Evaluation of new alternative methods for the identification of estrogenic, androgenic and steroidogenic effects: a comparative in vitro/in silico study

A suite of in vitro assays and in silico models were evaluated to identify which best detected the endocrine-disrupting (ED) potential of 10 test chemicals according to their estrogenic, androgenic and steroidogenic (EAS) potential compared to the outcomes from ToxCast. In vitro methods included receptor-binding, CALUX transactivation, H295R steroidogenesis, aromatase activity inhibition and the Yeast oestrogen (YES) and Yeast androgen screen (YAS) assays. The impact of metabolism was also evaluated. The YES/YAS assays exhibited a high sensitivity for ER effects and, despite some challenges in predicting AR effects, is a good initial screening assay. Results from receptor-binding and CALUX assays generally correlated and were in accordance with classifications based on ToxCast assays. ER agonism and AR antagonism of benzyl butyl phthalate were abolished when CALUX assays included liver S9. In silico final calls were mostly in agreement with the in vitro assays, and predicted ER and AR effects well. The efficiency of the in silico models (reflecting applicability domains or inconclusive results) was 43-100%. The percentage of correct calls for ER (50-100%), AR (57-100%) and aromatase (33-100%) effects when compared to the final ToxCast call covered a wide range from highly reliable to less reliable models. In conclusion, Danish (Q)SAR, Opera, ADMET Lab LBD and ProToxII models demonstrated the best overall performance for ER and AR effects. These can be combined with the YES/YAS assays in an initial screen of chemicals in the early tiers of an NGRA to inform on the MoA and the design of mechanistic in vitro assays used later in the assessment. Inhibition of aromatase was best predicted by the Vega, AdmetLab and ProToxII models. Other mechanisms and exposure should be considered when making a conclusion with respect to ED effects.

A genome-wide genomic score added to standard recommended stratification tools does not improve the identification of patients with very low bone mineral density

The role of integrating genomic scores (GSs) needs to be assessed. Adding a GS to recommended stratification tools does not improve the prediction of very low bone mineral density. However, we noticed that the GS performed equally or above individual risk factors in discrimination.

PURPOSE

We aimed to investigate whether adding a genomic score (GS) to recommended stratification tools improves the discrimination of participants with very low bone mineral density (BMD).

METHODS

BMD was measured in three thoracic vertebrae using CT. All participants provided information on standard osteoporosis risk factors. GSs and FRAX scores were calculated. Participants were grouped according to mean BMD into very low (<80 mg/cm3), low (80-120 mg/cm3), and normal (>120 mg/cm3) and according to the Bone Health and Osteoporosis Foundation recommendations for BMD testing into an "indication for BMD testing" and "no indication for BMD testing" group. Different models were assessed using the area under the receiver operating characteristics curves (AUC) and reclassification analyses.

RESULTS

In the total cohort (n=1421), the AUC for the GS was 0.57 (95% CI 0.52-0.61) corresponding to AUCs for osteoporosis risk factors. In participants without indication for BMD testing, the AUC was 0.60 (95% CI 0.52-0.69) above or equal to AUCs for osteoporosis risk factors. Adding the GS to a clinical risk factor (CRF) model resulted in AUCs not statistically significant from the CRF model. Using probability cutoff values of 6, 12, and 24%, we found no improved reclassification or risk discrimination using the CRF-GS model compared to the CRF model.

CONCLUSION

Our results suggest adding a GS to a CRF model does not improve prediction. However, we noticed that the GS performed equally or above individual risk factors in discrimination. Clinical risk factors combined showed superior discrimination to individual risk factors and the GS, underlining the value of combined CRFs in routine clinics as a stratification tool.

Bias in self-reported height and weight in a cohort of young adults – perspectives for cardio-metabolic risk prevention programmes

Background

Precise assessment of obesity is essential in evaluating and applying preventive strategies to avoid adverse cardio-metabolic risk profiles later in life. Self-reported measures of height and weight is often used in cohort and cross-sectoral studies due to practical and financial reasons. However, bias due to self-reporting is well known with risk of overestimation of height and underestimation of weight. The latter is particular reported among women and persons with obesity. Little is known about the influence of educational factors in the self-reporting of height and weight. To gain insight into the extent to which different factors bias self-reporting, is important to assess the validity of self-reported body mass index (BMI) within groups of people with certain characteristics.

Purpose

The aim was to investigate the validity of self-reported height and weight versus objective measured height and weight. Additionally, the study aimed to examine if sex, measured BMI, and educational factors biased the self-reporting differenially.

Methods

The study included 264 participants, all aged 28 years who were a sub-sample from an ongoing cohort in Central Denmark Region. The participants attended a physical health examination, including measures of height and weight after having self-reported these not knowing they were to be objectively measured later. Data of their own and parental educational levels were drawn from registries. Paired t-tests were used to assess the descriptive differences between self-reported and measured values and linear regression was used to assess the independent effects of sex, education, and BMI on the differences. In model 1 adjustment for all other variables except for BMI was conducted and full adjustments were made in model 2.

