Spindle Cell Malignancy and Asbestos Exposure: A Case Report

We outline the presentation of a 68-year-old woman who received a chest radiograph due to her insurance requirements, resulting in the discovery of a left-sided pleural effusion. The effusion was further characterized as loculated on subsequent imaging. Thoracentesis yielded exudative fluid, leading to the patient undergoing video-assisted thoracoscopic surgery (VATS). During this procedure, a cystic mass was visualized, with the conversion of the operation to an open thoracotomy and left lower lobe lobectomy. Pathology was positive for spindle cell sarcoma. A thorough history of the patient revealed a decades-long occupational exposure to asbestos. The significance of this report is to illustrate the clinical presentation, immunohistochemical characteristics, and management of a rare spindle cell malignancy. Our case also raises the importance of screening patients on an individualized, shared decision-making basis.

Systematic update to the mammalian relative potency estimate database and development of best estimate toxic equivalency factors for dioxin-like compounds

The World Health Organization (WHO) assesses potential health risks of dioxin-like compounds using Toxic Equivalency Factors (TEFs). This study systematically updated the relative potency (REP) database underlying the 2005 WHO TEFs and applied advanced methods for quantitative integration of study quality and dose-response. Data obtained from fifty-one publications more than doubled the size of the previous REP database (∼1300 datasets). REP quality and relevance for these data was assessed via application of a consensus-based weighting framework. Using Bayesian dose-response modeling, available data were modeled to produce standardized dose/concentration-response Hill curves. Study quality and REP data were synthesized via Bayesian meta-analysis to integrate dose/concentration-response data, author-calculated REPs and benchmark ratios. The output is a prediction of the most likely relationship between each congener and its reference as model-predicted TEF uncertainty distributions, or the 'best estimate TEF' (BE-TEF). The resulting weighted BE-TEFs were similar to the 2005 TEFs, though provide more information to inform selection of TEF values as well as to provide risk assessors and managers with information needed to quantitatively characterize uncertainty around TEF values. Collectively, these efforts produce an updated REP database and an objective, reproducible approach to support development of TEF values based on all available data.

Direct current cardioversion in pregnancy: a multicentre study

OBJECTIVE

Direct current cardioversion (DCCV) in pregnancy is rarely required and typically only documented in single case reports or case series. A recent UK confidential enquiry reported on several maternal deaths where appropriate DCCV appeared to have been withheld.

DESIGN

Retrospective cohort study.

SETTING

Seventeen UK and Ireland specialist maternity centres.

SAMPLE

Twenty-seven pregnant women requiring DCCV in pregnancy.

MAIN OUTCOME MEASURES

Maternal and fetal outcomes following DCCV.

RESULTS

Twenty-seven women had a total of 29 DCCVs in pregnancy. Of these, 19 (70%) initial presentations were to Emergency Departments and eight (30%) to maternity settings. There were no maternal deaths. Seventeen of the women (63%) had a prior history of heart disease. Median gestation at DCCV was 28 weeks, median gestation at delivery was 35 weeks, with a live birth in all cases. The abnormal heart rhythms documented at the first cardioversion were atrial fibrillation in 12/27 (44%) cases, atrial flutter in 8/27 (30%), supraventricular tachycardia in 5/27 (19%) and atrial tachycardia in 2/27 (7%). Fetal monitoring was undertaken following DCCV on 14/29 (48%) occasions (10 of 19 (53%) at ≥26 weeks) and on 2/29 (7%) occasions, urgent delivery was required post DCCV.

CONCLUSIONS

Direct current cardioversion in pregnancy is rarely required but should be undertaken when clinically indicated according to standard algorithms to optimise maternal wellbeing. Once the woman is stable post DCCV, gestation-relevant fetal monitoring should be undertaken. Maternity units should develop multidisciplinary processes to ensure pregnant women receive the same standard of care as their non-pregnant counterparts.

