diastolic transition was observed (figure). After correction for covariates that were univariably associated with outcome (p<0.100, age, NYHA-class≥3, and left atrial (LA) conduit strain), flow reversal from base-apex to apex-base in the diastole was independently associated with outcome in the total cohort (HR 2.91, 95%-Confidence interval (95%-CI) [1.16–7.32], p=0.023; Table). In patients without pressure reversal (N=279) in the systolic-diastolic transition, IVPG during the total cardiac cycle (HR 0.88 [0.81–0.96], p=0.003), the systolic ejection force (HR 0.92 [0.87–0.97], p=0.003), and the E-wave decelerative force “C” (passive diastolic filling, HR 0.85 [0.74–0.97], p=0.013) were predictors of outcome, independent of other covariates (age, sex, NYHA class ≥3, LV ejection fraction, late gadolinium enhancement, LV longitudinal strain, LA volume index and LA conduit strain, table).

Conclusion

CMR-derived LV-IVPG analysis showed pressure reversal in the systolic-diastolic transition in one-third of DCM patients, and flow reversal was an independent predictor of worse outcome in these patients. In patients without this pressure reversal, LV-IVPG during the total cardiac cyle, the systolic ejection force, and the E-wave decelerative force were predictors of outcome, independent of all evauluated clinical and imaging parameters.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Netherlands Cardiovascular Research Initiative (initiative with support of the Dutch Heart Foundation) and CVON (She-PREDICTS, grant 2017-21 & CVON-DCVA Double Dosis 2021)

Bio-distribution and longevity of mesenchymal stromal cell derived membrane particles

Vesicle-based medicines hold great promise for therapy development but essential knowledge on the bio-distribution and longevity of vesicles after administration is lacking. We generated vesicles from the membranes of human mesenchymal stromal cells (MSC) and we demonstrated earlier that these so-called membrane particles (MP) mediate immunomodulatory and regenerative responses in target cells. In the present study we examined the bio-distribution and longevity of MP after intravenous administration in mice. While most vesicle tracking methods are based on imaging techniques, which require labeling of vesicles and can only detect dense accumulations of vesicles, we used proteomics analysis to detect the presence of MP-derived proteins in multiple organs and tissues. MP proteins were mainly present in plasma and leukocytes at 1 h after injection, indicating that MP - in contrast to whole MSC - do not accumulate in the lungs upon first passage but remain in circulation. After 24 h, MP proteins were still present in plasma but were most abundant in the liver. RNA sequencing of livers demonstrated that MP impact liver function and in particular induce metabolic pathways. These data provide a clear view of the bio-distribution and longevity of MP, which is likely extrapolatable to other types of vesicles, and demonstrate that MP circulate for up to 24 h and may be a tool for targeting the liver.

Right atrial and ventricular strain detects subclinical changes in right ventricular function in precapillary pulmonary hypertension

Right ventricular (RV) ejection fraction (EF) by cardiac magnetic resonance (CMR) correlates to outcome in precapillary pulmonary hypertension (pPH) patients, but is insensitive to early changes. Strain might provide incremental information. In this study, we compare right atrial (RA) and RV strain in pPH patients to healthy controls, and evaluate the prognostic value of strain in pPH. In this cross-sectional study, 45 pPH patients and 20 healthy controls underwent CMR, and feature-tracking derived RA and RV strain were evaluated. pPH patients had impaired RA reservoir and conduit strain, and RV longitudinal strain (LS), compared to healthy controls. In pPH patients with preserved RVEF (≥ 50%, n = 18), RA reservoir (35% ± 9 vs. 41% ± 6, p = 0.02) and conduit strain (16% ± 8 vs. 23% ± 5, p = 0.004), and RV-LS (-25% ± 4 vs. -31% ± 4, p < 0.001) remained impaired, compared to healthy controls. The association of strain with the primary endpoint (combination of all-cause death, lung transplantation, and heart failure hospitalization) was evaluated using a multivariable Cox regression model. RV-LS (HR 1.18, 95%-CI 1.04-1.34, p = 0.01) and RA strain (reservoir: HR 0.87, 95%-CI 0.80-0.94, p = 0.001; conduit: HR 0.85, 95%-CI 0.75-0.97, p = 0.02, booster: HR 0.81, 95%-CI 0.71-0.92, p = 0.001) were independent predictors of outcome, beyond clinical and imaging features. In conclusion, pPH patients have impaired RA strain and RV-LS, even when RVEF is preserved. In addition, RA strain and RV-LS were independent predictors of adverse prognosis. These results emphasize the incremental value of RA and RV strain analyses, to detect alterations in RV function, even before RVEF declines.

COVID-19 survivors are physically inactive with high levels of sedentary time, regardless of patient characteristics, disease severity or cardiac dysfunction

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation

Background

More than 250 million cases of the coronavirus disease-2019 (COVID-19) infection were confirmed across the globe since 2020, leading to a substantial number of COVID-19 related hospital admissions. Many COVID-19 survivors experience long-term health consequences, but data on physical activity patterns and the impact on recovery post-infection are scarce.

Purpose

This study aimed to objectively assess physical (in)activity patterns among COVID-19 survivors and to explore the association with patient characteristics, disease severity and cardiac dysfunction. We hypothesized that COVID-19 survivors will demonstrate low volumes of physical activity and a high sedentary time, especially those with a more severe disease course (e.g. longer hospital duration; admission to intensive care), cardiac dysfunction, and persistent symptoms at 3-6 months post-discharge.

