The association between persistent cognitive difficulties and depression and functional outcomes in people with major depressive disorder

BACKGROUND

Cognitive symptoms are common during and following episodes of depression. Little is known about the persistence of self-reported and performance-based cognition with depression and functional outcomes.

METHODS

This is a secondary analysis of a prospective naturalistic observational clinical cohort study of individuals with recurrent major depressive disorder (MDD; N = 623). Participants completed app-based self-reported and performance-based cognitive function assessments alongside validated measures of depression, functional disability, and self-esteem every 3 months. Participants were followed-up for a maximum of 2-years. Multilevel hierarchically nested modelling was employed to explore between- and within-participant variation over time to identify whether persistent cognitive difficulties are related to levels of depression and functional impairment during follow-up.

RESULTS

508 individuals (81.5%) provided data (mean age: 46.6, s.d.: 15.6; 76.2% female). Increasing persistence of self-reported cognitive difficulty was associated with higher levels of depression and functional impairment throughout the follow-up. In comparison to low persistence of objective cognitive difficulty (<25% of timepoints), those with high persistence (>75% of timepoints) reported significantly higher levels of depression (B = 5.17, s.e. = 2.21, p = 0.019) and functional impairment (B = 4.82, s.e. = 1.79, p = 0.002) over time. Examination of the individual cognitive modules shows that persistently impaired executive function is associated with worse functioning, and poor processing speed is particularly important for worsened depressive symptoms.

CONCLUSIONS

We replicated previous findings of greater persistence of cognitive difficulty with increasing severity of depression and further demonstrate that these cognitive difficulties are associated with pervasive functional disability. Difficulties with cognition may be an indicator and target for further treatment input.

Improvement in Dysphagia Outcomes Following Clinical Target Volume Reduction in the De-ESCALaTE Study

AIMS

The De-ESCALaTE study showed an overall survival advantage for the administration of synchronous cisplatin chemotherapy with radiotherapy in low-risk oropharyngeal cancer when compared with synchronous cetuximab. During the trial, a radiotherapy quality assurance protocol amendment permitted centres to swap from the original radiotherapy contouring protocol (incorporating the whole oropharynx into the high-dose clinical target volume (CTV); anatomical protocol) to a protocol that incorporated the gross tumour volume with a 10 mm margin into the CTV (volumetric protocol). The purpose of this study was to examine both toxicity and tumour control related to this protocol amendment.

MATERIALS AND METHODS

Overall survival and recurrence at 2 years were used to compare tumour control in the two contouring cohorts. For toxicity, the cohorts were compared by both the number of severe (grades 3-5) and all grades acute and late toxicities. In addition, quality of life and swallowing were compared using EORTC-C30 and MD Anderson Dysphagia Inventory, respectively.

RESULTS

Of 327 patients included in this study, 185 were contoured according to the anatomical protocol and 142 by the volumetric protocol. The two cohorts were well balanced, with the exception of significantly more patients in the anatomical cohort undergoing prophylactic feeding tube insertion (P < 0.001). With a minimum of 2 years of follow-up there was no significant difference in overall survival or recurrence between the two contouring protocols. Similarly, there was no significant difference in the rate of reported severe or all grades acute or late toxicity and no sustained significant difference in quality of life. However, there was a significant difference in favour of volumetric contouring in several domains of the MD Anderson Dysphagia Inventory questionnaire at 1 year, which persisted to 2 years in the dysphagia functional (P = 0.002), dysphagia physical (P = 0.009) and dysphagia overall function (P = 0.008) domains.

CONCLUSION

In the context of the unplanned post-hoc analysis of a randomised trial, measurable improvement in long-term dysphagia has been shown following a reduction in the CTV. Further reductions in the CTV should be subject to similar scrutiny within the confines of a prospective study.

Real-world comparison of the last generation balloon-expandable and self-expanding valves in patients undergoing TAVI

Background/Introduction

The balloon expandable (BE) Edwards Sapien-S3/Ultra, and the self-expanding (SE) Medtronic Evolut-Pro represent the main volume of transcatheter aortic valve implantation (TAVI) procedures conducted worldwide.

Purpose

The present study represents the largest real-world comparison of periprocedural and short-term outcome between the aforementioned last generation devices.

Methods

Consecutive patients who had undergone TAVI with either the BE (S3/Ultra) or SE (Evolut-Pro/R-34mm if 34mm valve was required) device, in five centers were retrospectively studied. Periprocedural and short-term outcomes were recorded and compared.

Results

In total, 1341 patients (58.5% male) were treated with contemporary BE and SE valves (574 and 767pts with BE and SE respectively) and followed up for a median of 18.7 (IQR 30) months. Baseline demographics were similar between the two groups apart from severe left ventricle (LV) systolic impairment and extensive aorta calcification, being more prevalent amongst BE and SE groups respectively. Patients treated with the Evolut-Pro/R34mm device had significantly lower peak (16±9mmHg for SE vs 23.9±6mmHg for the BE valves, p=0.001) and mean (8.6±6mmHg SE vs 11.2±5.2mmHg BE, p=0.001) gradients at discharge.

Conversely, the BE group demonstrated significantly lower rates of at least moderate residual aortic regurgitation (AR) post-operatively (0.7% vs 5.2% for BE and SE valves respectively, p&lt;0.001). Interestingly, the rate of new permanent pacemaker (PPM) required after the implantation in initially pacemaker-free patients, was higher for the S3/Ultra cohort compared to the self-expanding valve group (14.4% vs 12.3% respectively, p=0.001). No statistical difference was recorded between valve groups regarding cerebrovascular events (3.4% vs. 2.7% for SE and BE respectively, p=0.466), major vascular complications (4.2% vs. 3.0% for SE and BE respectively, p=0.251) and death to hospital discharge (1.6% vs. 2.9% for SE and BE respectively, p=0.117).

