The Calcium Score's power of zero in 82-Rubidium PET depending on age group and sex

Background

Coronary calcium score (CAC) is a well-validated method to detect coronary artery disease (CAD). A significant number of patients referred for functional ischaemia tests reveal a normal result. CAC could be a potential gatekeeper to reduce unnecessary testing.

Purpose

Study aims were to describe the frequency of zero calcium and its diagnostic power to exclude abnormal perfusion stratified by age and sex in a large cohort undergoing 82-Rubidium Positron Emission Tomography (PET).

Methods

All consecutive patients with suspected CAD who were referred for myocardial perfusion PET at our tertiary center between 2016 and 2021 were identified. Baseline and scan related data were extracted from the electronic database. Patients were included for this retrospective analysis if CAC and semi-quantitative analysis of perfusion study were available. Percentiles and test characteristics of zero calcium were calculated stratified by age and sex. Summed stress score (SSS) ≥4 on PET was considered abnormal.

Results

2640 patients were included. Mean age was 65±11 years; 54% were male. Angina and dyspnea were present in 39% and 60%, respectively. 21% (558/2640) of the scans were abnormal and median CAC was 62 [0–374]. 685 patients (26%) had no calcium. Stratified by age, the proportion of zero calcium was 89% (<40 years), 61% (40–49y), 40% (50–59y), 21% (60–69y), 14% (70–79y) and 6% (≥80y). CAC was higher in abnormal scans (median 561 vs. 27, p<0.001) and zero CAC was associated with a lower risk of abnormal PET (2.6% vs. 27.6%, p<0.001). The negative predictive value (NPV) of calcium zero to exclude abnormal PET was 97%, 96% and 98% for all patients, males and females, respectively. Test characteristics are displayed in Table 1. Percentiles of CAC according to scan result are depicted in Figure 1.

Conclusion

The proportion of zero calcium is frequent and declines with increasing age. The absence of coronary calcium is associated with less abnormal PET scans. Zero calcium to exclude an abnormal scan performed best in young patients (<50) with a NPV ≥98%. CAC could act as a gatekeeper. However, further studies including safety endpoints are needed.

The upper calcium score indicates the 90th percentile of patients with normal PET. The lower calcium score indicates the 5th percentile of patients with abnormal PET. Calcium scores within the white area are unlikely to be associated with abnormal PET (since this area includes only the 5% of abnormal PET scans). The dark grey area indicates patients with a high likelihood of positive PET. For better readability, different scales were used.

Funding Acknowledgement

Type of funding sources: None.

POS0256 CLINICAL PREDICTORS OF ATTENUATED ANTIBODY RESPONSE TO PRIMARY SARS-CoV-2 VACCINATION IN A LARGE PROSPECTIVE STUDY OF PATIENTS WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES

Background

An attenuated humoral response to SARS-CoV-2 vaccination has been observed in some patients with rheumatic and musculoskeletal diseases (RMD) (1). We sought to identify clinical factors associated with poor humoral response following primary (two-dose mRNA or single adenoviral vector dose) SARS-COV-2 vaccination in patients with RMD on immunosuppression.

Objectives

To identify clinical predictors of an attenuated antibody response to primary SARS-CoV-2 vaccination in RMD patients on immunosuppression.

Methods

We included patients ≥18 years old with RMD on immunosuppression who received either two-dose mRNA or single dose Janssen/Johnson and Johnson (J&J) vaccination. Demographics, diagnoses, and therapeutic regimens were collected via participant report; those with prior COVID-19 infection were excluded. One month after vaccination, participants underwent SARS-CoV-2 antibody testing on the semi-quantitative Roche Elecsys anti-SARS-CoV-2 S enzyme immunoassay, which measures antibody to the SARS-CoV-2 S-receptor binding domain (RBD) protein (ceiling >250U/mL later expanded to >2500U/mL). Associations were evaluated using Fisher’s exact and Wilcoxon rank sum tests. Logistic regression analyses were performed to evaluate for clinical factors associated with antibody response. We adapted survival methods to address right-truncation of titers; this methodology was used to calculate medians. Participants provided informed consent electronically and the study was approved by the local Institutional Review Board.