Methods

In this cross-sectional cohort study, we objectively assessed physical activity, sedentary behaviour and sleep duration for 24 hrs/day during 8 subsequent days in COVID-19 survivors at 3-6 months post-hospitalisation. Activity patterns were compared across pre-defined subgroups based on patient- and disease characteristics, cardiac biomarker release during hospitalisation, abnormal transthoracic echocardiogram regarding left- and right ventricular function and volumes at 3-6 months of follow-up, and persistence of symptoms post-discharge.

Results

Physical activity patterns were assessed in 37 patients (60±10 years old; 78% male) at 125 [116; 132] days after discharge. Patients spent 4.2 [3.2; 5.3] hrs/day in light-intensity physical activity and 1.0 [0.8; 1.4] hrs/day in moderate-to-vigorous intensity physical activity. Median sleep duration was 8.6 [8.2; 9.1] hrs/day. Time spent sitting was 9.8 [8.7; 11.2] hrs/day, which was accumulated in 6.0 [4.7; 6.9] prolonged sitting bouts (≥30 min) and 41.4 [31.5; 48.1] short sitting bouts (<30 min, Central Figure). No differences in activity patterns were found across subgroups, but sleep duration was slightly higher in women versus men (9.2 vs 8.5 hrs/day, p=0.03) and patients with versus without persistent symptoms (9.1 vs 8.3 hrs/day, p=0.02).

Conclusions

COVID-19 survivors are physically inactive for most of their time at 3-6 months post-hospitalisation. Physical (in)activity patterns are not impacted by patient- nor disease characteristics, underlining the need for a uniform approach for re-activation of COVID-19 survivors.

Central Figure.

A: objectively measured light-intensity physical activity (LIPA), moderate-to-vigorous intensity physical activity (MVPA), sleep duration and sedentary time in COVID-19 patients at 3-6 months post-hospitalisation (median and interquartile range).

B: sitting bout frequency (mean + standard deviation).

A Case Of Disseminated Histoplasmosis In A Patient With Sarcoidosis

Introduction/Objective

Sarcoidosis is a syndrome of unknown cause that may manifest with clinical, radiographic and pathological findings similar to those seen with histoplasmosis. We present a case of disseminated histoplasmosis in an immunocompetent patient previously diagnosed with sarcoidosis.

Methods/Case Report

A 69-year-old obese male with a history of hypertension, diabetes mellitus and long-standing sarcoidosis was admitted to the hospital for several months of intermittent fevers and pancytopenia. His sarcoidosis was diagnosed 21 years prior, initially involving the lungs and eventually showing cardiac involvement, requiring a pacemaker. He had been treated with methotrexate and prednisone. His recent medical history was also significant for COVID-19 infection, diagnosed 3 months before admission. His fevers were initially attributed to sarcoidosis and his pancytopenia to methotrexate. However, his symptoms continued despite discontinuation of his medications, and further workup was initiated.

Computed tomography showed hepatomegaly, splenomegaly, and lymphadenopathy, concerning for a lymphoproliferative disorder. The patient underwent a bone marrow biopsy that showed noncaseating granulomas and microorganisms consistent with histoplasmosis on fungal stain. Bone marrow cultures were not possible as the marrow was inaspirable. The patient subsequently underwent a lymph node biopsy with both morphology and culture identifying histoplasmosis. Urine and serum histoplasma antigen also returned positive. The patient’s overall clinical picture was consistent with disseminated histoplasmosis and he was administered intravenous Amphotericin B for 3 weeks followed by oral itraconazole for 1 year. One month follow-up after discharge showed significant improvement in the patient’s condition.

Results (if a Case Study enter NA)

N/A

Conclusion

Sarcoidosis reduces T-cell activity, and treatment with steroids causes further immunosuppression and vulnerability for development of a disseminated infection. COVID-19 also presumably increases the predisposition to acquire bacterial or fungal co-infections. Clinicians and pathologists should be aware of the overlap in clinical, radiologic and pathological presentations of sarcoidosis and histoplasmosis to make the correct diagnosis and administer the appropriate treatment.

Comparison between myocardial function assessed by echocardiography during hospitalization for COVID-19 and at 4 months follow-up

In patients hospitalized for corona virus infectious disease 19 (COVID-19) it is currently unknown whether myocardial function changes after recovery and whether this is related to elevated cardiac biomarkers. In this single center, prospective cohort study we consecutively enrolled hospitalized COVID-19 patients between 1 April and 12 May 2020. All patients underwent transthoracic echocardiography (TTE) evaluation during hospitalization and at a median of 131 days (IQR; 116–136) follow-up. Of the 51 patients included at baseline, 40 (age: 62 years (IQR; 54–68), 78% male) were available for follow-up TTE. At baseline, 68% of the patients had a normal TTE, regarding left ventricular (LV) and right ventricular (RV) volumes and function, compared to 83% at follow-up (p = 0.07). Median LV ejection fraction (60% vs. 58%, p = 0.54) and tricuspid annular plane systolic excursion (23 vs 22 mm, p = 0.18) were comparable between hospitalization and follow-up, but a significantly lower RV diameter (39 vs. 34 mm, p = 0.002) and trend towards better global longitudinal strain (GLS) (− 18.5% vs − 19.1%, p = 0.07) was found at follow-up. Subgroup analysis showed no relation between patients with and without elevated TroponinT and/or NT-proBNP during hospitalization and myocardial function at follow-up. Although there were no significant differences in individual myocardial function parameters at 4 months follow-up compared to hospitalisation for COVID-19, there was an overall trend towards normalization in myocardial function, predominantly due to a higher rate of normal GLS at follow-up.