One-year Kaplan-Meier estimated survival was similar between the two groups (88.7% for BE vs. 91.4% for SE valves, plog-rank=0.093). When adjusting for age, extensive calcification of the aorta and baseline LV function all caused mortality hazard ratios were similar between patients treated with BE vs SE valves (HR 1.39; 95% CI 0.97 to 1.98, p=0.07).

Conclusions

Real life comparison of the last generation balloon expandable and self-expanding devices demonstrates superiority of the former in terms of residual PVL, at the expense of higher transvalvular gradients and higher need of new PPM implantation. The latter however may represent differences in center practices with regards to thresholds for permanent pacing. Long-term follow-up and future larger trials are required to establish any potential long-term difference in clinical outcomes and prognosis.

Funding Acknowledgement

Type of funding sources: None.

Diffusion tensor cardiovascular magnetic resonance detects altered myocardial microstructure in patients with acute st-elevation myocardial infarction

Background

Diffusion Tensor Cardiovascular Magnetic Resonance (DT-CMR) can quantify metrics of tissue integrity (mean diffusivity [MD] and fractional anisotropy [FA]) and changes in laminar microstructures (sheetlets), which reorientate from more wall-parallel in diastole (DIA) towards wall-perpendicular in systole (SYS) as the myocardium thickens, quantified by E2 angle [E2A]. Microstructural changes after STEMI may provide new insights into adverse LV remodelling and risk stratification.

Methods

In vivo DT-CMR was performed 3–5 days after PPCI for first presentation STEMI (N=19, mean age 57±9, 79% male). DT-CMR was acquired in 2 short-axes (SYS & DIA) using a STEAM-EPI sequence. 12 segment analysis of MD, FA, E2A and E2A mobility (ΔE2A = E2ASYS − E2ADIA) was performed. Infarct (INF) segments were defined as &gt;25% LGE, adjacent (ADJ, located contiguous to INF) and remote (REM, all other segments). Wilcoxon signed rank tests were used with threshold P&lt;0.017 (Bonferroni corrected).

Results

See Table.

MD in both SYS and DIA was significantly higher in INF and ADJ regions compared to REM. FA in both SYS and DIA was lower in the INF and ADJ compared to REM. E2ADIA was higher in INF, indicating a more wall-perpendicular orientation of sheetlets, compared to ADJ and REM zones. E2ASYS in INF was significantly reduced, indicating a more wall-parallel orientation of sheetlets, compared to ADJ and REM regions, resulting in significantly reduced sheetlet mobility (ΔE2A).

Conclusions

Microstructural changes can be detected after acute STEMI by in vivo DT-CMR. Zonal changes in MD and FA may suggest loss of barriers to water diffusion and altered cardiomyocyte organisation, respectively. We provide the first report of reduced sheetlet mobility after acute STEMI in INF. Ongoing work is evaluating the mechanisms and prognostic importance of altered sheetlet mobility after STEMI.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship

Real-world comparison of the last generation main balloon-expandable and self-expanding valves in patients undergoing TAVI. Does the type matter?

Background/Introduction

The balloon expandable Edwards Sapien-S3 and Ultra, and the self-expanding Medtronic Evolut-Pro and Evolut-R 34mm represent the main volume of transcatheter aortic valve implantation (TAVI) procedures conducted worldwide.

Purpose

In the present study, we aim to compare the peri-procedural and one-year clinical outcomes between these last generation devices.

Methods

Consecutive patients from the ATLAS (Athens-Tokyo-London Aortic Stenosis) registry, who had undergone TAVI with either the S3/Ultra or Evolut-Pro/R 34mm device, in four centers were retrospectively studied. In-hospital procedural characteristics and outcomes were recorded and compared. Kaplan-Meier estimated 1-year all-cause mortality was compared between groups.

Results

In total, 692 patients (352pts treated with S3/Ultra and 340pts with Evolut-Pro/R34mm device) were included in the analysis. Baseline demographics (age, coronary artery disease risk factors, logistic Euroscore and aortic valve hemodynamics) were similar between the two groups.

In terms of peri-procedural and short-term outcomes, patients treated with the Evolut-Pro/R34mm device had significantly lower peak (25.4±3.6mmHg for S3/Ultra vs 14.9±0.6mmHg for the self-expanding valves, p=0.002) and mean (10.7±0.3mmHg S3/Ultra vs 7.9±0.4mmHg Evolut PRO/R34, p&lt;0.001) gradients at discharge.

Conversely, the S3 demonstrated significantly lower rates of at least moderate residual aortic regurgitation (AR) post-operatively (0.3% vs 4.8% for S3 and Evolut-Pro/R34mm respectively, p=0.001). Interestingly, the rate of new permanent pacemaker (PPM) required after the implantation in pacemaker-free patients on baseline, was higher for the S3/Ultra cohort compared to the self-expanding valve group (17.6% vs 11.7% respectively, p=0.054), however not reaching statistical significance yet. As expected, the need for balloon post dilatation of the implanted prosthesis was less among the S3/Ultra patients (5.5% vs 26.1%, p=0.001).