Results

We studied 1138 RMD participants on immunosuppression; most were female (93%) and white (91%) (Table 1). One-hundred and fifteen (10%) had anti-RBD response in the negative range at a median (IQR) of 29 days (28-34) following completion of vaccine series. A greater proportion of participants with negative response were non-white, received J&J vaccine, reported use of mycophenolate, rituximab, or glucocorticoids. Antibody response differed by immunosuppressive regimen, with those receiving rituximab having poorest response (Figure 1). Use of mycophenolate (aOR 9.92, p=0.001), rituximab (aOR 56.99, p=0.001), glucocorticoids (aOR 2.99, p=0.001) or receipt of J&J (aOR 3.13, p=0.039) were associated with negative antibody response.

Table 1.

Clinical characteristics stratified by anti-SARS-CoV-2 RBD response

Negative (n=115)*Positive (n=1023)*p-value†Age,median(IQR)49(42, 58)47(37, 58)0.07Female sex,no.(%)108(94%)952(93%)0.78Non-white,no.(%)16(13.9%)83(8.1%)0.04Diagnosis,no.(%)Inflammatory arthritis22(19.1%)469(45.8%)<0.01SLE27(23.5%)193(18.9%)0.27Sjὅgren’s syndrome5(4.3%)46(4.5%)0.53Myositis13(11.3%)49(4.8%)<0.01Systemic sclerosis2(1.7%)9(0.9%)0.55Vasculitis12(10.4%)16(1.6%)<0.01Overlap connective tissue disease¶34(29.5%)24(23.6%)0.65  Vaccine,no.(%) Pfizer/BioNTech66(57.4%)548(53.6%)0.01Moderna38(33.0%)438(42.8%)J&J11(9.6%)37(3.6%)Non-biologic in regimen89(77.4%)725(70.9%)0.52Biologic in regimen84(73.0%)570(55.7%)0.01 Mycophenolate**56(48.7%)120(11.7%)<0.01 Rituximab54(47.0%)29(2.8%)<0.01 Glucocorticoid**61(53.0%)284(27.8%)<0.01Withheld immunosuppression18(21.2%)260(39.6%)<0.01

* Negative defined as anti-RBD titer <0.8 U/mL.

† Comparisons between negative and positive groups.

¶ Denotes a combination of two or more of the above conditions

** Mycophenolate: mycophenolic acid and mycophenolate mofetil. Corticosteroid: prednisone and prednisone equivalents

Figure 1.

Conclusion

Use of mycophenolate, glucocorticoids, rituximab and receipt of J&J vaccine were the strongest predictors of an attenuated antibody response to primary SARS-CoV-2 vaccination; these data support use of an additional primary dose in RMD patients.

References

[1]Deepak P, Kim W, Paley MA, et al. Effect of Immunosuppression on the Immunogenicity of mRNA Vaccines to SARS-CoV-2: A Prospective Cohort Study. Ann Intern Med. 2021.

Acknowledgements

We would like to acknowledge the contributions of: Brian J. Boyarsky MD, PhD, Jake A. Ruddy BS, and Jacqueline M. Garonzik-Wang MD PhD.

Disclosure of Interests

Caoilfhionn Connolly: None declared, Teresa Po-Yu Chiang: None declared, Mayan Teles: None declared, Sarah Frey: None declared, Jennifer Alejo: None declared, Allan Massie: None declared, Lisa Christopher Stine Consultant of: Janssen, Boehringer-Ingelheim, Mallinckrodt, EMD-Serono, Allogene, and ArgenX., William Werbel: None declared, Dorry Segev Speakers bureau: Sanofi, Novartis, CSL Behring, Jazz Pharmaceuticals, Veloxis, Mallincrodt, Thermo Fisher Scientific, Regeneron, and Astra-Zeneca, Consultant of: Sanofi, Novartis, CSL Behring, Jazz Pharmaceuticals, Veloxis, Mallincrodt, Thermo Fisher Scientific, Regeneron, and Astra-Zeneca, Julie Paik: None declared

Factors influencing oral cancer screening preferences in patients attending Tertiary Care University Oral Health Clinic

BACKGROUND

Understanding factors that influence patients' preferences towards oral cancer (OC) screening is imperative to provide high-quality evidence-based OC screening interventions that can be targeted for population-level uptake. This study determined adult patients' knowledge and awareness of OC, and how health behaviours influenced their preferences towards OC screening.