Results

Overall, participants overestimated their height by 0.89 (0.67; 1.10) cm and underestimated their weight by 2.47 (1.78; 3.17) kg (Table 1). Female sex was found to independently bias underreporting of weight (β −1.51 (−2.86; −0.15)) and male sex overestimated height (β 0.83 (0.38; 1.27) (Table 2). Additionally, being overweight or obese also independently biased the underestimation of self-reported weight ((β 2.23 (0.64; 3.83) and β 5.22 (3.51; 6.94)) (Table 2). Additionally, participants with overweight were less likely to overestimate their height compared to those with normal weight. Without adjustments for BMI, low level of education also biased underestimation of weight significantly (Table 2).

Conclusion

Women and persons with obesity in particular underestimated weight. Participants with lower level of education also underestimated weight but this was explained by obesity. Men overestimated their height but participants with obesity were less likely to overestimate height compared to normal weighty. When screening for overweight and obesity to initiate interventions to prevent cardio-metabolic diseases, the lack of accuracy in self-reported values must be taken into account.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of coronary artery calcifications in patients with newly diagnosed prostate cancer

Background

Patients diagnosed with prostate cancer (PCa) are known to be at increased risk of cardiovascular events. Because of the ageing population and better cancer treatment, the number of these patients is increasing. A prostate-specific membrane antigen positron emission tomography (PSMA-PET) is guideline recommended as part of the diagnostic workup. This scan includes a non-ECG-gated computed tomography (CT) of the thorax, allowing assessment of coronary artery calcifications (CAC). It is not well-established, whether estimation of CAC based on this CT scan can identify patients with increased risk of major adverse cardiac events (MACE) and thus possibly improve therapy and prognosis.

Purpose

This study aims to assess CAC and evaluate whether high calcium scores predict the risk of MACE in patients newly diagnosed with PCa.

Methods

We identified 634 consecutive patients diagnosed with PCa and undergoing PSMA-PET from 2016 to 2019 in an area of 300.000 residents. In total, 63 patients were excluded due to prior revascularization. The remaining 571 patients (mean age 69.9±6.7 years) were included. Patients were followed until June 2021 or until an event occurred (mean follow-up 962±372 days). We used a standard cardiac CT software to assess CAC. Information on MACE defined as all-cause mortality, stroke and myocardial infarction were obtained from electronic patient files. We divided patients into five groups based on their coronary artery calcium score (CACS): 0–10, 11–99, 100–399, 400–999, and + 1000. Cox regression analysis was used to compute the hazard ratios (HR) for MACE with CACS 0–10 as reference while adjusting for age, hypertension diabetes, and treatment with aspirin and statins.

Results

We found a significantly increasing risk of MACE with increasing CACS after adjustment for risk factors. For CACS 100–399 (n=136): HR 2.10 (95% CI: 0.98–4.51, p=0.056), for CACS 400–999 (n=79): HR of 2.99 (95% CI: 1.35–6.59, p=0.007) and for CACS +1000 (n=150): HR 3.06 (95% CI: 1.37–6.85, p=0.006) (Figure 1). Cardiovascular disease prevention treatment with statins and aspirin was 53% and 16% in patients with CACS 400–999 and 52% and 19% in patients with CACS + 1000.

Conclusion

In patients with PCa, estimating coronary calcium score based on non-ECG-gated CT scans, which are performed as part of the diagnostic workup, predicts the occurrence of MACE. In the patient group with the highest CAC, a four-year event rate of 24% was found. In combination with the finding of infrequent use of statin and aspirin, this emphasizes the possibility of early detection of high CAC in patients with PCa and illustrates the potential for more extensive use of preventive treatment. Future studies should investigate the effect of preventive treatment being initiated in patients with PCa and high CAC.

Funding Acknowledgement

Type of funding sources: None.

An acoustic based risk score in addition to pre-test probability estimation for coronary artery disease improves risk classification in patients with suspected coronary artery disease

Background

The 2021 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline for Evaluation and Diagnosis of Chest Pain introduced a new pre-test probability (PTP)-table for risk stratification of patients with symptoms suggestive of coronary artery disease (CAD). The CAD-score, an acoustic-based risk score for obstructive CAD, has previously shown good rule out capability in patients with suggested CAD when added to PTP.

Purpose

To investigate the potential of the acoustic CAD-score to 1) reclassify patients from intermediate-high to low PTP, and 2) improve risk-stratification in patients with low PTP, when added to the 2021 AHA/ACC PTP.

Methods

This is a retrospective study of patients with successfully obtained CAD-score from The Danish study of Non-Invasive testing in Coronary artery Disease 1 (Dan-NICAD 1) of patients without known CAD referred for coronary computed tomography angiography with angina pectoris. Patients with suspected obstructive CAD underwent invasive angiography. CAD-score was obtained with a non-invasive acoustic device analysing heart sounds based on CAD-related turbulence. CAD-score≤20 indicated low probability of CAD. PTP was calculated from sex, age, and angina symptoms according to current AHA/ACC Guidelines. Low likelihood of CAD was defined as PTP≤15%, and intermediate-high likelihood as PTP&gt;15%. Hemodynamic obstructive CAD was defined as visual luminal diameter stenosis &gt;90% on angiography or FFR&lt;0.80%.