One-year Kaplan-Meier estimated survival was similar between the two groups (85.9% for S3 vs. 90% for Evolut-Pro/R34mm, plog-rank=0.071). Hazard ratio for all-cause mortality (Pro/R34 vs. S3/Ultra) after adjustment for gender and previous MI was similar between the groups (HR=0.73; 95% CI 0.47 to 1.14, p=0.165).

Conclusions

Real life comparison of the last generation balloon expandable and self-expanding devices demonstrates similar 1-year all-cause mortality. The S3/Ultra platforms, as compared to the Evolut-Pro/R34mm, demonstrate less paravalvular leak, at the expense of higher transvalvular gradients. Long-term follow-up and future larger trials are required to establish any potential long-term difference in clinical outcomes and prognosis.

Funding Acknowledgement

Type of funding source: None

P6516The association between prior coronary artery bypass graft surgery and outcome after percutaneous coronary intervention (PCI): an observational study of 123,780 patients

Background

Limited information exists regarding procedural success and clinical outcomes in patients with previous CABG undergoing percutaneous coronary intervention (PCI). We sought to compare outcomes in patients undergoing PCI with or without previous coronary artery bypass grafts (CABG).

Methods

This was an observational cohort study of 123,780 consecutive PCI procedures from the Pan-London (United Kingdom) PCI registry, from January 2005 to December 2015. The primary end-point was all-cause mortality at a median follow-up of 3.0 years (interquartile range 1.2–4.6 years).

Results

12,641 (10.2%) patients had a history of previous CABG, of whom 29.3% (n=3,703) underwent PCI to native vessels and 70.7% (n=8,938) to bypass grafts. There were significant differences in the demographic, clinical, and procedural characteristics of these groups. The risk of mortality during follow-up was significantly higher in patients with prior CABG (23.2%) (p=0.0005) compared to patients with no history of prior CABG (12.1%) and was seen for patients who underwent either native vessel (20.1%) or bypass graft PCI (24.2%, p<0.0001). However, after adjustment for baseline characteristics, there was no significant difference in outcomes seen between the groups when PCI was performed in native vessels in patients with previous CABG (HR 1.02, 95% CI 0.77–1.34; P=0.89) but a significant increase in mortality among patients with PCI to bypass grafts (HR 1.33 95% CI 1.03–1.71, P=0.026). This was seen after multivariate adjustment and propensity matching.

Figure 1. Kaplan-Meier Curves

Conclusion

Patients with prior CABG are older, with a greater comorbid burden and more complex procedural characteristics, but after adjustment for these differences clinical outcomes are similar to patients undergoing PCI without prior CABG. In these patients, native vessel PCI was associated with better outcomes compared to the treatment of vein grafts.

Nanotopography and plasma treatment: redesigning the surface for vascular graft endothelialisation

INTRODUCTION

Vascular graft materials in clinical use, such as polytetrafluoroethylene (PTFE) and Dacron, do not endothelialise and have low patency rates. The importance of an endothelial cell layer on the luminal surface of a vascular graft is well-known with surface topography and chemistry playing an important role. The aim of this study was to investigate the potential of plasma treatment and topographical structures on the luminal graft surface to enhance the self-endothelialisation potential of a nanocomposite vascular graft.

METHODS

POSS-PCU is a polycarbonate urea urethane (PCU) with a nanoparticle, polyhedral oligomeric silsesquioxane (POSS) incorporated within it. Planar, microgrooved, and nanopit patterned polymer films were fabricated using photolithography, electron beam lithography, reactive ion etching, and replication by solvent casting. Films were then exposed to oxygen plasma treatment at different powers for a fixed time (40 W, 60 W, 80 W/60 seconds). Effects of plasma treatment were assessed using scanning electron microscopy, atomic force microscopy and water contact angle analysis. Human umbilical vein endothelial cell (HUVEC) proliferation and morphology were characterised using immunostaining, live/dead staining, and Coomassie blue staining.

RESULTS

Successful embossing of the micro- and nanostructures was confirmed. Oxygen plasma treatment of the different samples showed that increasing power significantly increased the hydrophilicity of the samples (p < .0001). Improved HUVEC adhesion was seen on plasma modified compared with untreated samples (p < .0001). Coomassie blue staining showed that after 5 days, cells started to form monolayers and live/dead staining showed the cells were viable. Immunostaining showed that HUVECs expressed nitric oxide synthase on all topographies with focal adhesions appearing more pronounced on nanopit surfaces, showing retention of morphology and function.

CONCLUSION

These encouraging results indicate a future important role for plasma treatment and nanotopography in the development of endothelialised vascular grafts.

Biocompatible, smooth, plasma-treated nickel-titanium surface--an adequate platform for cell growth