Myocardial strain overrules left ventricular ejection fraction and late gadolinium enhancement extent in predicting MACE in CMR-proven acute myocarditis

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac magnetic resonance (CMR) plays a major role in both the diagnostic process and prognostic stratification in acute myocarditis. Presence of late gadolinium enhancement (LGE) and left ventricular (LV) ejection fraction (EF) are known predictors of major adverse cardiovascular events (MACE). However, in daily clinical practice it remains challenging to distinguish ‘the good from the bad’. The prognostic value of CMR feature tracking (FT) derived strain, with respect to LGE and LVEF, remains unclear.

Purpose

To evaluate the incremental prognostic value of left atrial (LA) phasic function, LV and right ventricular (RV) strain using CMR-FT in patients with CMR-proven acute myocarditis.

Methods

In this multicenter observational study, patients with CMR-proven acute myocarditis were included and followed with regard to MACE including all-cause mortality (ACM), heart-failure hospitalizations (HFH), and life-threatening arrhythmias (LTA). Using FT-derived strain, LV global longitudinal strain (GLS), circumferential strain (GCS), and radial strain (GRS), RV GLS and LA phasic function were measured. Uni- and multivariable analysis including clinical and CMR parameters were performed to assess the association with MACE.

Results

A total of 162 patients were included (75% male, 41 ±17 years). MACE occurred in 29 patients (18%, ACM n = 18, HFH n = 7, LTA n = 11) during a median follow-up of 5.5 (2.2-8.3) years. Forty-six percent had a STEMI-like presentation (combination of chest pain, elevated troponin, and ST-elevation, n = 74). LGE was present in 90% of patients and mean LVEF was 51 ± 12%. Patients with LVEF &lt;50% had a significantly worse prognosis compared to patients with LVEF ≥50% (p &lt; 0.0001, Figure A). When we categorized the study population into subgroups of quartile values of LV GLS, patients with LV GLS worse than 18% had a significant worse outcome compared to the other subgroups (p &lt; 0.05, Figure B). Subgroups of LGE extent did not show significantly different associations with outcome (p = 0.458, Figure C). Cox regression analysis showed that LV strain and LA phasic function were univariably associated with MACE, whereas RV GLS and LGE extent were not. All univariable associated strain parameters were separately included in a multivariable model, including age, sex, STEMI-like presentation, and LVEF. LV GLS (HR 1.08, p = 0.01), LV GCS (HR 1.15, p = 0.02), and LV GRS (HR 0.98, p = 0.02) were independent predictors of MACE.

Conclusions

LV strain parameters are independent and incremental predictors of prognosis in patients with acute myocarditis, while RV strain and LA phasic function are not. Therefore, LV strain is a promising novel parameter for risk stratification in acute myocarditis.

Update and, internal and temporal-validation of the FRANCE-2 and ACC-TAVI early-mortality prediction models for Transcatheter Aortic Valve Implantation (TAVI) using data from the Netherlands heart registration (NHR)

Background

The predictive performance of the models FRANCE-2 and ACC-TAVI for early-mortality after Transcatheter Aortic Valve Implantation (TAVI) can decline over time and can be enhanced by updating them on new populations. We aim to update and internally and temporally validate these models using a recent TAVI-cohort from the Netherlands Heart Registration (NHR).

Methods

We used data of TAVI-patients treated in 2013-2017. For each original-model, the best update-method (model-intercept, model-recalibration, or model-revision) was selected by a closed-testing procedure. We internally validated both updated models with 1000 bootstrap samples. We also updated the models on the 2013-2016 dataset and temporally validated them on the 2017-dataset. Performance measures were the Area-Under ROC-curve (AU-ROC), Brier-score, and calibration graphs.

Results

We included 6177 TAVI-patients, with 4.5% observed early-mortality. The selected update-method for FRANCE-2 was model-intercept-update. Internal validation showed an AU-ROC of 0.63 (95%CI 0.62-0.66) and Brier-score of 0.04 (0.04-0.05). Calibration graphs show that it overestimates early-mortality. In temporal-validation, the AU-ROC was 0.61 (0.53-0.67).The selected update-method for ACC-TAVI was model-revision. In internal-validation, the AU-ROC was 0.63 (0.63-0.66) and Brier-score was 0.04 (0.04-0.05). The updated ACC-TAVI calibrates well up to a probability of 20%, and subsequently underestimates early-mortality. In temporal-validation the AU-ROC was 0.65 (0.58-0.72).

Conclusion

Internal-validation of the updated models FRANCE-2 and ACC-TAVI with data from the NHR demonstrated improved performance, which was better than in external-validation studies and comparable to the original studies. In temporal-validation, ACC-TAVI outperformed FRANCE-2 because it suffered less from changes over time.

CMR markers for early right ventricular dysfunction in precapillary pulmonary hypertension

Introduction

Precapillary pulmonary hypertension (pPH) causes right ventricular (RV) pressure overload inducing RV remodeling, often resulting in dysfunction and dilatation, heart failure, and ultimately death. The ability of the right ventricle to adequately adapt to increased pressure loading is key for patients' prognosis. RV ejection fraction (RVEF) by cardiac magnetic resonance (CMR) is related to outcome in pPH patients, but this global measurement is not ideal for detecting early changes in RV function. Strain analysis on CMR using feature tracking (FT) software provides a more detailed assessment, and might therefore detect early changes in RV function.

Aim

1) To compare RV strain parameters in pPH patients and healthy controls, and 2) to compare strain parameters in a subgroup of pPH patients with preserved RVEF (pRVEF) and healthy controls.