Evidence of horizontal urban heat advection in London using six years of data from a citizen weather station network

Recent advances in citizen weather station (CWS) networks, with data accessible via crowd-sourcing, provide relevant climatic information to urban scientists and decision makers. In particular, CWS can provide long-term measurements of urban heat and valuable information on spatio-temporal heterogeneity related to horizontal heat advection. In this study, we make the first compilation of a quasi-climatologic dataset covering six years (2015-2020) of hourly near-surface air temperature measurements obtained via 1560 suitable CWS in a domain covering south-east England and Greater London. We investigated the spatio-temporal distribution of urban heat and the influences of local environments on climate, captured by CWS through the scope of Local Climate Zones (LCZ)-a land-use land-cover classification specifically designed for urban climate studies. We further calculate, for the first time, the amount of advected heat captured by CWS located in Greater London and the wider south east England region. We find that London is on average warmer by about 1.0 ∘C-1.5 ∘C than the rest of south-east England. Characteristics of the southern coastal climate are also captured in the analysis. We find that on average, urban heat advection (UHA) contributes to 0.22 ± 0.96 ∘C of the total urban heat in Greater London. Certain areas, mostly in the centre of London are deprived of urban heat through advection since heat is transferred more to downwind suburban areas. UHA can positively contribute to urban heat by up to 1.57 ∘C, on average and negatively by down to -1.21 ∘C. Our results also show an important degree of inter- and intra-LCZ variability in UHA, calling for more research in the future. Nevertheless, we already find that UHA can impact green areas and reduce their cooling benefit. Such outcomes show the added value of CWS when considering future urban design.

Temporal changes in total and metabolically active ruminal methanogens in dairy cows supplemented with 3-nitrooxypropanol

The purpose of this study was to investigate the effect of 3-nitrooxypropanol (3-NOP), a potent methane inhibitor, on total and metabolically active methanogens in the rumen of dairy cows over the course of the day and over a 12-wk period. Rumen contents of 8 ruminally cannulated early-lactation dairy cows were sampled at 2, 6, and 10 h after feeding during wk 4, 8, and 12 of a randomized complete block design experiment in which 3-NOP was fed at 60 mg/kg of feed dry matter. Cows (4 fed the control and 4 fed the 3-NOP diet) were blocked based on their previous lactation milk yield or predicted milk yield. Rumen samples were extracted for microbial DNA (total) and microbial RNA (metabolically active), PCR amplified for the 16S rRNA gene of archaea, sequenced on an Illumina platform, and analyzed for archaea diversity. In addition, the 16S copy number and 3 ruminal methanogenic species were quantified using the real-time quantitative PCR assay. We detected a difference between DNA and RNA (cDNA)-based archaea communities, revealing that ruminal methanogens differ in their metabolic activities. Within DNA and cDNA components, methanogenic communities differed by sampling hour, week, and treatment. Overall, Methanobrevibacter was the dominant genus (94.3%) followed by Methanosphaera, with the latter genus having greater abundance in the cDNA component (14.5%) compared with total populations (5.5%). Methanosphaera was higher at 2 h after feeding, whereas Methanobrevibacter increased at 6 and 10 h in both groups, showing diurnal patterns among individual methanogenic lineages. Methanobrevibacter was reduced at wk 4, whereas Methanosphaera was reduced at wk 8 and 12 in cows supplemented with 3-NOP compared with control cows, suggesting differential responses among methanogens to 3-NOP. A reduction in Methanobrevibacter ruminantium in all 3-NOP samples from wk 8 was confirmed using real-time quantitative PCR. The relative abundance of individual methanogens was driven by a combination of dietary composition, dry matter intake, and hydrogen concentrations in the rumen. This study provides novel information on the effects of 3-NOP on individual methanogenic lineages, but further studies are needed to understand temporal dynamics and to validate the effects of 3-NOP on individual lineages of ruminal methanogens.

COVID-19 testing in outbreak-free care homes: what are the public health benefits?

BACKGROUND

COVID-19 care home outbreaks represent a significant proportion of COVID-19 morbidity and mortality in the UK. National testing initially focused on symptomatic care home residents, before extending to asymptomatic cohorts.

AIM

The aim was to describe the epidemiology and transmission of COVID-19 in outbreak free care homes.