High nickel content is believed to reduce the number of biomedical applications of nickel-titanium alloy due to the reported toxicity of nickel. The reduction in nickel release and minimized exposure of the cell to nickel can optimize the biocompatibility of the alloy and increase its use in the application where its shape memory effects and pseudoelasticity are particularly useful, e.g., spinal implants. Many treatments have been tried to improve the biocompatibility of Ni-Ti, and results suggest that a native, smooth surface could provide sufficient tolerance, biologically. We hypothesized that the native surface of nickel-titanium supports cell differentiation and insures good biocompatibility. Three types of surface modifications were investigated: thermal oxidation, alkali treatment, and plasma sputtering, and compared with smooth, ground surface. Thermal oxidation caused a drop in surface nickel content, while negligible chemistry changes were observed for plasma-modified samples when compared with control ground samples. In contrast, alkali treatment caused significant increase in surface nickel concentration and accelerated nickel release. Nickel release was also accelerated in thermally oxidized samples at 600 °C, while in other samples it remained at low level. Both thermal oxidation and alkali treatment increased the roughness of the surface, but mean roughness R(a) was significantly greater for the alkali-treated ones. Ground and plasma-modified samples had 'smooth' surfaces with R(a)=4 nm. Deformability tests showed that the adhesion of the surface layers on samples oxidized at 600 °C and alkali treatment samples was not sufficient; the layer delaminated upon deformation. It was observed that the cell cytoskeletons on the samples with a high nickel content or release were less developed, suggesting some negative effects of nickel on cell growth. These effects were observed primarily during initial cell contact with the surface. The most favorable cell responses were observed for ground and plasma-sputtered surfaces. These studies indicated that smooth, plasma-modified surfaces provide sufficient properties for cells to grow.

Focal adhesions in osteoneogenesis

As materials technology and the field of tissue engineering advance, the role of cellular adhesive mechanisms, in particular, interactions with implantable devices, becomes more relevant in both research and clinical practice. A key tenet of medical device technology is to use the exquisite ability of biological systems to respond to the material surface or chemical stimuli in order to help to develop next-generation biomaterials. The focus of this review is on recent studies and developments concerning focal adhesion formation in osteoneogenesis, with an emphasis on the influence of synthetic constructs on integrin-mediated cellular adhesion and function.

Adhesion formation of primary human osteoblasts and the functional response of mesenchymal stem cells to 330nm deep microgrooves

The surface microtexture of an orthopaedic device can regulate cellular adhesion, a process fundamental in the initiation of osteoinduction and osteogenesis. Advances in fabrication techniques have evolved to include the field of surface modification; in particular, nanotechnology has allowed for the development of experimental nanoscale substrates for investigation into cell nanofeature interactions. Here primary human osteoblasts (HOBs) were cultured on ordered nanoscale groove/ridge arrays fabricated by photolithography. Grooves were 330nm deep and either 10, 25 or 100microm in width. Adhesion subtypes in HOBs were quantified by immunofluorescent microscopy and cell-substrate interactions were investigated via immunocytochemistry with scanning electron microscopy. To further investigate the effects of these substrates on cellular function, 1.7K gene microarray analysis was used to establish gene regulation profiles of mesenchymal stem cells cultured on these nanotopographies. Nanotopographies significantly affected the formation of focal complexes (FXs), focal adhesions (FAs) and supermature adhesions (SMAs). Planar control substrates induced widespread adhesion formation; 100microm wide groove/ridge arrays did not significantly affect adhesion formation yet induced upregulation of genes involved in skeletal development and increased osteospecific function; 25microm wide groove/ridge arrays were associated with a reduction in SMA and an increase in FX formation; and 10microm wide groove/ridge arrays significantly reduced osteoblast adhesion and induced an interplay of up- and downregulation of gene expression. This study indicates that groove/ridge topographies are important modulators of both cellular adhesion and osteospecific function and, critically, that groove/ridge width is important in determining cellular response.

Focal adhesion interactions with topographical structures: a novel method for immuno-SEM labelling of focal adhesions in S-phase cells

Current understanding of the mechanisms involved in osseointegration following implantation of a biomaterial has led to adhesion quantification being implemented as an assay of cytocompatibility. Such measurement can be hindered by intra-sample variation owing to morphological changes associated with the cell cycle. Here we report on a new scanning electron microscopical method for the simultaneous immunogold labelling of cellular focal adhesions and S-phase nuclei identified by BrdU incorporation. Prior to labelling, cellular membranes are removed by tritonization and antigens of non-interest blocked by serum incubation. Adhesion plaque-associated vinculin and S-phase nuclei were both separately labelled with a 1.4 nm gold colloid and visualized by subsequent colloid enhancement via silver deposition. This study is specifically concerned with the effects microgroove topographies have on adhesion formation in S-phase osteoblasts. By combining backscattered electron (BSE) imaging with secondary electron (SE) imaging it was possible to visualize S-phase nuclei and the immunogold-labelled adhesion sites in one energy 'plane' and the underlying nanotopography in another. Osteoblast adhesion to these nanotopographies was ascertained by quantification of adhesion complex formation.

Regulation of implant surface cell adhesion: characterization and quantification of S-phase primary osteoblast adhesions on biomimetic nanoscale substrates