Methods

In this prospective study, a CMR was performed in pPH patients and healthy controls. Using FT-software on standard cine images, the following RV strain parameters were analyzed: global, septal, and free wall longitudinal strain (GLS, sept-LS, free wall-LS), time to peak strain (TTP, as a % of the whole cardiac cycle), the fractional area change (FAC), global circumferential strain (GCS), global longitudinal and global circumferential strain rate (GLSR and GCSR, respectively). A pRVEF is defined as a RVEF &gt;50%. To compare RV strain parameters in pPH patients to healthy controls, the Mann-Whitney U test was used.

Results

33 pPH-patients (55 [45–63] yrs; 10 (30%) male) and 22 healthy controls (40 [36–48] yrs; 15 (68%) male) were included. All RV strain parameters were significantly reduced in pPH patients compared to healthy controls (see table), except for GCS and GCSR. Most importantly, in pPH patients with pRVEF (n=8) GLS (−26.6% [−22.6 to −27.3] vs. −28.1% [−26.2 to −30.6], p=0.04), sept-LS (−21.2% [−19.8 to −23.2] vs. −26.0% [−24.0 to −27.9], p=0.005), and FAC (39% [35–44] vs. 44% [42–47], p=0.02) were still significantly impaired compared to healthy controls. The RV TTP was significantly increased in pPH patients compared to healthy controls (47% [44–57] vs. 40% [33–43], p≤0.001).

Conclusions

Several CMR-FT strain parameters of the right ventricle are impaired in pPH patients when compared to healthy controls. Moreover, even in pPH patients with a preserved RVEF multiple RV strain parameters (GLS, sept-LS, and FAC) remained significantly impaired, and TTP significantly prolonged, in comparison to healthy controls. This suggests that RV strain parameters may be used as an early marker of RV dysfunction in pPH patients.

Funding Acknowledgement

Type of funding source: None

Cardiac function in relation to myocardial injury in hospitalised patients with COVID-19

BACKGROUND

Previous studies have reported on myocardial injury in patients with coronavirus infectious disease 19 (COVID-19) defined as elevated cardiac biomarkers. Whether elevated biomarkers truly represent myocardial dysfunction is not known. The aim of this study was to explore the incidence of ventricular dysfunction and assess its relationship with biomarker analyses.

METHODS

This cross-sectional study ran from April 1 to May 12, 2020, and consisted of all consecutively admitted patients to the Radboud university medical centre nursing ward for COVID-19. Laboratory assessment included high-sensitivity Troponin T and N‑terminal pro-B-type natriuretic peptide (NT-proBNP). Echocardiographic evaluation focused on left and right ventricular systolic function and global longitudinal strain (GLS).

RESULTS

In total, 51 patients were included, with a median age of 63 years (range 51-68 years) of whom 80% was male. Troponin T was elevated (>14 ng/l) in 47%, and a clinically relevant Troponin T elevation (10 × URL) was found in three patients (6%). NT-proBNP was elevated (>300 pg/ml) in 24 patients (47%), and in four (8%) the NT-proBNP concentration was >1,000 pg/ml. Left ventricular dysfunction (ejection fraction <52% and/or GLS >-18%) was observed in 27%, while right ventricular dysfunction (TAPSE <17 mm and/or RV S' < 10 cm/s) was seen in 10%. There was no association between elevated Troponin T or NT-proBNP and left or right ventricular dysfunction. Patients with confirmed pulmonary embolism had normal right ventricular function.

CONCLUSIONS

In hospitalised patients, it seems that COVID-19 predominantly affects the respiratory system, while cardiac dysfunction occurs less often. Based on a single echocardiographic evaluation, we found no relation between elevated Troponin T or NT-proBNP, and ventricular dysfunction. Echocardiography has limited value in screening for ventricular dysfunction.

The rationale of using cerebral embolic protection devices during transcatheter aortic valve implantation

Aortic valve stenosis is one of the most common valvular abnormalities, which can manifest as angina, syncope, dyspnoea and sudden cardiac death. Transcatheter aortic valve implantation (TAVI) has been introduced as an alternative to surgical valve replacement in patients with severe aortic valve stenosis, resulting in less morbidity, shorter time to recovery and similar mortality rates. Progress in this field has reduced complication rates. However, the incidence of peri-procedural stroke remains relatively high (around 4%). To fully utilise the potential of TAVI, cerebral embolic protection devices (CEPD) have been developed and introduced. In this position paper, we aim to summarise the available data on several CEPD.

Analysis of the Prevalence and Causes of Ultrafiltration Failure during Long-Term Peritoneal Dialysis: A Cross-Sectional Study

Background

Ultrafiltration failure (UFF) is a major complication of peritoneal dialysis (PD). It can occur at any stage of PD, but develops in time and is, therefore, especially important in long-term treatment. To investigate its prevalence and to identify possible causes, we performed a multicenter study in The Netherlands, where patients treated with PD for more than 4 years were studied using a peritoneal function test (standard peritoneal permeability analysis) with 3.86% glucose. UFF was defined as net UF < 400 mL after a 4-hour dwell.