METHODS

A two-point prevalence survey of COVID-19, in 34 Liverpool care homes, was performed in April and May 2020. Changes in prevalence were analysed. Associations between care home characteristics, reported infection, prevention and control interventions, and COVID-19 status were described and analysed.

FINDINGS

No resident developed COVID-19 symptoms during the study. There was no significant difference between: the number of care homes containing at least one test positive resident between the first (17.6%, 95% confidence interval (CI) 6.8-34.5) and second round (14.7%, 95% CI 5.0-31.1) of testing (p>0.99); and the number of residents testing positive between the first (2.1%, 95% CI 1.2-3.4) and second round (1.0%, 95% CI 0.5-2.1) of testing (P=0.11). Care homes providing nursing care (risk ratio (RR) 7.99, 95% CI 1.1-57.3) and employing agency staff (RR 8.4, 95% CI 1.2-60.8) were more likely to contain test positive residents. Closing residents shared space was not associated with residents testing positive (RR 2.63, 95% CI 0.4-18.5).

CONCLUSIONS

Asymptomatic COVID-19 care homes showed no evidence of disease transmission or development of outbreaks; suggesting that current infection prevention and control measures are effective in preventing transmission. Repeat testing at two to three weeks had limited or no public health benefits over regular daily monitoring of staff and residents for symptoms. These results should inform policies calling for regular testing of asymptomatic residents.

Multicentre study on pulmonary arterial hypertension therapies in fontan patients: underutilised or of limited use?

Introduction

The Fontan circulation is successful in abolishing cyanosis and chronic volume overload in congenital heart disease (CHD) patients with single ventricle physiology. “Fontan failure” is a major cause of poor quality of life and mortality in these patients. Recently, pulmonary arterial hypertension (PAH) therapies have been used in Fontan patients with variable success, even though patients included in these studies are generally at the best end of the spectrum.

Aim

To assess contemporary patterns of PAH therapy in Fontan patients in large specialist CHD centres.

Methods

We identified all adult patients with a Fontan-type circulation under active follow-up in 8 specialist CHD centres between 2009 and 2019. Patients on PAH therapies were matched by age and gender to untreated patients (1:1 or 1:2). Baseline data were collated immediately prior to initiation of therapy (treated group) or from a synchronous routine clinical assessment (untreated group).

Results

During the study period, 70 Fontan patients were started on PAH therapy (6.5% of those under follow-up). The majority 63 (90.0%) were started on monotherapy with a phosphodiesterase-5 (PDE5) inhibitor, 6 (8.6%) patients were started on an endothelin receptor antagonist (ERA) and 1 (1.4%) received early sequential therapy with a PDE5 inhibitor and ERA. Prostacyclin analogues were not used, and no patients received triple therapy. Overall, 51 (72.9%) patients started therapy electively (49% in outpatient clinic, 51% as day case admission), while 18 (25.7%) were treated following urgent hospital admission with fluid overload +/− acute kidney injury. The remainder (2,2.9%) started therapy following cardiac surgery. Adverse events during treatment were rare. Patients starting PAH therapy were matched to 112 untreated patients (table 1). Patients were well matched between groups for age (p=0.52) and sex (p=0.27). Treated patients were more likely to be significantly impaired than matched patients (56.7% vs. 8.6% in NYHA class III/IV, p<0.0001) and were more likely to have ascites (16.2% vs. 0.9%, p=0.0002). Treated patients were also more likely to have a lower albumin level (43 [14–56] vs. 45 [29–54], p=0.01) or to be on a loop diuretic e.g. furosemide (p<0.0001), at a higher daily dose (p<0.0001) than matched patients. Only a quarter of patients on therapies had no high-risk features (24.2%), 80% of whom were from a single centre.

Conclusion

A small minority of Fontan patients followed in specialist centres receive PAH therapies. PAH therapy was reserved in most centres for patients with more advanced disease, targeting predominantly those with a “failing Fontan” in an individualised approach, in line with the recent adult CHD American Heart Association (AHA) guidelines. Further studied are needed to establish the role of PAH therapies in Fontan patients, provided that adult patients with advanced disease who are at increased risk of adverse outcome are included.