Integration of an orthopedic prosthesis for bone repair must be associated with osseointegration and implant fixation, an ideal that can be approached via topographical modification of the implant/bone interface. It is thought that osteoblasts use cellular extensions to gather spatial information of the topographical surroundings prior to adhesion formation and cellular flattening. Focal adhesions (FAs) are dynamic structures associated with the actin cytoskeleton that form adhesion plaques of clustered integrin receptors that function in coupling the cell cytoskeleton to the extracellular matrix (ECM). FAs contain structural and signalling molecules crucial to cell adhesion and survival. To investigate the effects of ordered nanotopographies on osteoblast adhesion formation, primary human osteoblasts (HOBs) were cultured on experimental substrates possessing a defined array of nanoscale pits. Nickel shims of controlled nanopit dimension and configuration were fabricated by electron beam lithography and transferred to polycarbonate (PC) discs via injection molding. Nanopits measuring 120 nm diameter and 100 nm in depth with 300 nm center-center spacing were fabricated in three unique geometric conformations: square, hexagonal, and near-square (300 nm spaced pits in square pattern, but with +/-50 nm disorder). Immunofluorescent labeling of vinculin allowed HOB adhesion complexes to be visualized and quantified by image software. Perhipheral adhesions as well as those within the perinuclear region were observed, and adhesion length and number were seen to vary on nanopit substrates relative to smooth PC. S-phase cells on experimental substrates were identified with bromodeoxyuridine (BrdU) immunofluorescent detection, allowing adhesion quantification to be conducted on a uniform flattened population of cells within the S-phase of the cell cycle. Findings of this study demonstrate the disruptive effects of ordered nanopits on adhesion formation and the role the conformation of nanofeatures plays in modulating these effects. Highly ordered arrays of nanopits resulted in decreased adhesion formation and a reduction in adhesion length, while introducing a degree of controlled disorder present in near-square arrays, was shown to increase focal adhesion formation and size. HOBs were also shown to be affected morphologicaly by the presence and conformation of nanopits. Ordered arrays affected cellular spreading, and induced an elongated cellular phenotype, indicative of increased motility, while near-square nanopit symmetries induced HOB spreading. It is postulated that nanopits affect osteoblast-substrate adhesion by directly or indirectly affecting adhesion complex formation, a phenomenon dependent on nanopit dimension and conformation.

The effects of nanoscale pits on primary human osteoblast adhesion formation and cellular spreading

Current understanding of the mechanisms involved in ossesoinegration following implantation of a biomaterial has led to an emphasis being placed on the modification of material topography to control interface reactions. Recent studies have inferred nanoscale topography as an important mediator of cell adhesion and differentiation. Biomimetic strategies in orthopaedic research aim to exploit these influences to regulate cellular adhesion and subsequent bony tissue formation. Here experimental topographies of nanoscale pits demonstrating varying order have been fabricated by electron-beam lithography in (poly)carbonate. Osteoblast adhesion to these nanotopographies was ascertained by quantification of the relation between adhesion complex formation and total cell area. This study is specifically concerned with the effects these nanotopographies have on adhesion formation in S-phase osteoblasts as identified by BrdU incorporation. Nanopits were found to reduce cellular spreading and adhesion formation.

The interaction of human bone marrow cells with nanotopographical features in three dimensional constructs

Until now, nanotopography has been considered in 2D construct designs. This has been due to fabrication limitations with traditional lithographic processes relying on the ability to focus radiation that will expose a radiation sensitive resist (e.g. photolithography and electron beam lithography). More recently, alternative methods that offer rapid and cheap nanofabrication have been developed; such methods include polymer demixing and colloidal lithography. Polymer demixing in 2D has relied on spin casting of polymer blends-such as polystyrene and polybromostyrene in a solvent such as toluene. As the solvent evaporates, the polymers phase separate and form nanoislands. In this study, the polymer blend solution has been blown through fine tubes and allowed to demix, thus providing 3D constructs for cell biology. The ability to fabricate in tubes may be useful in many applications, for example stents, conduits, and bone repair (when considering structures such as Haversian tubes and Volkmann's canals). As proof of concept, human osteoprogenitor cells have been used to test the cell response to the nanopatterned tubes. The results show that nanofeatures of size X, diameter Y, and spacing Z decrease cell spreading, reduce cytoskeletal organization, and increase endocytotic activity within the cells.

Radiation dose reduction without compromise of image quality in cardiac angiography and intervention with the use of a flat panel detector without an antiscatter grid

OBJECTIVE

To test the hypothesis that replacing the antiscatter grid with an air gap will reduce patient radiation exposure without significant compromise of image quality.

METHODS

457 patients having either uncomplicated diagnostic studies or a single vessel angioplasty (percutaneous transluminal coronary angioplasty (PTCA)) on a flat plate system (GE Innova) were studied. For two months their total dose-area product score was recorded on standard gridded images and then for two months on images made with the grid out, with an air gap used to reduce scatter. Detector magnification was reduced one step when an air gap was used to achieve the same final image size. A sample set of studies was reviewed blind by five observers, who scored sharpness and contrast on a non-linear scale.

RESULTS

The average dose-area product was significantly reduced, both in the diagnostic group (n = 276), from a mean (SD) of 26.2 (14.7) Gy.cm2 with the grid in to 16.1 (12) Gy.cm2 with the grid out (p = 0.01), and in the PTCA group (n = 181), from 48.2 (36.2) to 37 (27.5) (p = 0.01). The mean image quality scores of the gridless cohort were not significantly different from those of the gridded cohort.

CONCLUSION

With the use of a flat plate detector, air gap gridless angiography reduces the radiation dose to the patient and, in consequence, to the operator without significantly affecting image quality. It is proposed that gridless imaging should be the default technique for adults and children and in most installations.

Morphological and microarray analysis of human fibroblasts cultured on nanocolumns produced by colloidal lithography

The environment around a cell during in vitro culture is unlikely to mimic those in vivo. Preliminary experiments with nanotopography have shown that nanoscale features can strongly influence cell morphology, adhesion, proliferation and gene regulation, but the mechanisms mediating this cell response remain unclear. In this study a well defined nanotopography, consisting of 100 nm wide and 160 nm high cylindrical columns, was used in fibroblast culture. In order to build on previously published morphological data that showed changes in cell spreading on the nanocolumns, in this study gene regulation was monitored using a 1718 gene microarray. Transmission electron microscopy, fluorescent observation of actin and Rac and area quantification have been used to re-affirm the microarray observations. The results indicate that changes in cell spreading correlate with a number of gene up- and down-regulations as will be described within the manuscript.