Results

55 patients unselected for the presence or absence of UFF were analyzed. Mean age was 48 years (range 18 – 74 years); duration of PD ranged from 48 to 144 months (median 61 months); UFF was present in 20 patients (36%). Patients with and without UFF did not differ in age or duration of PD. Median values for patients with normal UF compared to patients with UFF were, for net UF 659 mL versus 120 mL ( p < 0.01), transcapillary UF rate 3.8 versus 2.1 mL/minute ( p < 0.01), effective lymphatic absorption 1.0 versus 1.6 mL/min ( p < 0.05), mass transfer area coefficient (MTAC) for creatinine 9.0 versus 12.9 mL/min ( p < 0.01), dialysate-to-plasma ratio (D/P) for creatinine 0.71 versus 0.86 ( p < 0.01), glucose absorption 60% versus 73% ( p < 0.01), maximum dip in D/P sodium (as a measure of free water transport) 0.109 versus 0.032 ( p < 0.01), and osmotic conductance to glucose 3.0 versus 2.1 μL/min/mmHg ( p < 0.05). As causes for UFF, high MTAC creatinine, defined as > 12.5 mL/min, or a glucose absorption > 72%, both reflecting a large vascular surface, a lymphatic absorption rate (LAR) of > 2.14 mL/min, and a decreased dip in D/P sodium of < 0.046 were identified. Most patients had a combination of causes (12 patients), whereas there was only a decreased dip in D/P sodium in 3 patients, only high MTAC creatinine in 1 patient, and only high LAR in 2 patients. We could not identify a cause in 2 patients. Both groups had similar clearances of serum proteins and peritoneal restriction coefficients. However, dialysate cancer antigen 125 concentrations, reflecting mesothelial cell mass, were lower in the UFF patients (2.79 vs 5.38 U/L).

Conclusion

The prevalence of UFF is high in long-term PD. It is caused mainly by a large vascular surface area and by impaired channel-mediated water transport. In addition, these patients also had signs of a reduced mesothelial cell mass, indicating damage of the peritoneum on both vascular and mesothelial sites.

Nurses as a source of system-level resilience: Secondary analysis of qualitative data from a study of intravenous infusion safety in English hospitals

Background

Deviations from local policy and national recommended best practice are common in the administration of intravenous infusions, but not all result in negative consequences. Some are the result of nurses’ clinical judgement. However, little is known about such practices and their effects on the safety of intravenous infusions. Our objective was to explore ways in which nurses contribute to system-level resilience when administering intravenous infusions.

Methods

We conducted a secondary analysis of qualitative data from debriefs and focus groups from a mixed methods study of errors and policy deviations in intravenous infusion administration across 16 English hospitals. Analysis focused on nurses’ contributions to system-level resilience, drawing on Larcos’s et al. framework of types of resilience.

Results

Five types of system-level resilience were identified in nurses’ behaviour: anticipatory resilience, responsive resilience, resilience based on past experience, workarounds and nurses performing informal ‘risk assessments’ in relation to how best to treat individual patients. Examples of practices contributing to infusion safety were found for each of these types of resilience.

Conclusion

Our findings suggest nurses are a key source of system-level resilience. Some behaviours that may be considered deviations from policy or best practice are the result of reasoned clinical judgement to improve infusion safety in response to the specific situation at hand. Adaptive behaviour is necessary to cope with the complexity of practice. There is a tension between standardisation and supporting flexibility in safety management.

Spontaneous Platelet Aggregation in Cerebrovascular Disease

50 patients from a group of 130 patients with transient ischaemic attacks or cerebral infarction were found to demonstrate in vitro spontaneous platelet aggregation (SPA) while 80 normal subjects tested never showed this phenomenon.

The following additional findings point towards a possible platelet abnormality:

1. Platelets from 10 patients with SPA when isolated and resuspended in normal plasma still demonstrated SPA while isolated normal platelets resuspended in patient’s plasma did not.

2. Platelets demonstrating SPA showed an increased aggregation tendency upon incubation with ADP while normal platelets developed the expected refractory state.

SPA was found to be dependant upon the presence of divalent cations and could further be inhibited by phentolamine and adenosine. Aspirin effectively abolished SPA in 50 patients and relieved the clinical symptoms of patients with recurrent complaints of transient blindness and paraesthesia.

Spontaneous Platelet Aggregation in Cerebrovascular Disease II

A group of 186 patients with Transient Ischaemic Attacks (TIA) or cerebral Infarction (Cl) was found to demonstrate in vitro Spontaneous Platelet Aggregation (SPA) in 39% of those studied. Of the 176 normal subjects studied the incidence of in vitro SPA was found to be 5%. Further investigation of the phenomenon of SPA revealed that:

1. it is associated with ADP-hyperaggregability, i. e. the threshold concentration to induce second wave aggregation is decreased;

2. it is dependant on the increase in pH which occurs in platelet-rich plasma stirring in an aggregometer while concurrent ADP-hyperaggregability is independant of this change in pH;

3. it is associated with malondialdehyde production and the release of endogenous 5- hydroxytryptamine; and that

4. in addition Km and Vmax values for [14C]-5HT incorporation are normal; and that

5. no gross abnormalities of the platelet membrane glycoproteins were apparent although occasionally glycoprotein III was found to be increased.

This study demonstrates abnormal platelet behaviour in patients with TIA and Cl where the enzyme system involved in thromboxane production is sufficiently stimulated, by stirring alone, to induce aggregation of platelets and the release reaction.

Acetylsalicylic acid abolishes SPA and prolongs the bleeding time with similar characteristics as has been described for normal individuals. Plasma (3-thromboglobulin levels are significantly increased in the patients studied. However, no correlation was established with the incidence of in vitro SPA.