Results

Among the 1475 included patients (52.3% women, median age 57 years IQR [50–64[), 36.4% were categorized as low likelihood of CAD (PTP≤15%), and 9.8% of patients had obstructive CAD. Compared to patients with PTP≤15%, patients with PTP&gt;15%, were older, more often hypertensive (49.8% vs. 35.5%), had a higher median CAD-score (28 [22–38] vs. 16 [12–22]), and had more obstructive CAD (12.4% vs. 5.2%). CAD-score reclassified 17.6% of patients with intermediate-high likelihood to a low likelihood of CAD and decreased the post-test probability of obstructive CAD from 5.2% to 4.7%. Subgroup analyses showed reclassification was greater in men, patients with PTP ≤25%, age &lt;70 years or no hypertension. In the 432 patients with PTP&gt;15%, age&lt;70 and no hypertension, 35.4% were reclassified to low likelihood, whereas only 2.4% of patients with PTP&gt;15%, age≥70 years or hypertension were ruled out by CAD-score ≤20. In patients with low PTP≤15%, CAD-score≤20 risk-stratified 361 (67.2%) patients to very low and 176 (32.8%) to an intermediate-low likelihood of CAD, but the post-test probabilities of CAD in both subgroups were still below the cut-off of 15 (3.6% vs. 8.5%).

Conclusion

Adding an acoustic-based CAD-score to the AHA/ACC PTP could potentially reduce the need for further diagnostic testing by 17.6% in patients with intermediate-high likelihood of CAD and in subgroups a reduction of 35% can be achieved. Use of CAD-score in low-likelihood patients only moderately improves risk classification.

Funding Acknowledgement

Type of funding sources: None.

External validation of prediction models for obstructive coronary artery disease in patients with suspected stable coronary artery disease

Background

Pre-test probability (PTP) is an important tool in the diagnostic work-up for obstructive coronary artery disease (CAD) but must be calibrated to the declining disease prevalence in patients referred to diagnostic testing.

Purpose

To externally validate the published basic and clinical PTP models in a contemporary angina cohort with low prevalence of CAD and to compare with the reference European Society of Cardiology 2019 PTP (ESC 2019 PTP).

Methods

The validation cohort consisted of 42.328 patients (54% women, age ≥30 years, no previous CAD) with symptoms of CAD referred for cardiac computed tomography angiography in the western region of Denmark from 2008–2017 (3.3 million inhabitants). Obstructive CAD was defined from either invasive angiography as stenosis &gt;50%, or when performed, from FFR &lt;0.8 in coronary arteries with diameters &gt;2 mm.

The basic prediction model included type of angina, sex, and age, and the clinical model added diabetes, family history of CAD, and dyslipidemia. The ESC 2019 PTP was calculated from age, sex, and angina symptoms. Discrimination, calibration, and negative predictive value (NPV) were measured for all three models.

Results

Obstructive CAD was present in 3718 (8.8%). In the ESC 2019 PTP model, the basic model, and the clinical model 19.5%, 48.5%, and 55.7% were classified as very low risk and only 1.6%, 3.7%, and 3.5% of these had obstructive CAD, respectively (figure 1). Discrimination was similar for the three models with AUC of 0.76 (95% CI 0.75–0.77), 0.74 [0.73–0.75], and 0.76 [0.75–0.76], for the ESC 2019 PTP, basic, and clinical model, respectively. At the clinically relevant very low predicted probability (≤5%) of CAD, the clinical and basic model were very well calibrated, whereas the ESC 2019 PTP model overestimated the CAD prevalence. NPV at cut-off ≤5% were 98.4% [98.1–98.7] for the ESC 2019 PTP model, 96.3% [96.1–96.6] for the basic model, and 96.5% [96.3–96.7] for the clinical model. At cut-off &lt;15%, NPVs were 96.1% [95.8–96.3] for the ESC 2019 PTP model, 94.5% [94.2–94.7] for the basic model, and 94.2% [94.0–94.5] for the clinical model.

Conclusion

In a population with a prevalence of 8.8% obstructive CAD, a clinical prediction model including diabetes, family history of CAD, and dyslipidemia in addition to the variables of the ESC 2019 PTP model ruled out 36.2% more patients than the ESC 2019 PTP model (23.592 vs. 8245 patients) while only overlooking 1.9% more cases of obstructive CAD when choosing a cut-off ≤5%. Use of this model is therefore potentially cost saving.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Socioeconomic disparity in cardiovascular disease: a proteomic approach

Background and purpose

A large unexplained social disparity in the occurrence of cardiovascular disease (CVD) has been documented. The precise mechanism behind these disparities is largely unknown. Biomarkers have improved our understanding of the pathophysiology of CVD. In this study we investigated differences in 184 biomarkers linked to CVD, with the aim of understanding the underlying mechanisms behind socioeconomic disparity in CVD and explore potential preventive measures.