Cells React to Nanoscale Order and Symmetry in Their Surroundings

Mammalian cells react to microstructured surfaces, but there is little information on the reactions to nanostructured surfaces, and such as have been tested are poorly ordered or random in their structure. We now report that ordered surface arrays (orthogonal or hexagonal) of nanopits in polycaprolactone or polymethylmethacrylate have marked effects in reducing cell adhesion compared with less regular arrays or planar surfaces. The pits had diameters of 35, 75, and 120 nm, respectively, with pitch between the pits of 100, 200, and 300 nm, respectively. The cells appear to be able to distinguish between different symmetries of array. We suggest that interfacial forces may be organized by the nanostructures to affect the cells in the same way as they affect liquid crystal orientations.

Cell response to nano-islands produced by polymer demixing: a brief review

This review looks at the present literature available regarding cell response to nano-islands produced by nanotopography. Polymer demixing is a chemical method of fabricating large areas of nanotopography quickly and cheaply, making it ideal for cell testing and thus allowing it to be one of the first well-researched methods in cell engineering. The review shows that cells respond strongly to the islands (cell types observed include endothelial cells, fibroblasts, osteoblasts, leucocytes and platelets). Such changes include differences in adhesion, growth, gene expression and morphology.

Rapid fibroblast adhesion to 27nm high polymer demixed nano-topography

It is well known that many cell types react strongly to micro-topography. It is rapidly becoming clear than cells will also react to nano-topography. Polymer demixing is a rapid and low-cost chemical method of producing nano-topography. This manuscript investigates human fibroblast response to 27nm high nano-islands produced by polymer demixing. Cell spreading, cytoskeleton, focal adhesion and Rac localisation were studied. The results showed that an initial rapid adhesion and cytoskeletal formation on the islands at 4 days of culture gave way to poorly formed contacts and vimentin cytoskeleton at 30 days of culture.

Investigating the limits of filopodial sensing: a brief report using SEM to image the interaction between 10 nm high nano-topography and fibroblast filopodia

Having the ability to control cell behaviour would be of great advantage in tissue engineering. One method of gaining control over cell adhesion, proliferation, guidance and differentiation is use of topography. Whilst it has be known for some time that cells can be guided by micro-topography, it is only recently becoming clear that cells will respond strongly to nano-scale topography. The fact that cells will take cues from their micro- and nano-environment suggests that the cells are in some way 'spatially aware'. It is likely that cells probe the shape of their surroundings using filopodia, and that this initial filopodia/topography interaction may be critical to down-stream cell reactions to biomaterials, or indeed, the extracellular matrix. One intriguing question is how small a feature can cells sense? In order to investigate the limits of cell sensing, high-resolution scanning electron microscopy has been used to simultaneously view cell filopodia and 10 nm high nano-islands. Fluorescence microscopy has also been used to look at adhesion formation. The results showed distinct filopodial/nano-island interaction and changes in adhesion morphology.

Transfer for Primary Angioplasty Versus Immediate Thrombolysis in Acute Myocardial Infarction

Background— The benefit of primary percutaneous coronary intervention (PCI) over thrombolysis has been clearly demonstrated in acute myocardial infarction (AMI). However, the best therapeutic strategy for a patient with AMI presenting to acute care services without catheterization facilities remains under debate. Our objective was to gather all available information from clinical trials comparing transfer of patients experiencing AMI for angioplasty versus immediate thrombolysis.

Methods and Results— We performed a meta-analysis of all data available from published randomized trials and from presentations in scientific sessions of major cardiology congresses comparing the 2 strategies. The primary end point was the combined criteria (CC) of death/reinfarction/stroke as defined in each trial. Relative risk (RR) evaluated the treatment effect. We identified 6 clinical trials including 3750 patients. Transfer time was always <3 hours. The CC was significantly reduced by 42% (95% confidence interval [CI] 29% to 53%, P <0.001) in the group transferred for primary PCI compared with the group receiving on-site thrombolysis. When CC parameters were considered separately, reinfarction was significantly reduced by 68% (95% CI, 34% to 84%; P <0.001) and stroke by 56% (95% CI, −15% to 77%; P =0.015). There was a trend toward reduction in all-cause mortality of 19% (95% CI, −3% to 36%; P =0.08) with transfer for PCI.

Conclusion— Even when transfer to an angioplasty center is necessary, primary PCI remains superior to immediate thrombolysis. Organization of ambulance systems, prehospital management, and adequate PCI capacity appear now to be the key issues in providing reperfusion therapy for AMI.

Enhanced HAPEX topography: comparison of osteoblast response to established cement

The use of poly(methylmethacrylate) PMMA cement by Charnley in the 1960s revolutionized orthopaedic medicine. Since this time, however, little has changed. The development of bioactive composites, such as HAPEX (a composite of 40% vol hydroxyapatite (HA) in a polyethylene matrix) have potential in orthopaedic applications. The composite has been shown to allow direct bone bonding in vivo, and in vitro studies have shown preferential attachment to HA exposed on the composite surface. In vitro study has also shown that altering the topography HAPEX can enhance osteoblast response. This study uses microscopical investigation of osteoblast cytoskeleton, and biochemical measurement of proliferation (by thymidine incorporation) and phenotype (by alkaline phosphatase activity) to compare primary human osteoblast (HOB) activity on HAPEX and PMMA cement. The study shows large increases in HOB response to the new generation material compared to PMMA, the current implant standard.