Orientation-dependent stereo Wigner time delay and electron localization in a small molecule

Attosecond metrology of atoms has accessed the time scale of the most fundamental processes in quantum mechanics. Transferring the time-resolved photoelectric effect from atoms to molecules considerably increases experimental and theoretical challenges. Here we show that orientation- and energy-resolved measurements characterize the molecular stereo Wigner time delay. This observable provides direct information on the localization of the excited electron wave packet within the molecular potential. Furthermore, we demonstrate that photoelectrons resulting from the dissociative ionization process of the CO molecule are preferentially emitted from the carbon end for dissociative ²Σ states and from the center and oxygen end for the ²Π states of the molecular ion. Supported by comprehensive theoretical calculations, this work constitutes a complete spatially and temporally resolved reconstruction of the molecular photoelectric effect.

Defining and Measuring a Standard Set of Patient-Relevant Outcomes in Coronary Artery Disease

Systematic outcome measurement enables to continuously improve treatment results and stimulates dissemination of best practices. For patients with coronary artery disease, no examples yet exist of standard sets of patient-relevant outcome measures that have already been fully implemented at a large scale in clinical care. The aim of this paper is twofold: (1) to share the standard set of outcome measures as developed by Meetbaar Beter, and (2) to show how the standard set is presented and published to support improvement of cardiac care. A step-wise approach was followed by an expert panel to construct a standard set of outcome measures. This resulted in a comprehensive set of relevant outcome measures, comprising 4 generic and 11 treatment-specific outcomes. Both short-term and long-term outcomes measures up to 5 years of follow-up were included. Relevant initial conditions were selected to enable case-mix adjustment. The standard set has been implemented in 21 hospitals across the Netherlands. The results and experiences have been used to fine-tune the set in 4 reporting cycles in 2012 to 2016, using an annual maintenance cycle. Currently about 83,000 percutaneous coronary interventions and 30,000 coronary artery bypass graftings are included in the dataset, covering the majority of all percutaneous coronary interventions and coronary artery bypass graftings in the Netherlands. In conclusion, Meetbaar Beter has defined and implemented a comprehensive set of patient-relevant outcome measures for coronary artery disease, and the variation of the results among the centers indicates that there are sufficient opportunities to further improve cardiac care in the Netherlands.

Comparison of attosecond streaking and RABBITT

Recent progress in the generation of ultra-short laser pulses has enabled the measurement of photoionization time delays with attosecond precision. For single photoemission time delays the most common techniques are based on attosecond streaking and the reconstruction of attosecond beating by interference of two-photon transitions (RABBITT). These are pump-probe techniques employing an extreme-ultraviolet (XUV) single attosecond pump pulse for streaking or an attosecond pump pulse train for RABBITT, and a phase-locked infrared (IR) probe pulse. These techniques can only extract relative timing information between electrons originating from different initial states within the same atom or different atoms. Here we address the question whether the two techniques give identical timing information. We present a complete study, supported by both experiments and simulations, comparing these two techniques for the measurement of the photoemission time delay difference between valence electrons emitted from the Ne 2p and Ar 3p ground states. We highlight not only the differences and similarities between the two techniques, but also critically investigate the reliability of the methods used to extract the timing information.

Prophylactic intraoperative antithrombotics in open infrainguinal arterial bypass surgery: a systematic review

Unfractionated heparin (UFH) is used intraoperatively as antithrombotic by most vascular surgeons worldwide during infrainguinal bypass surgery (IABS) to reduce the risk of peroperative and early graft thrombosis. To reduce the harmful side effects of UFH (bleeding complications, HIT) and to reduce peroperative and early graft failure, other pharmaceuticals have been suggested for IABS. A systematic review was performed using MEDLINE, EMBASE and Cochrane databases. Only 9 studies on IABS and intraoperative antithrombotic use were eligible for review. Between studies heterogeneity was high and investigated study populations were often of small size. No study was retrieved comparing UFH to no-UFH. Dextran, human antithrombin and iloprost showed no beneficial effect compared to UFH alone for patency, mortality and morbidity. Low molecular weight heparin (LMWH) has potential benefits compared to UFH, but a statistically significant effect could not be demonstrated from the current review. The use of UFH during IABS to prevent intraoperative graft thrombosis has not been proven in randomized clinical trials. Dextran, human antithrombin and iloprost showed to be of no added beneficial effect for the patient compared to UFH alone. Data on the use of LMWH instead of UFH are promising, but no statistically significant benefit could be reproduced from literature. Results from a recent Cochrane review were favourable for LMWH, but it appeared that included data were not complete in that review. Randomized controlled trials are required for intra-operative use of antithrombotics and to improve peroperative and early patency after IABS.

Perioperative prophylactic antithrombotic strategies in vascular surgery: current practice in the Netherlands

AIM

The aim of this study was to evaluate the current practice of the use of perioperative antithrombotic drugs to prevent arterial thrombo-embolic complications during arterial vascular surgery by Dutch vascular surgeons. Aim was also to compare the results with the literature and to evaluate the effect of guidelines.

METHODS

A comprehensive questionnaire was sent to all Dutch vascular surgeons performing arterial reconstructive surgery.

RESULTS

The response rate was 84%. Acetylsalicylic acid (ASA) was continued perioperatively by most surgeons (91%). Clopidogrel was discontinued by the majority of respondents (65%). During operation 97% of surgeons administered unfractionated heparin (UFH) before arterial clamping. A minority (11%) measures peroperatively anticoagulant activity in patients' blood. After infrainguinal venous bypass most surgeons (81%) preferred monotherapy with vitamin K antagonists (VKA), in agreement with the Dutch guideline in this respect. Before the introduction of the guideline in 2005, a survey was performed in 2004. Results of our 2011 survey showed more respondents (6% to 11%) prescribed ASA or VKA according to these guidelines.