METHODS

This cross-sectional study used a 42-point questionnaire, between February and May 2020 using a combination of in-person and telephone interviews. Chi-square test and multiple logistic regression analysis were applied to confounding factors that returned statistical significance against OC knowledge and awareness. Significance of P < 0.05 was accepted.

RESULTS

Sixty-eight (38.6%) participants out of a total 176 had good knowledge of OC and 89 (50.6%) had good awareness. A total of 31.8% reported preference for OC screening by a general dental practitioner (GDP) over a general medical practitioner (GMP). Majority (72.7%) reported acceptance of OC screening at their next GDP visit. Ages 56-70 (OR = 0.357, 95% CI) and previous smokers (OR = 0.336, 95% CI) significantly influenced screening preferences. Knowledge of risk factors did not significantly influence OC screening preferences (χ²  = 3.178, P = 0.075).

CONCLUSIONS

Significant gaps in OC knowledge, screening and role of GDPs exist with smoking history and age influencing OC screening preferences.

Influence of adenosine and regadenoson on left ventricular ejection fraction, myocardial blood flow and hemodynamics in vasodilator 82-Rubidium PET

Funding Acknowledgements

Type of funding sources: None.

Introduction

Most 82Rubidium-(Rb)-Positron emission tomography (PET) studies for myocardial perfusion, dipyridamole was used as vasodilator. Less data is available for adenosine and regadenoson.

Purpose

Therefore, the aim was to evaluate the influence of adenosine and regadenoson on left ventricular ejection fraction (LVEF), myocardial blood flow (MBF) and hemodynamics in vasodilator 82Rb-PET.

Methods

Consecutive patients (n = 2299) with suspected or known coronary artery disease (CAD) undergoing 82Rb-PET were studied and compared according to CAD status and normal/abnormal PET (abnormal defined as summed stress score ≥4). Differences between stress and rest values (LVEF, MBF, hemodynamics) were calculated. The threshold of stress LVEF able to exclude a relevant ischemia (as defined by ≥10% myocardium ischemic based on SDS score) was assessed.

Results

Rest and stress LVEF differed significantly depending on CAD status and scan results. In patients with suspected CAD, rest/stress LVEF were 68 ± 12% and 73 ± 12% (p &lt; 0.001), in patients with prior CAD 60 ± 14% and 63 ± 15% (p &lt; 0.001). LVEF during stress increased 5 ± 6% in normal compared to 1 ± 8% in abnormal PET (p &lt; 0.001). Global rest MBF (rMBF), stress MBF (sMBF) and myocardial flow reserve (sMBF/rMBF) were significantly higher in suspected CAD patients compared to prior CAD patients (1.3 ± 0.5, 3.3 ± 0.9, 2.6 ± 0.8 and 1.2 ± 0.4, 2.6 ± 0.8, 2.4 ± 0.8 ml/g/min, respectively, p &lt; 0.001), and in normal versus abnormal scans, irrespective of CAD status (no CAD: 1.4 ± 0.5, 3.5 ± 0.8, 2.8 ± 0.8 and 1.2 ± 0.8, 2.5 ± 0.8, 2.2 ± 0.7; known CAD: 1.3 ± 0.4, 3.1 ± 0.8, 2.7 ± 0.8 and 1.1 ± 0.4, 2.3 ± 0.7, 2.2 ± 0.7 ml/g/min, respectively, p &lt; 0.001). LVEF and hemodynamic values were similar for adenosine and regadenoson stress. Stress LVEF ≥70% excluded relevant ischemia with a negative predictive value (NPV) of 94% (CI 92-95%).

Conclusions

Rest/stress LVEF, LVEF reserve and MBF values are lower in abnormal compared with normal scans. Adenosine and regadenoson seem to have similar effect on stress LVEF, MBF and hemodynamics. A stress LVEF ≥70% has a high NPV to exclude relevant ischemia.