Methods

We included 1144 participants from the Copenhagen City Heart Study, age 55- 64 years, without known CVD. Socioeconomic position (SEP) was defined by educational length in years. Blood samples were obtained and analyzed in two CVD proteomics panels (CVD panel II and III) with a total of 184 protein biomarkers. Associations between biomarkers and SEP were investigated by Pearson correlation coefficient and linear regression with multivariate adjustment for CVD risk factors.

Results

Median educational length was 10 (IQR 7–11) years. Of the measured biomarkers 53 were significantly correlated (p value &lt;0.05) to educational length, 17 positively and 36 negatively (fig. 1). After adjusting for age and gender, 41 biomarkers and after multivariate adjustment 14 biomarkers remained significantly associated with educational length. Some of the strongest negative associations was seen for Leptin (LEP), Von Willebrand factor (vWF), Interleukin-6 (IL6), Fibroblast growth factor 21 (FGF21), Renin (REN) and Growth/differentiation factor 15 (GDF_15) while the strongest positive associations were seen for Growth Hormone (GH), Receptor for advanced glycosylation end products (RAGE) and Myoglobin (MB) (fig. 2).

Conclusion

SEP was associated with elevated levels of multiple biomarkers linked with CVD. The range of biomarkers indicate that pathways involving inflammation (IL6, LEP, RAGE), platelet-activation (vWF, IL6, RAGE), blood pressure (REN, LEP), MAPK cascade (GDF_15, FGF21, LEP, IL6, REN, GH) and weigh (LEP) regulation contribute to the socioeconomic gradient in CVD. Further exploration is needed to identify possible candidates for intervention.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark.

Combining minimal risk stratification and prediction of obstructive CAD – clinical utility of a dual pre-test probability model

Background

The recently updated pre-test probability (PTP) model for diagnosing chronic coronary syndrome suggested by the European Society of Cardiology (ESC) was designed to predict the presence of obstructive coronary artery disease (CAD). In addition to this model, identification of non-obstructive CAD and utilization of preventive interventions may also lower rates of death and non-fatal myocardial infarction. Opposite to the ESC PTP, the minimal risk tool (MRT) is a new model developed to identify individuals without CAD but symptoms suggestive of CAD. We explored a combined use of the 2 models to predict the absence or presence of obstructive CAD.

Methods

This was a sub-study of the Danish study of Non-Invasive testing in Coronary Artery Disease (Dan-NICAD) which included patients with low-intermediate PTP of CAD. Minimal risk was defined as having a coronary calcium score of 0, no evidence of coronary atherosclerosis at coronary computed tomography angiography, and no cardiovascular (CV) events defined as myocardial infarction, death or revascularization in the mean observation period of 3.1 [2.7–3.4] years. Obstructive CAD was defined as a fractional flow reserve &lt;0.80 in a major vessel during invasive coronary angiography (ICA) or a high-grade stenosis by visual assessment (&gt;90% lumen reduction).

The risk factors included in the MRT were age, sex, smoking history, diabetes mellitus, dyslipidaemia, family history of premature CAD, hypertension, symptoms related to stress, and high-density lipoprotein concentration. Based on a point-system ranging from 0–5, the MRT and the ESC PTP were combined (dual-PTP) (figure 1). A dual-PTP ≤1 indicated very low risk. Using both minimal risk and obstructive CAD as references, the dual PTP was compared to the MRT and the ESC PTP through tests of model discrimination.

Results

Of the 1544 eligible patients, 710 (46%) had normal coronary arteries and no CV events. Obstructive CAD was diagnosed in 152 (10%).

Equivalent to a dual-PTP &lt;1 point, 209 patients with ESC PTP&lt;5% and MRT&gt;50% or ESC PTP 5–15% and MRT &gt;75% were classified as very low risk. Of these patients, 84% were at true minimal risk (red area figure 1). Furthermore, only 6 patients would have been diagnosed with obstructive CAD at ICA, and 0 events would be missed. The dual-PTP was non-inferior to the MRT and the ESC PTP in identifying patients having minimal risk and obstructive CAD, respectively (minimal risk: c-statistics 0.74 (0.72–0.77) vs. 0.76 (0.73–0.78); obstructive CAD: c-statistics 0.66 (0.62–0.70) vs. (0.67 (0.63–0.72)). The dual-PTP was superior to the ESC PTP in discriminating patients at minimal risk (c-statistics 0.74 (0.72–0.77) vs. 0.69 (0.67–0.71).