Fibroblast reaction to island topography: changes in cytoskeleton and morphology with time

In order to develop next-generation tissue engineering materials, the understanding of cell responses to novel material surfaces needs to be better understood. Topography presents powerful cues for cells, and it is becoming clear that cells will react to nanometric, as well as micrometric, scale surface features. Polymer-demixing of polystyrene and polybromostyrene has been found to produce nanoscale islands of reproducible height, and is very cheap and fast compared to techniques such as electron beam lithography. This study observed temporal changes in cell morphology and actin and tubulin cytoskeleton using scanning electron and fluorescence microscopy. The results show large differences in cell response to 95 nm high islands from 5 min to 3 weeks of culture. The results also show a change in cell response from initial fast organisation of cytoskeleton in reaction to the islands, through to lack of cell spreading and low recruitment of cell numbers on the islands.

The effect of varying percentage hydroxyapatite in poly(ethylmethacrylate) bone cement on human osteoblast-like cells

Poly(ethylmethacrylate) (PEMA) bone cement has been developed, and the cements mechanical properties are improved by the incorporation of particulate fillers, such as hydroxyapatite (HA). In this in vitro study, human osteoblast-like (HOB) cells were used to examine the effect on cellular behavior of the addition of HA to PEMA using a plain PEMA control. Thymidine uptake ((3)H-TdR) and total DNA were used to assess cell growth and proliferation. Confocal laser scanning microscopy (CLSM) was used to study focal contacts and actin cytoskeletal organisation. Scanning electron microscopy (SEM) and transmission electron microscopy (TEM) were used to assess cell morphology and cellular ultrastucture. The early time points showed preferential anchorage to the HA exposed on the cement surface, but no difference in adhesion or proliferation. These results have been attributed to increases in residual monomer with HA incorporation, as shown by proton nuclear magnetic resonance (H(1)-NMR) spectra.

Nonadhesive nanotopography: Fibroblast response to poly(n-butyl methacrylate)-poly(styrene) demixed surface features

It is becoming clear that cells do not only respond to micrometric scale topography, but may also respond to topography at the nanometric scale. Nano-fabrication methods such as electron beam lithography are, however, expensive and time consuming. Polymer demixing of poly(styrene) and poly(4-bromostyrene) has been found to produce nano-scale islands of reproducible height, and the islands have been previously shown to effect cell events such as adhesion, spreading, proliferation, and differentiation. This study uses demixed poly(styrene) and poly(n-butyl methacrylate) to produce nano-islands with closer packing and narrower widths compared with those previously studied. Observations have been made of morphological and cytoskeletal changes in human fibroblasts interacting with 10- and 50-nm-high islands. The methods used included scanning electron microscopy, fluorescent microscopy, and optical microscopy. The results indicated that the cells do not respond differently to the 10-nm islands compared with planar samples but, in contrast, the 50-nm islands are nonadhesive.

Polymer-demixed nanotopography: control of fibroblast spreading and proliferation

Cell response to nanometric scale topography is a growing field. Nanometric topography production has traditionally relied on expensive and time-consuming techniques such as electron beam lithography. This presents disadvantages to the cell biologist in regard to material availability. New research is focusing on less expensive methods of nanotopography production for in vitro cell engineering. One such method is the spontaneous demixing of polymers (in this case polystyrene and polybromostyrene) to produce nanometrically high islands. This article observes fibroblast response to nanometric islands (13, 35, and 95 nm in height) produced by polymer demixing. Changes in cell morphology, cytoskeleton, and proliferation are observed by light, fluorescence, and scanning electron microscopy. Morphological features produced by cells in response to the materials were selected, and cell shape parameters were measured with shape-recognition software. The results showed that island height could either increase or reduce cell spreading and proliferation in relation to control, with 13-nm islands producing cells with the greatest area and 95 nm islands producing cells with the lowest areas. Interaction of filopodia with the islands could been seen to increase as island size was increased.

Transfer for primary angioplasty: who and how?

Randomised trials have led to the conclusion that percutaneous coronary intervention (PCI) is the best reperfusion strategy for most patients with acute myocardial infarction (AMI). However, these trials have limited application to routine practice. Modern trials of mechanical reperfusion strategies need to take account of logistics, transfer times, and adjunctive drug treatment during transfer (facilitated PCI). Such PCI protocols need to be judged against very early thrombolysis with modern agents. This has been the thrust behind a series of recent studies addressing these "real world" issues in early AMI management

New acrylic bone cements conjugated to vitamin E: curing parameters, properties, and biocompatibility

Acrylic bone cement formulations with antioxidant character were prepared by incorporation of a methacrylic monomer derived from vitamin E (MVE). Increasing concentrations of this monomer provided decreasing peak temperature values, ranging from 62 to 36 degrees C, and increasing setting time with values between 17 and 25 min. Mechanical properties were evaluated by compression and tension tests. Compressive strength of the new formulations were superior to 70 MPa in all cases. The cement containing 25 wt % MVE, however, showed a significant decrease in tensile properties. Biocompatibility of the new formulations was studied in vitro. The analysis of the effect of leachables from cements into the media showed continued cell proliferation and cell viability with a significant increase for the cement containing 15 wt % MVE. This formulation also showed a significant increase in cellular proliferation over a period of 7 days as indicated by the Alamar Blue test. The cells were able to differentiate and express phenotypical markers in presence of all materials. A significant increase in alkaline phosphatase activity was observed on the cements prepared in presence of 15-25 wt % MVE compared with PMMA. Morphological assessment showed that the human osteoblast (HOB) cells were able to adhere, retain their morphology, and proliferate on all the cements.