Figure 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Dr Constantine received an educational grant from Actelion Pharmaceuticals, a Janssen company of Johnson & Johnson, which helped to pay for travel for data collection.

The single-use rhinolaryngoscope: an evaluation and cost comparison

BACKGROUND

This study investigated whether the single-use rhinolaryngoscope is clinically and economically comparable to the conventional reusable rhinolaryngoscope within a tertiary otolaryngology centre in the UK.

METHODS

A non-blinded, prospective and single-arm evaluation was carried out over a 5-day period, in which micro-costing was used to compare single-use rhinolaryngoscopes with reusable rhinolaryngoscopes.

RESULTS

Overall, 68 per cent of the investigators perceived the single-use rhinolaryngoscope to be 'good' or 'very good', while 85 per cent believed the single-use rhinolaryngoscope could replace the reusable rhinolaryngoscope (n = 59). The incremental costs of reusable rhinolaryngoscope eyepieces and videoscopes in the out-patient clinic, when compared to single-use rhinolaryngoscopes, were £30 and £11, respectively. The incremental costs of reusable rhinolaryngoscope eyepieces and videoscopes in the acute surgical assessment unit, when compared to single-use rhinolaryngoscopes, were -£4 and -£73, respectively.

CONCLUSION

The single-use rhinolaryngoscope provides a clinically comparable, and potentially cost-minimising, alternative to the reusable rhinolaryngoscope for use in the acute surgical assessment unit of our hospital.

A-09 The Relationship Between Subjective Cognitive Complaints, Depression, and Executive Functioning in mTBI Veterans

Objective

Among individuals with mild traumatic brain injury (mTBI), those with depression report greater subjective cognitive complaints than those without depression. In mTBI patients with general cognitive complaints, depression may account for poor performance on objective neuropsychological measures. This study seeks to expand this research by examining depression, subjective executive functioning (EF) complaints, and objective EF performance in Veterans with mTBI.

Method

Fifty-seven Veterans with deployment-related mTBI (12% female; age M = 42.0, SD = 13.6; years education M = 15.0, SD = 1.8) with (n = 29) or without (n = 28) a chart diagnosis of depression. Participants were administered the Behavioral Rating Inventory of Executive Functioning (BRIEF) and objective neuropsychological measures of working memory (i.e., Weschler Adult Intelligence Scale-IV Working Memory Index) and aspects of EF (i.e., Trail Making Test B and Delis-Kaplan Executive Functioning System (D-KEFS) subtests).

Results

Principal component analysis identified similar domains of EF to the BRIEF, including: task monitoring (Trail Making Test B, D-KEFS Letter Fluency, and D-KEFS Tower Test, eigenvalue = 1.93) and shifting (D-KEFS: Color-Word Interference Conditions 3 and 4, and Category Switching, eigenvalue = 1.24). Individuals with depression had greater subjective EF complaints in each BRIEF domain than non-depressed individuals (p’s ≤ .01). However, subjective complaints in these domains were not related to objective performance (r’s = −0.17,-0.19, p’s > .05). Moreover, depressed and non-depressed individuals performed similarly on all EF measures (p’s > .05).

Conclusions

mTBI Veterans with depression report more subjective EF complaints than those without depression. The lack of association between subjective complaints and objective EF performance suggests it is important to treat depression in mTBI patients to remedy perceived cognitive deficits.

C-24 Longitudinal Trajectories of Working Memory Performance in Typically Aging Older Adults

Objective

Cross-sectional studies have shown age-related differences in working memory (WM), but the trajectory is unclear due to the scarcity of longitudinal studies. Additional research is needed to better characterize the course of age-related changes in WM in older adults. The present study sought to address this gap in the literature by conducting serial assessments of WM in a longitudinally followed cohort of typically aging adults. We hypothesized a significant age × time interaction, such that WM would show pronounced declines with advancing age.

Methods

640 functionally intact participants in an aging cohort (clinical dementia rating = 0; age range 52-99, mean age = 75) completed a computerized WM measure, Running Letter Memory (RLM), every ~15 months for up to 8.5 years (mean follow-up = 1.9 years). Longitudinal changes in RLM scores were analyzed using linear mixed effects models, allowing for random slopes and intercepts. All models were adjusted for sex and education.