Conclusions

Combining the ESC PTP and the MRT, the dual-PTP seems to enable accurate prediction of both patients with minimal risk and patients with obstructive CAD. Based on the dual-PTP, patients can safely be deferred from or referred for diagnostic testing

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Aarhus University, Health Research Fund of Central Denmark Region

Vericiguat clinical pharmacology programme: biopharmaceutical properties and potential intrinsic and extrinsic factor effects

Introduction

The Phase III VICTORIA study (NCT02861534), which evaluated vericiguat vs placebo in patients with worsening chronic heart failure (WCHF) with ejection fraction &lt;45%, demonstrated a significant reduction in the primary composite endpoint of cardiovascular death and HF hospitalisation.

Purpose

A comprehensive clinical pharmacological programme of 28 Phase I trials in &gt;650 participants was performed to inform use of vericiguat.

Methods

Biopharmaceutical properties, pharmacokinetics (PK) and the potential for intrinsic factors to influence vericiguat dose administration were investigated. The PK and pharmacodynamic (PD) interaction potential of vericiguat with other drugs was assessed.

Results

Vericiguat had a mean half-life of approximately 24 h and high bioavailability when taken with food, leading to the recommendation of once daily dosing with food. Due to the multi-pathway metabolism and excretion profile of vericiguat, there was a low risk of PK drug–drug interactions (DDI; Table). No clinically relevant PD DDI were identified between vericiguat and aspirin, warfarin, sacubitril/valsartan or nitrates. There was a relatively minor influence of intrinsic factors on vericiguat PK.

Conclusion

This clinical pharmacology programme supports use of vericiguat in patients with WCHF who are characterised by multiple comorbidities and polypharmacy.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Funding for this research was provided by Bayer AG, Berlin, Germany and Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA

P3624Prevalence and severity of coronary artery disease linked to prognosis in psoriasis patients referred for coronary computed tomography angiography: A multicentre cohort study

Background

Psoriasis (Pso) is a disease characterized by systemic inflammation and is associated with an increased risk of cardiovascular disease. However, the degree of coronary artery calcification in Pso and its relation to prognosis is largely unknown.

Purpose

The aim of this study was 1) to estimate the prevalence and severity of coronary artery disease (CAD) in this patient group and 2) to asses the risk of major adverse cardiovascular events (MACE) including revascularization and all-cause mortality after initial diagnosis and treatment in a large-scale cohort of patients who underwent coronary computed tomography angiography (CCTA) due to angina symptoms.

Methods

This study consists of two parts using data from the Western Denmark Heart Registry; a cross-sectional study included 40,125 patients and a follow-up study included 42,861 patients. Pso patients were identified by the National Patient Registry and verified by nationwide prescription and treatment code registers. Primary outcome in the cross-sectional study was a coronary artery calcium score (CACS) >0, with a secondary outcome defined as a CACS ≥400. In the follow-up study, the primary outcome was a combined outcome including myocardial infarction, revascularization, ischemic or unspecified stroke and all-cause mortality. Events within the first 90 days after CCTA were attributed to initial treatment and consequently excluded. All outcomes were adjusted for common cardiovascular risk factors and comorbidities.

Results

In the cross-sectional study 1,407 (3.5%) Pso patients were identified. OR was 1.31 (95% CI; 1.15–1.49) for CACS >0 and 1.33 (95% CI; 1.10–1.62) for CACS ≥400 in Pso patients compared to non-Pso patients. In the follow-up study 1,591 (3.7%) Pso patients were identified. The mean duration of follow-up after CCTA was 4.0 years (min/max 0.0/10.2). Crude HR for the combined outcome was 1.52 (95% CI; 1.24–1.87), while adjusted HR was 1.16 (95% CI; 0.95–1.43).

Conclusion

In this clinically relevant cohort of patients referred to CCTA for CAD rule out, coronary artery calcification was more frequent and more severe in Pso patients even compared to the control patients with several risk factors and angina symptoms, but without inflammatory diseases. An increased risk of the combined outcome of MACE including revascularization and all-cause mortality after initial treatment in Pso patients was found in the crude analysis. The increased risk seemed predominantly carried by an increase in traditional risk factors.

Coronary artery disease risk reclassification by a new acoustic-based score

To determine the potential of a non-invasive acoustic device (CADScor®System) to reclassify patients with intermediate pre-test probability (PTP) and clinically suspected stable coronary artery disease (CAD) into a low probability group thereby ruling out significant CAD. Audio recordings and clinical data from three studies were collected in a single database. In all studies, patients with a coronary CT angiography indicating CAD were referred to coronary angiography. Audio recordings of heart sounds were processed to construct a CAD-score. PTP was calculated using the updated Diamond-Forrester score and patients were classified according to the current ESC guidelines for stable CAD: low < 15%, intermediate 15–85% and high > 85% PTP. Intermediate PTP patients were re-classified to low probability if the CAD-score was ≤ 20. Of 2245 patients, 212 (9.4%) had significant CAD confirmed by coronary angiography ( ≥ 50% diameter stenosis). The average CAD-score was higher in patients with significant CAD (38.4 ± 13.9) compared to the remaining patients (25.1 ± 13.8; p < 0.001). The reclassification increased the proportion of low PTP patients from 13.6% to 41.8%, reducing the proportion of intermediate PTP patients from 83.4% to 55.2%. Before reclassification 7 (3.1%) low PTP patients had CAD, whereas post-reclassification this number increased to 28 (4.0%) (p = 0.52). The net reclassification index was 0.209. Utilization of a low-cost acoustic device in patients with intermediate PTP could potentially reduce the number of patients referred for further testing, without a significant increase in the false negative rate, and thus improve the cost-effectiveness for patients with suspected stable CAD.