CONCLUSION

This survey showed a recognizable pattern of variation for perioperative arterial thrombosis prophylaxis amongst Dutch vascular surgeons, in agreement with reports from other countries over the past 20 years. Although a higher percentage of surgeons complied in 2011 with existing guidelines than in 2004, guidelines were not completely met. Possibly because current guidelines are not fully supported by evidence and do not cover all aspects of perioperative arterial thrombosis prophylaxis. Clearly there is need for (more) convincing data based on RCT's concerning the various aspects of perioperative arterial thrombosis prophylaxis.

Leaf photosynthesis and respiration of three bioenergy crops in relation to temperature and leaf nitrogen: how conserved are biochemical model parameters among crop species?

Given the need for parallel increases in food and energy production from crops in the context of global change, crop simulation models and data sets to feed these models with photosynthesis and respiration parameters are increasingly important. This study provides information on photosynthesis and respiration for three energy crops (sunflower, kenaf, and cynara), reviews relevant information for five other crops (wheat, barley, cotton, tobacco, and grape), and assesses how conserved photosynthesis parameters are among crops. Using large data sets and optimization techniques, the C(3) leaf photosynthesis model of Farquhar, von Caemmerer, and Berry (FvCB) and an empirical night respiration model for tested energy crops accounting for effects of temperature and leaf nitrogen were parameterized. Instead of the common approach of using information on net photosynthesis response to CO(2) at the stomatal cavity (A(n)-C(i)), the model was parameterized by analysing the photosynthesis response to incident light intensity (A(n)-I(inc)). Convincing evidence is provided that the maximum Rubisco carboxylation rate or the maximum electron transport rate was very similar whether derived from A(n)-C(i) or from A(n)-I(inc) data sets. Parameters characterizing Rubisco limitation, electron transport limitation, the degree to which light inhibits leaf respiration, night respiration, and the minimum leaf nitrogen required for photosynthesis were then determined. Model predictions were validated against independent sets. Only a few FvCB parameters were conserved among crop species, thus species-specific FvCB model parameters are needed for crop modelling. Therefore, information from readily available but underexplored A(n)-I(inc) data should be re-analysed, thereby expanding the potential of combining classical photosynthetic data and the biochemical model.

Ultrasound-accelerated thrombolysis for lower extremity ischemia: multicenter experience and literature review

AIM

This study evaluates the short-term outcome of ultrasound-accelerated thrombolysis in patients with lower extremity ischemia caused by thromboembolic occlusions.

METHODS

A retrospective cohort study was conducted from December 2008 to May 2011 of 57 patients (42 men; median age, 66 ± 11 years) undergoing 62 episodes of ultrasound-accelerated thrombolysis for thromboembolic arterial occlusions of the lower extremities. The EKOS EndoWave System (EKOS Corporation, Bothell, WA, USA) was combined with urokinase (100000 IU/hour). Thirty-day and 6-month follow-up consisted of clinical evaluation, and Duplex scan or magnetic resonance angiography of the treated extremity.

RESULTS

Initial technical success was 97%, radiologic success was 82%, and overall clinical success was 77%. Median thrombolysis time was 21 hours (IQR, 15-24). In 38 of 51 procedures with successful lysis (75%) complete lysis was achieved within 24 hours. Major hemorrhage occurred in 2 procedures (3%), and distal embolization in 2 procedures (3%). During the initial hospitalization, the major amputation rate was 8% (N.=5) and the mortality rate was 2% (N.=1). The 30-day patency rate was 81%, without additional mortality. During a median 6-month (range, 2-14) follow-up, 9 reinterventions were performed. Two patients underwent major amputation and 3 patients died; because of malignancy (N.=2) and stroke (N.=1).

CONCLUSION

Initial success rates of ultrasound-accelerated thrombolysis are high and complication rate is low. However, reintervention rate during short-term follow-up for recurrent ischemia is substantial. Results from a randomized controlled trial comparing ultrasound-accelerated thrombolysis with standard thrombolysis for lower extremity ischemia (DUET, Current Controlled Trials, ISRCTN72676102) are eagerly awaited.

Simulation of wheat growth and development based on organ-level photosynthesis and assimilate allocation

Intimate relationships exist between form and function of plants, determining many processes governing their growth and development. However, in most crop simulation models that have been created to simulate plant growth and, for example, predict biomass production, plant structure has been neglected. In this study, a detailed simulation model of growth and development of spring wheat (Triticum aestivum) is presented, which integrates degree of tillering and canopy architecture with organ-level light interception, photosynthesis, and dry-matter partitioning. An existing spatially explicit 3D architectural model of wheat development was extended with routines for organ-level microclimate, photosynthesis, assimilate distribution within the plant structure according to organ demands, and organ growth and development. Outgrowth of tiller buds was made dependent on the ratio between assimilate supply and demand of the plants. Organ-level photosynthesis, biomass production, and bud outgrowth were simulated satisfactorily. However, to improve crop simulation results more efforts are needed mechanistically to model other major plant physiological processes such as nitrogen uptake and distribution, tiller death, and leaf senescence. Nevertheless, the work presented here is a significant step forwards towards a mechanistic functional-structural plant model, which integrates plant architecture with key plant processes.