In vitro reaction of endothelial cells to polymer demixed nanotopography

The introduction of topography to material surfaces has been shown to strongly affect cell behaviour, and the effects of micrometric surface morphologies have been extensively characterised. Research is now starting to investigate the reaction of cells to nanometric topography. This study used polymer demixing of polystyrene and poly(4-bromostyrene) producing nanometrically high islands, and observed endothelial cell response to the islands. Three island heights were investigated; these were 13, 35 and 95 nm. The cells were seen to be more spread on the manufactured topographies than that on flat surfaces of similar chemistry. Other morphological differences were also noted by histology, fluorescence and scanning electron microscopy, with many arcuate cells noted on the test surfaces, and cytoskeletal alignment along the arcuate features. Of the nanotopographies, the 13 nm islands were seen to give the largest response, with highly spread cell morphologies containing well-defined cytoskeleton.

In vitro adhesion and biocompatability of osteoblast-like cells to poly(methylmethacrylate) and poly(ethylmethacrylate) bone cements

A bone cement, poly(ethylmethacrylate)/n-butylmethacrylate (PEMA/nBMA) has been developed with lower exotherm and monomer leaching compared to the traditional poly(methylmethacrylate)/methylmethacrylate (PMMA/MMA) cement. This study compares the in vitro biological response to the cements using primary human osteoblast-like cells (HOB). Cell attachment was qualified by immunolocalization of vinculin and actin cytoskeleton, showing more organization on PEMA/nBMA compared to PMMA/MMA. Proliferation was assessed using tritiated thymidine incorporation, and phenotype expression determined by measuring alkaline phosphatase (ALP) activity. An increase in proliferation and ALP activity was observed on PEMA/nBMA compared to PMMA/MMA. The results confirm the biocompatability of PEMA/nBMA, and an enhanced cell attachment and expression of differentiated cell phenotype.

Initial attachment of osteoblasts to an optimised HAPEX topography

The interactions between an implant material and the surrounding tissue are of a complicated nature, and the initial attachment of cells to the surface is important in determining the implant success. HAPEX has been developed as a second-generation orthopaedic biomaterial, with both mechanical and biological characteristics that make it suitable for bone augmentation. Further optimisation of the material is being continued to increase the attachment of osteoblasts coupled with improving mechanical characteristics, so it may be used in load bearing applications. It has been previously observed that polishing followed by roughening the surface of HAPEX enhances osteoblast proliferation and phenotype. This article discusses the recruitment of primary human osteoblast cells onto the optimised surface, by examining morphology and cytoskeletal changes using scanning electron microscopy and confocal laser scanning microscopy. The results show that the cells attach in greater numbers to the optimised surface, and develop notably faster, than cells on machined HAPEX.

Osteoblast behaviour on HA/PE composite surfaces with different HA volumes

A hydroxyapatite (HA) reinforced polyethylene (PE) composite (designated HAPEX), with high mechanical specification and a bioactive HA phase, has been optimised as a bone analogue material. Manufacturing conditions and machining of the materials were carefully controlled to give a reproducible material surface roughness with minimal batch variation. The effect of surface composition was examined in vitro using primary human osteoblasts (HOB). HOBs were cultured in direct contact with the test materials containing 20% and 40% vol. HA. The results showed that 40% HA/PE enhanced cellular activity by increasing proliferation rate and differentiation compared to the 20% vol. HA composite. The cytoskeletal organisation of the cells was also examined and HOBs cultured on 40% HA/PE were flatter and had an enhanced rate of cytoskeletal organisation and an increase in focal contact points compared to the 20% HA/PE.

Increasing hydroxyapatite incorporation into poly(methylmethacrylate) cement increases osteoblast adhesion and response

Poly(methylmethacrylate) (PMMA) is the current standard for cement held prostheses. It forms a strong bond with the implant, but the bond between the cement and the bone is considered to be weak, with fibroblastic cells observed at the implant site, rather than direct bone contact, a contributing factor leading to implant failure. Incorporation of hydroxyapatite (HA) increases the biological response to the cement from tissue around the implant site, thus giving increased bone apposition. In this study, PMMA discs with 0, 4.6 and 8.8 vol%. HA were examined. Primary human osteoblast-like cells (HOBs) were used for the biological evaluation of the response to the cements in vitro. Morphology was observed using scanning electron microscopy (SEM) and confocal laser scanning microscopy (CLSM). Measurement of tritiated thymidine (3H-TdR) incorporation and alkaline phosphatase (ALP) activity were used to assess proliferation and differentiation. A synergy between increasing focal contact formation, cytoskeletal organisation, cell proliferation and expression of phenotype was observed with increasing HA volume. Preferential anchorage of HOBs to HA rather than PMMA was a prominent observation.

Initial interaction of osteoblasts with the surface of a hydroxyapatite-poly(methylmethacrylate) cement

Failure of the bone/cement interface in cemented joint prostheses is a contributor to implant loosening. The introduction of a bioactive phase, such as hydroxyapatite (HA), to cement may enhance fixation by encouraging direct bone apposition rather than encapsulation of the implant by fibrous tissue. The effect of poly(methylmethacrylate) (PMMA) bone cement (incorporating 17.5% HA wt.) on bioactivity has been investigated using primary human osteoblast-like cells (HOB). A significantly higher cell proliferation and differentiation was seen on the PMMA/HA cement compared to the PMMA cement alone, with retention of phenotype up to 21 days of culture on both materials.