Defining global benchmarks in elective secondary bariatric surgery comprising conversional, revisional and reversal procedures

Objective

Management of poor response and of long-term complications after bariatric surgery (BS) is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. Benchmarking uses best performance in a given field as reference point for improvement. Our aim was to define ‘‘best possible’’ outcomes for elective secondary BS.

Methods

The establishment of benchmarks in secondary BS followed a standardized methodology, based on recommendations of a Delphi consensus panel of experts. This multicenter study analyzed patients undergoing elective secondary BS in 18 high-volume centers on 4 continents from 06/2013 to 05/2019. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of the centers. Benchmark cases had no: previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI&gt;50kg/m2 or age&gt;65 years. Descriptive statistics, multivariate logistic regression and data visualization were performed using the R software.

Results

Out of 44’884 elective bariatric procedures performed in the participating centers, 5’328 secondary BS cases were identified. The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8±10 years, 8.4±5.3 years after primary BS, with a body mass index 35.2±7kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.57% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.36) and after conversional or revisional procedures with gastrointestinal suture/stapling (OR 1.7). Benchmark cutoffs at 90-days postoperatively were ≤5.8% re-intervention and ≤8.8% re-operation rate. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation.

Conclusion

Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

A comprehensive secondary prevention benchmark (2PBM) score identifying differences in secondary prevention care in patients after acute coronary syndrome

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Unrestricted grands from AstraZeneca, Boehringer Ingelheim and Sanofi

Background

Reaching secondary prevention targets improves long-term prognosis in patients after acute coronary syndrome (ACS). Although prevention targets are defined by guidelines, their achievement rates are insufficiently documented. Suitable benchmarking tools are lacking.

Purpose

 We aimed to determine the degree of secondary prevention care by creating a secondary prevention benchmark score (2PBM) and using it in patients undergoing ambulatory cardiac rehabilitation (CR) after an acute coronary syndrome. 

Methods

In this observational cohort study, 472 consecutive ACS patients who completed the local ambulatory CR programme between 2017-2019 were included. Benchmarks for secondary prevention medication, clinical and lifestyle targets were predefined and combined in the complete 2PBM with maximum 10 points. The association of patient characteristics and achievement rates of individual components and the complete 2PBM were assessed using multivariable logistic regression analysis. 

Results

Patients were on average 62 ± 11 years old and predominantly male (n = 406; 86%). Type of ACS was ST-elevation myocardial infarction (STEMI) in 241 patients (51%) and non-ST-elevation myocardial infarction in 216 patients (46%). Achievement rates for individual components of the 2PBM were 71% for medication, 35% for clinical and 61% for lifestyle benchmarks. Achievement of medication benchmark was associated with younger age [odds ratio (OR): 0.979, 95% confidence interval (CI) 0.959-0.996, p = 0.021] and history of STEMI [OR: 2.05, 95% CI 1.35-3.12, p = 0.001]. Achievement of clinical benchmark was associated with medication benchmark [OR: 1.66, 95% CI 1.03-2.71, p = 0.042]. The complete 2PBM was achieved by 74 patients (16%), while 362 patients (77%) reached ≥8 points. Achievement of complete 2PBM was independently associated with a history of STEMI [OR: 1.79, 95 CI 1.06-3.08 p = 0.032]. 

Conclusion

Benchmarking with 2PBM identifies gaps and achievements in secondary prevention care. A history of STEMI was associated with the highest 2PBM score, suggesting best secondary prevention care in patients after STEMI. 2PBM may be used for internal quality control, comparison of cohorts and future correlation studies between CR targets and outcomes.

Abstract Figure.