[Acute Kidney Failure Due to Urachal Cyst?]

A 34-year-old para V woman was referred to our centre at 35+1 weeks of gestation for an assumed fetal malformation with prenatal renal impairment and anhydramnios. Prenatal ultrasound demonstrated unilateral renal agenesis; the bladder was not detectable. The baby was born by caesarian section at 36+2 weeks of gestation because of placental insufficiency. Postnatal adaptation was uneventful, but the newborn presented external stigmas of trisomy 21 and progressive renal impairment with anuria. Nevertheless, the postnatal ultrasound showed two enlarged kidneys in loco typico with impaired perfusion but without signs of malformations. In the lower abdomen, a rosette-shaped structure of unknown origin was noted. Its origin could not be cleared by imaging including voiding cystourethrography and colon contrast radiography. Explorative laparotomy identified the structure as a persistent urachal cyst with secondary obstruction of the upper urinary tract. After removal of the urachus with reconstruction of the bladder dome, renal function recovered completely while urine was drained continuously via suprapubic catheter. A voiding cystourethrogram 3 weeks later showed a posterior urethral valve as an additional unexpected diagnosis. The valve was slit at the age of 6 months without complications, the renal function remained stable in the further course. In retrospect, the main cause for the renal failure remains unclear. It appears to be the obstruction due to the space-consuming character of the urachal cyst, especially because the megacystis typically associated with urethral valve was not viewable. Alternatively, the additional proximal stenosis may have only masked the typical findings of PUV.

Noninvasive stratum corneum sampling and electron microscopical examination of skin barrier integrity: pilot study with a topical glycerin formulation for atopic dermatitis

INTRODUCTION

Therapy of atopic dermatitis encloses use of medicated and nonmedicated preparations. Results of clinical and biophysical procedures indirectly describe the condition of the impaired skin barrier (SB). Direct evaluation of SB integrity is only possible by electron microscopical visualization, e.g. intercellular lipid lamellae (ICLL) organization of the stratum corneum.

METHOD

SB integrity was measured by morphometric analysis of ICLL in healthy and atopic skin and after a 15-day treatment (plus 7-day follow-up) of atopic skin with a glycerin preparation.

RESULTS

Significant treatment effect was shown by the restoration of the ICLL.

CONCLUSIONS

The study reveals that morphometric analysis of ICLL organization is suitable to differentiate between healthy and diseased skin and to semiquantitatively determine the effect of a nonmedicated glycerin formulation.

LIMITATION

Small treatment cohort.

Filtration at the microfluidic level: enrichment of nanoparticles by tunable filters

We present an electrohydrodynamic device for filtration of nanometre-sized particles from suspensions. A high-frequency electric field is locally generated through the action of mutually parallel microelectrodes integrated into a microfluidic channel. Due to the mechanism of ohmic heating, a thermal gradient arises above these electrodes. In conjunction with temperature-sensitive properties of the fluid, an eddy flow behaviour emerges in the laminar environment. This acts as an adjustable filter. For quantification of the filtration efficiency, we tested a wide range of particle concentrations at different electric field strengths and overall external flow velocities. Particles with a diameter of 200 nm were retained in this manner at rates of up to 100%. Numerical simulations of a model taking into account the hydrodynamic as well as electric conditions, but no interactions between the point-shaped particles, yield results that are similar to the experiment in both the flow trajectories and the particle accumulation. Our easy technique could become a valuable tool that complements conventional filtration methods for handling nanometre-scaled particles in medicine and biotechnology, e.g. bacteria and viruses.

Pooled RNAi Screens - Technical and Biological Aspects

RNA interference (RNAi) screens have recently emerged as an exciting new tool for studying gene function in mammalian cells. In order to facilitate those studies, short hairpin RNA (shRNA) expression libraries covering the entire human transcriptome have become commercially available. To make use of the full potential of such large-scale shRNA libraries, microarray-based methods have been developed to analyze complex pooled RNAi screens. In terms of microarray analysis, different strategies have been pursued by different research groups, largely influenced by the employed shRNA library. In this review, we compare the three major shRNA expression libraries with a focus on their suitability for a microarray-based analysis of pooled screens. We analyze and compare approaches previously used to perform pooled RNAi screens and point out their advantages as well as limitations.

Four-digit replantation in a mentally retarded person: a case report

This report describes a case where 4 digits were replanted in a mentally retarded patient with a history of smoking and the inability to follow postoperative arrangements.