Results

RLM performance did not significantly decline over time (b = -.14, p = .43). As hypothesized, there was a significant age × time interaction predicting RLM scores (b = -.08, p = .006). Specifically, RLM performance remained relatively stable (or slightly improved) until around age 75, beyond which increasingly precipitous declines were observed with advancing age.

Conclusion

The present results suggest that WM performance does not evidence declines until the mid-70s in typically aging adults, at which point increasingly steep decline trajectories are observed with advancing age. These findings highlight that cognitive aging does not occur at a constant rate in late life.

Maternal and fetal outcomes in pregnancies complicated by the inherited aortopathy Loeys-Dietz syndrome

OBJECTIVE

Pregnancies in women with Loeys-Dietz syndrome (LDS) are rare and are typically documented in case reports only. Early reports suggested high rates of maternal complications during pregnancy and the puerperium, including aortic dissection and uterine rupture, but information on fetal outcomes was very limited.

DESIGN

A retrospective cohort study.

SETTING

Eight specialist UK centres.

SAMPLE

Pregnant women with LDS.

METHODS

Data was collated on cardiac, obstetric, and neonatal outcomes.

MAIN OUTCOME MEASURES

Maternal and perinatal outcomes in pregnancies complicated by LDS.

RESULTS

Twenty pregnancies in 13 women with LDS were identified. There was one miscarriage, one termination of pregnancy, and 18 livebirths. In eight women the diagnosis was known prior to pregnancy but only one woman had preconception counselling. In four women the diagnosis was made during pregnancy through positive genotyping, and the other was diagnosed following delivery. Five women had a family history of aortic dissection. There were no aortic dissections in our cohort during pregnancy or postpartum. Obstetric complications were common, including postpartum haemorrhage (33%) and preterm delivery (50%). In all, 14/18 (78%) of deliveries were by elective caesarean section, at a median gestational age at delivery of 37 weeks. Over half the infants (56%) were admitted to the neonatal unit following delivery.

CONCLUSION

Women with LDS require multidisciplinary specialist management throughout pregnancy. Women should be referred for preconception counselling to make informed decisions around pregnancy risk and outcomes. Early elective preterm delivery needs to be balanced against a high infant admission rate to the neonatal unit.

TWEETABLE ABSTRACT

Pregnancy outcomes in women with Loeys-Dietz syndrome.

Screening for Atrial Fibrillation

Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country- and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.

First Report of Meloidogyne marylandi Infecting Bermudagrass in Oklahoma

Meloidogyne marylandi is a nematode commonly associated with turfgrasses and has been reported to occur in Texas and Arkansas (1,3). In the fall of 2013, a stand of ultradwarf bermudagrass (Cynodon dactylon × C. transvaalensis) plants in a sand-based, research putting green in Stillwater, Oklahoma, exhibited symptoms of decline. Roots of the affected plants had small galls and upon staining of the root system, numerous egg masses were evident. Egg masses were collected, placed in water, and the morphology of 20 hatched, second-stage juveniles were examined. The characteristics of the juveniles were: body length averaged 393.1 ± 19.87 (range: 361 to 425) μm, mean width averaged 16.6 ± 0.7 (15.6 to 17.8) μm, stylet lengths averaged 12.1 ± 0.7 (10.4 to 12.9) μm, dorsal gland orifice from stylet base averaged 2.9 ± 0.4 (2.5 to 3.6) μm, tail lengths averaged 53.7 ± 3.8 (46.2 to 60.4) μm, and the hyaline region of the tails averaged 10.4 ± 1.1 (8.4 to 12.7) μm. Genomic DNA was extracted from six females that were removed from roots. Amplification and sequencing of the mitochondrial DNA region between COII and 16S rRNA genes was performed with primers 1RNAF (5'-TACCTTTGACCAATCACGCT-3') and CO11R (5'-GGTCAATGTTCAGAAATTTGTGG-3') as previously described (2). A PCR product approximately 510 bp in length was obtained and sequenced at the Oklahoma State University Core Facility. Sequences were compared with those in NCBI's nucleotide database using BLAST and had 97% identity with two sequences from M. marylandi (KC473862.1 and KC473863.1) and the next most similar species being M. graminis (JN241898.1) with 83% identity. To our knowledge, this is the first report of the root-knot nematode M. marylandi in Oklahoma. As bermudagrass becomes more commonly used for putting greens in the turfgrass transition zone, M. marylandi may become a more common and damaging pathogen in the region. References: (1) A. A. Elmi et al. Grass For. Sci. 55:166, 2000. (2) M. A. McClure et al. Plant Dis. 96:635, 2012. (3) J. L. Starr et al. Nematrop. 37:43, 2007.