Analysing lodging of the panicle bearing cereal teff (Eragrostis tef)

Lodging, the permanent displacement of crop plants from their vertical because of root or shoot failure, is a major yield constraint of the gluten free, panicle bearing cereal teff. The objective of this paper was to analyse the causes of lodging of teff by using, modifying and validating conventional biomechanical models. The model parameters were obtained from a field trial with two contrasting teff cultivars, using novel in situ and laboratory measurements under wet and dry conditions. Cross-species model validation was done with rice (Oryza sativa). Teff is more susceptible to root lodging than to shoot lodging, although the data indicated that shoot strength is also insufficient. Hence, simultaneously breeding for both improved root anchorage and shoot strength is advocated. The study showed that the lodging model, derived for the spike-bearing cereal wheat, needed modifications in order to be able to deal with panicle-bearing plants such as teff and rice. Water adhering to plants owing to rain or dew increased calculated lodging susceptibility. To prevent underestimation of lodging susceptibility, future lodging research should be done under completely wet conditions (water saturated soil and wetted shoots).

Functional-structural plant modelling: a new versatile tool in crop science

Plants react to their environment and to management interventions by adjusting physiological functions and structure. Functional-structural plant models (FSPM), combine the representation of three-dimensional (3D) plant structure with selected physiological functions. An FSPM consists of an architectural part (plant structure) and a process part (plant functioning). The first deals with (i) the types of organs that are initiated and the way these are connected (topology), (ii) co-ordination in organ expansion dynamics, and (iii) geometrical variables (e.g. leaf angles, leaf curvature). The process part may include any physiological or physical process that affects plant growth and development (e.g. photosynthesis, carbon allocation). This paper addresses the following questions: (i) how are FSPM constructed, and (ii) for what purposes are they useful? Static, architectural models are distinguished from dynamic models. Static models are useful in order to study the significance of plant structure, such as light distribution in the canopy, gas exchange, remote sensing, pesticide spraying studies, and interactions between plants and biotic agents. Dynamic models serve quantitatively to integrate knowledge on plant functions and morphology as modulated by environment. Applications are in the domain of plant sciences, for example the study of plant plasticity as related to changes in the red:far red ratio of light in the canopy. With increasing availability of genetic information, FSPM will play a role in the assessment of the significance towards plant performance of variation in genetic traits across environments. In many crops, growers actively manipulate plant structure. FSPM is a promising tool to explore divergent management strategies.

[High mortality in a herd with signs of jejunal hemorrhage syndrome]

Eleven cows from a herd of 80 dairy cows (14%) died over a 7-month period. Death occurred within 12-24 hours of the onset of the first clinical signs, namely, dullness and a decrease (mean 25%) in milk production. Within 12 hours the cows were unable to rise, felt cold, and were restless. Examined mucous membranes were pale. Two of three cows examined at necropsy had blood in the jejunum and high counts of Clostridium perfringens. Jejunal hemorrhage syndrome was diagnosed in these two cows on the basis of the clinical signs and postmortem findings.

[Stillbirth/perinatal weak calf syndrome in dairy heifers: results of a pilot study]

A pilot study of 10 Dutch dairy herds was performed to investigate possible causes of stillbirth/perinatal weak calf syndrome in heifers. Possible causes and advice for further investigations on farms affected by this syndrome are discussed based on the results of investigations of blood and urine from pregnant young stock, postmortem examination of still-born calves, and a questionnaire held among farmers. Infections with Neospora caninum, Salmonella spp. or Leptospira hardjo, or a deficiency of iodine could be excluded.

Sonotherapy, antirestenotic therapeutic ultrasound in coronary arteries: the first clinical experience

We studied the safety and feasibility of intracoronary sonotherapy (IST) and its effect on the coronary vessel at 6 months. Thirty-seven patients with stable or unstable angina were included (40 lesions). The indication was de novo lesion (n = 26), restenosis (n = 2), in-stent restenosis (n = 11), and a total occlusion of a venous bypass graft. After successful angioplasty, IST was performed using a 5 Fr catheter with three serial ultrasound transducers operating at 1 MHz. IST was successfully performed in 36 lesions (success rate, 90%). IST exposure time per lesion was 718 +/- 127 sec. During hospital stay, one patient died due to a bleeding complication. At 6-month follow-up, one patient experienced acute myocardial infarction, eight patients underwent repeat PTCA. No patient underwent CABG. Late lumen loss was 1.05 +/- 0.70 mm with a restenosis rate of 25%. IVUS analysis revealed a neointima burden of 25% +/- 11%. IST can be applied safely and with high acute procedural success. Sonotherapy-related major adverse events were not observed. Late lumen loss and neointimal growth were similar to conventional PTCA approaches. These results justify the initiation of randomized clinical efficacy studies.

Reduced impact of migraine in everyday life: an observational study in the Dutch Society of Headache Patients

OBJECTIVE

To explore the percentage of patients who report a reduced impact of migraine on their life, and to which factors this improvement can be attributed.

METHODS

Four hundred forty-eight members of the Dutch Society of Headache Patients answered a set of structured questionnaires, including the Migraine-Specific Quality of Life instrument (MSQOL).

RESULTS

Of this group, 70% reported a reduced impact of migraine. The most frequently reported reason for this reduction was a change in medication (77%); in particular, change to a triptan. Other favorable factors included a change in life-style (56%): 42% of patients reported more relaxed coping with migraine, a reduction of stress in general (28%) and of stress related to work (24%), and leading a more regular life-style (21%). In addition, social support was frequently mentioned, particularly that offered by the Dutch Society of Headache Patients (58%), family (46%), and their general practitioner (28%). The patients who reported a reduced impact of migraine had less migraine attacks and a higher quality of life than those who did not report such a reduction.

CONCLUSION

The results confirm that factors that are proven effective in clinical trials on migraine also have these effects outside a formal experimental environment.