The Impact of National Press Coverage on Early Phase Clinical Trial Recruitment and Enrollment

The American Society of Clinical Oncologists reports that only 5% of cancer patients ultimately enroll in a clinical trial. According to the National Cancer Institute, one key barrier to participation is a lack of knowledge about clinical trials, both on behalf of oncologists and the patients themselves. Unfortunately, many investigator-initiated and academic clinical trials simply do not have budgets that permit implementation of large-scale recruitment efforts. Recent experience by our group demonstrates that press coverage by national media is a particularly effective tool for generating public interest in clinical research, as well as increasing trial enrollment.In the third quarter of 2008, our academic translational research group was featured on a national news program. In the week following the broadcast, our group's website, which had been listed in the broadcast and accompanying web story, received an unprecedented number of hits. Not only did the broadcast generate interest in our group's research; more specifically, it translated to substantial increases in potential clinical trial candidates, and subsequently, increased trial enrollment. In the month following the broadcast, our group received 125 new clinical trial inquiries as a result of the feature. That number represented a seven-fold increase in new inquiries during the same period in 2007. Of those 125 contacts, more than half of patients were potentially eligible for one of our clinical trials based on an initial screening. From November 2008 to the present, nearly one-third of all clinical trial enrollments can be attributed to the news story. Enrollment to the vaccine trial specifically described in the news feature increased four fold in comparison to the same 6-month period in 2008-2009, with half of all new enrollments attributable to the news feature.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6078.

[Airbag associated deceleration trauma with complete infradiaphragmatic dissection of the inferior vena cava (IVC) and tear of liver veins]

Numerous investigations have demonstrated that the ability of passenger airbag systems to reduce both injury severity and mortality in car accidents is restricted to the simultaneous application of seatbelts and airbags. Depending on the impact force during the accident and also on the driver's position to the airbag an isolated airbag deployment can even produce severe injuries. We describe a complete infradiaphragmatic dissection of the IVC and a tear of liver veins after an airbag deployment without seatbelt use. We discuss different airbag associated injuries, the possible pathomechanism of the described injury, frequency and prognosis of abdominal vascular injuries and their emergency treatment. In the presented case the isolated severe vascular injury resulted in an intraoperative death caused by exsanguination. In blunt trauma with accompanying hypotension pre-arrival alarming of the ER, rapid transport to the hospital and immediate surgery are most important for the outcome.

Combined use of confocal laser scanning microscopy and transmission electron microscopy for visualisation of identical cells processed by cryotechniques

Successive visualisation of identical plant cells by light and electron microscopy is reported. For this purpose segments of pea and barley leaves were prepared by high-pressure freezing, freeze-substitution, and low-temperature embedding. The use of Safranin O during low-temperature dehydration allowed, on one hand, staining of all cellular components as investigated by confocal laser scanning microscopy and, on the other hand, excellent ultrastructural and antigenic preservation. A newly constructed specimen holder enabled precise relocation of the target cells for electron microscopic investigations. Transmission electron microscopy and immunohistochemistry revealed that during the whole procedure the ultrastructure of the cells as well as the antigenicity of cell constituents were preserved.

Precision and comparability of Abuscreen OnLine assays for drugs of abuse screening in urine on Hitachi 917 with other immunochemical tests and with GC/MS

Abuscreen OnLine assays for drugs of abuse screening in urine have recently been developed for use on Hitachi 917 analyzers (Roche Diagnostics GmbH). The assays are based on the kinetic interaction of microparticles as measured by changes in light transmission. Drug in a sample inhibits the formation of particle aggregates and diminishes absorbance change increases. It was the goal of this study to evaluate precision and comparability of the new asssys with CEDIA drugs of abuse tests on Hitachi 917 in different laboratories (three European and three US). The assays were calibrated in the nonlinear mode with four to six standards (semiquantitative application). Initial within-run (21 replicates, four labs) and between-day (10 days, two labs) imprecision studies using Abuscreen OnLine tests and commercial negative (0.5 x cut-off) and positive (1.5 x cut-off) controls revealed the following median CVs [withinrun neg./pos. control/between-day neg./pos. control]: amphetamines 1.9/1.3/3.4/2.4, barbiturates 3.0/1.6/3.9/3.1, benzodiazepines 4.7/1.5/6.3/3.0, cocaine metabolite 1.8/0.9/2.4/1.7, methadone 5.4/1.6/5.5/2.2, opiates 5.5/2.8/5.3/2.7, THC 8.9/4.8/21.8/12.1. CVs < 10% were obtained for the THC test using controls with concentrations closer to the cut-off. An identical set of 170 GC/MS analyzed urine samples was distributed to the six laboratories and measured with Abuscreen OnLine tests on Hitachi 917. The median values for each individual sample were calculated and compared with the results obtained on individual Hitachi 917 analyzers by Passing-Bablok regression analysis. A good agreement between the laboratories was found with less than +/- 11% slope deviation and intercepts below 7% of the cut-off except for benzodiazepines (one slope 17%, one slope--26%) and THC (one slope 34%, one slope--18%). The comparability with CEDIA tests was analyzed by concordance plots using randomized routine samples in three laboratories. The following results were obtained in one of the participating laboratories [cut-off ng/mL] (No. of positive/negative/discrepant samples): amphetamines [500] 2/147/0, barbiturates [200] 1/148/0, benzodiazepines [100] 52/91/7, cocaine metabolite [300] 17/129/3, methadone [300] 113/34/2, opiates [300] 31/114/4, THC [50] 66/81/2. GC/MS was performed for clarification of the discrepant results. In summary, Abuscreen OnLine tests on Hitachi 917 give precise results which compare well when analyzed in different laboratories. They can be rated as convenient and flexible methods for drugs of abuse screening in the routine.

alpha-1-Microglobulin: epidemiological indicator for tubular dysfunction induced by cadmium?