Effects of an exogenous protease on the fermentation and nutritive value of corn silage harvested at different dry matter contents and ensiled for various lengths of time

The objective of this experiment was to evaluate the effects of adding an experimental protease to corn plants harvested at different maturities on silage fermentation and in vitro ruminal starch digestibility (IVSD). Corn plants were harvested at maturities resulting in plants with 31 or 40% dry matter (DM). Plants were chopped, kernel processed, and treated with (1) only a 0.1 M phosphate buffer (pH 5.5, 5% vol/wt of fresh forage), (2) buffer with protease to obtain a final concentration of 20mg of protease/kg of wet forage, and (3) buffer with protease to obtain a final concentration of 2,000 mg of protease/kg of wet forage. Treated forages (about 500 g) were ensiled in nylon-polyethylene pouches and stored between 21 and 23°C for 0, 45, 90, and 150 d. Data were analyzed as a 2 × 3 × 4 factorial arrangement of treatments, with the main effects of harvest DM, dose of protease, days of ensiling, and their interactions. The treatment with the highest dose of protease resulted in more robust fermentations across harvest DM with higher concentrations of lactic and acetic acids compared with untreated silage. Concentrations of soluble protein (% of crude protein) increased with time of ensiling, regardless of DM content at harvest. However, averaged over both harvest DM contents, it increased by 37% for silages treated with the high dose of protease compared with an average 11% increase for untreated silages and silage treated with the low dose of protease, between d 0 and 45. Averaged over both harvest DM contents, the concentration of soluble protein peaked in silages treated with the high dose of protease after 45 d of ensiling, whereas it peaked at d 90 in untreated silages and silage treated with the low dose of protease. Similar changes occurred in the concentration of NH3-N due to length of ensiling and treatment with protease. In fresh forages, the concentration of starch for early- and late-harvested forages was similar, but IVSD was lower in the latter. After 45 d of ensiling, IVSD was highest in both early- and late-harvested silages that were treated with the high level of protease. After 150 d of ensiling, IVSD was similar among silages treated with protease, regardless of DM at harvest. Treating corn plants with a high dose of an experimental protease at harvest accelerated proteolysis during ensiling, resulting in corn silages with levels of IVSD after 45 d of ensiling that were only obtained in untreated corn silages after 150 d of ensiling.

Attainment of metabolic goals in the integrated UK islet transplant program with locally isolated and transported preparations

The objective was to determine whether metabolic goals have been achieved with locally isolated and transported preparations over the first 3 years of the UK's nationally funded integrated islet transplant program. Twenty islet recipients with C-peptide negative type 1 diabetes and recurrent severe hypoglycemia consented to the study, including standardized meal tolerance tests. Participants received a total of 35 infusions (seven recipients: single graft; 11 recipients: two grafts: two recipients: three grafts). Graft function was maintained in 80% at [median (interquartile range)] 24 (13.5-36) months postfirst transplant. Severe hypoglycemia was reduced from 20 (7-50) episodes/patient-year pretransplant to 0.3 (0-1.6) episodes/patient-year posttransplant (p < 0.001). Resolution of impaired hypoglycemia awareness was confirmed [pretransplant: Gold score 6 (5-7); 24 (13.5-36) months: 3 (1.5-4.5); p < 0.03]. Target HbA1c of <7.0% was attained/maintained in 70% of recipients [pretransplant: 8.0 (7.0-9.6)%; 24 (13.5-36) months: 6.2 (5.7-8.4)%; p < 0.001], with 60% reduction in insulin dose [pretransplant: 0.51 (0.41-0.62) units/kg; 24 (13.5-36) months: 0.20 (0-0.37) units/kg; p < 0.001]. Metabolic outcomes were comparable 12 months posttransplant in those receiving transported versus only locally isolated islets [12 month stimulated C-peptide: transported 788 (114-1764) pmol/L (n = 9); locally isolated 407 (126-830) pmol/L (n = 11); p = 0.32]. Metabolic goals have been attained within the equitably available, fully integrated UK islet transplant program with both transported and locally isolated preparations.