OBJECTIVES

To evaluate the suitability of alpha-1-microglobulin as a marker for cadmium induced renal dysfunction.

METHODS

alpha-1-Microglobulin was studied in a cross sectional survey in relation to the body burden of cadmium. Concentrations of alpha-1-microglobulin in 24 h urine of 831 people aged 2-87 years were analysed in association with urinary cadmium excretion, cadmium blood concentration, age, sex, occupational and smoking history, and estimated creatinine clearance. Participants came from a population residentially exposed to cadmium and from two control populations matched for socioeconomic status.

RESULTS

The excretion of alpha-1-microglobulin/24 h ranged from 0.1 mg to 176.3 mg and 44.4% of samples showed concentrations near the detection limit. Ordinal logistic regression analysis of people of all ages identified a high risk only for males compared with females (odds ratio (OR) 2.14; 95% confidence interval (95% CI) 1.56 to 2.94), age group, and duration of living on contaminated soil (OR 1.03/year; 95% CI 1.02 to 1.04), but not urinary cadmium excretion (OR 1.30; 95% CI 0.96 to 1.77) as significant predictors. For people < or = 50 years of age a weaker effect of sex (OR 1.76; 95% CI 1.13 to 2.73) and age group and an effect of similar magnitude for the duration of soil exposure (OR 1.03; 95% CI 1.01 to 1.04) were found. Also, the urinary cadmium excretion (OR 2.26; 95% CI 1.38 to 3.70) and occupational exposure (OR 1.71; 95% CI 1.03 to 2.83) were found to be significant in this younger age group. The estimated creatinine clearance had no significant impact on the alpha-1-microglobulin excretion.

CONCLUSION

alpha-1-Microglobulin is a suitable marker for early tubular changes only for people < or = 50 years. It may not be sufficiently specific for cadmium, and therefore not a suitable surrogate for cadmium exposure in epidemiological studies.

[Must the recurrent nerve in thyroid gland resection always be exposed? A prospective randomized study]

It was the purpose of this study to establish whether it is necessary to identify the recurrent laryngeal nerve intraoperatively when resecting the endemic nodular goiter. We prospectively formed two groups from 800 subtotal unilateral resections ("nerves at risk"). In group I (382 subtotal resections, 48.4%) the nerve was not identified intraoperatively. In group II (413 subtotal resections, 51.6%) the recurrent laryngeal nerve was routinely identified in all cases. The operative technique was standardized, giving special attention to the "anterior lamella". For all patients, preoperative and postoperative evaluation of the vocal cords was performed routinely. Altogether we saw 4 (0.5%) transient vocal cord palsies: 2 in group I and 2 in group II. All 4 laryngeal nerve palsies recovered within 4 months. These data demonstrated that no benefit is gained from routine dissection of the laryngeal nerve during resection of endemic nodular goiter. Therefore the demand for obligatory intraoperative identification of the recurrent nerve is not tenable.

The use of a multidisciplinary group meeting for families of critically ill trauma patients

Family members of any trauma patient admitted to the Level I trauma center are invited by the trauma staff to attend weekly multidisciplinary meetings. By the use of these meetings, family concerns can become a positive care factor and the tasks of nurses, doctors and social workers alike made easier.

Broviac catheter insertion: operating room or neonatal intensive care unit

We reviewed the records of all infants hospitalized in the neonatal intensive care unit (NICU) who underwent insertion of a Broviac catheter from July 1, 1984 through August 30, 1985. Eighty-six catheters were inserted in 81 patients. Thirty-one catheters were inserted in the NICU and the remainder were inserted in the operating room (OR). The patient's average weight at the time of catheter insertion was the same in both groups. Fifty-two of the 55 OR catheters (95%) were inserted in the external or internal jugular vein while only 68% of the NICU catheters were placed in the jugular veins. Six of the NICU catheters (19%) and 11 of the OR catheters (20%) developed catheter-associated sepsis with positive blood cultures. The infection rate per catheter day was similar in both groups as was the incidence of catheter occlusion. The NICU catheters were in place for an average of 51 days, and there was an average 46 day lifespan for the OR inserted catheters. Broviac catheter insertion can safely be performed in the NICU without an increase in morbidity. Broviac catheter insertion in the NICU is less costly and saves transportation of the sick neonate to the operating room.