Permanent pacemaker insertion after CoreValve transcatheter aortic valve implantation: incidence and contributing factors (the UK CoreValve Collaborative)

BACKGROUND

Permanent pacemaker (PPM) requirement is a recognized complication of transcatheter aortic valve implantation. We assessed the UK incidence of permanent pacing within 30 days of CoreValve implantation and formulated an anatomic and electrophysiological model.

METHODS AND RESULTS

Data from 270 patients at 10 centers in the United Kingdom were examined. Twenty-five patients (8%) had preexisting PPMs; 2 patients had incomplete data. The remaining 243 were 81.3±6.7 years of age; 50.6% were male. QRS duration increased from 105±23 to 135±29 milliseconds (P<0.01). Left bundle-branch block incidence was 13% at baseline and 61% after the procedure (P<0.001). Eighty-one patients (33.3%) required a PPM within 30 days. Rates of pacing according to preexisting ECG abnormalities were as follows: right bundle-branch block, 65.2%; left bundle-branch block, 43.75%; normal QRS, 27.6%. Among patients who required PPM implantation, the median time to insertion was 4.0 days (interquartile range, 2.0 to 7.75 days). Multivariable analysis revealed that periprocedural atrioventricular block (odds ratio, 6.29; 95% confidence interval, 3.55 to 11.15), balloon predilatation (odds ratio, 2.68; 95% confidence interval, 2.00 to 3.47), use of the larger (29 mm) CoreValve prosthesis (odds ratio, 2.50; 95% confidence interval, 1.22 to 5.11), interventricular septum diameter (odds ratio, 1.18; 95% confidence interval, 1.10 to 3.06), and prolonged QRS duration (odds ratio, 3.45; 95% confidence interval, 1.61 to 7.40) were independently associated with the need for PPM.

CONCLUSION

One third of patients undergoing a CoreValve transcatheter aortic valve implantation procedure require a PPM within 30 days. Periprocedural atrioventricular block, balloon predilatation, use of the larger CoreValve prosthesis, increased interventricular septum diameter and prolonged QRS duration were associated with the need for PPM.

Copy number variations of chromosome 16p13.1 region associated with schizophrenia

Deletions and reciprocal duplications of the chromosome 16p13.1 region have recently been reported in several cases of autism and mental retardation (MR). As genomic copy number variants found in these two disorders may also associate with schizophrenia, we examined 4345 schizophrenia patients and 35,079 controls from 8 European populations for duplications and deletions at the 16p13.1 locus, using microarray data. We found a threefold excess of duplications and deletions in schizophrenia cases compared with controls, with duplications present in 0.30% of cases versus 0.09% of controls (P=0.007) and deletions in 0.12 % of cases and 0.04% of controls (P>0.05). The region can be divided into three intervals defined by flanking low copy repeats. Duplications spanning intervals I and II showed the most significant (P = 0.00010) association with schizophrenia. The age of onset in duplication and deletion carriers among cases ranged from 12 to 35 years, and the majority were males with a family history of psychiatric disorders. In a single Icelandic family, a duplication spanning intervals I and II was present in two cases of schizophrenia, and individual cases of alcoholism, attention deficit hyperactivity disorder and dyslexia. Candidate genes in the region include NTAN1 and NDE1. We conclude that duplications and perhaps also deletions of chromosome 16p13.1, previously reported to be associated with autism and MR, also confer risk of schizophrenia.