The human sialic acid-binding immunoglobulin-like lectin Siglec-9 and its murine homolog Siglec-E control osteoclast activity and bone resorption

Regulation of osteoclast differentiation and function is a central element in bone homeostasis. While the role of soluble factors, such as cytokines, hormones and growth factors, in controlling osteoclast differentiation has been intensively characterized, the function of surface receptors is less well understood. Sialic acid-binding immunoglobulin-like lectin (Siglec)-9 and its murine homolog Siglec-E are sialic acid-recognizing inhibitory receptors from the CD33-related Siglec-family and mainly expressed on myeloid cells. We found Siglec-9 and Siglec-E to be expressed at all stages of human and murine osteoclastogenesis, respectively. Siglec-E knockout mice displayed lower bone mass despite unchanged osteoclast numbers and an increased bone formation rate. Ex vivo osteoclast assays using Siglec-E knockout cells or a blocking antibody against human Siglec-9 confirmed the suppressive effect of Siglec-9/Siglec-E on osteoclast function. Although osteoclast numbers were unchanged or even slightly decreased, the blockade/absence of Siglec-9/Siglec-E resulted in an augmented resorption activity of mature osteoclasts. This increased resorption activity was associated with enlarged actin rings. Together, our results suggest Siglec-9/Siglec-E to inhibit osteoclast activation independently from osteoclast differentiation and thereby propose a new mechanism for the control of local bone resorption.

Using non-invasive neuroimaging to enhance the care, well-being and experimental outcomes of laboratory non-human primates (monkeys)

Over the past 10-20 years, neuroscience witnessed an explosion in the use of non-invasive imaging methods, particularly magnetic resonance imaging (MRI), to study brain structure and function. Simultaneously, with access to MRI in many research institutions, MRI has become an indispensable tool for researchers and veterinarians to guide improvements in surgical procedures and implants and thus, experimental as well as clinical outcomes, given that access to MRI also allows for improved diagnosis and monitoring for brain disease. As part of the PRIMEatE Data Exchange, we gathered expert scientists, veterinarians, and clinicians who treat humans, to provide an overview of the use of non-invasive imaging tools, primarily MRI, to enhance experimental and welfare outcomes for laboratory non-human primates engaged in neuroscientific experiments. We aimed to provide guidance for other researchers, scientists and veterinarians in the use of this powerful imaging technology as well as to foster a larger conversation and community of scientists and veterinarians with a shared goal of improving the well-being and experimental outcomes for laboratory animals.

The Complexity of Porous Media Flow Characterized in a Microfluidic Model Based on Confocal Laser Scanning Microscopy and Micro-PIV

Abstract

In this study, the complexity of a steady-state flow through porous media is revealed using confocal laser scanning microscopy (CLSM). Micro-particle image velocimetry (micro-PIV) is applied to construct movies of colloidal particles. The calculated velocity vector fields from images are further utilized to obtain laminar flow streamlines. Fluid flow through a single straight channel is used to confirm that quantitative CLSM measurements can be conducted. Next, the coupling between the flow in a channel and the movement within an intersecting dead-end region is studied. Quantitative CLSM measurements confirm the numerically determined coupling parameter from earlier work of the authors. The fluid flow complexity is demonstrated using a porous medium consisting of a regular grid of pores in contact with a flowing fluid channel. The porous media structure was further used as the simulation domain for numerical modeling. Both the simulation, based on solving Stokes equations, and the experimental data show presence of non-trivial streamline trajectories across the pore structures. In view of the results, we argue that the hydrodynamic mixing is a combination of non-trivial streamline routing and Brownian motion by pore-scale diffusion. The results provide insight into challenges in upscaling hydrodynamic dispersion from pore scale to representative elementary volume (REV) scale. Furthermore, the successful quantitative validation of CLSM-based data from a microfluidic model fed by an electrical syringe pump provided a valuable benchmark for qualitative validation of computer simulation results.

Graphic Abstract

E-learning and an action model for promoting psychosocial health: knowledge transfer in a university

Background

Promotion of the psychosocial health of individuals, groups and society, is becoming an increasingly important task for healthcare professions. In the Department of Health Professions at the Bern University of Applied Sciences, an interdisciplinary team of professors and researchers developed an e-learning programme, which highlights a new action model. This innovative model guides health professionals in systematically utilizing health promotion and prevention, to promote psychosocial health among their target groups. Internationally, such a model does not exist. Therefore, it offers an new and systematic approach to promoting psychosocial health among various population health levels.

Objectives

2019-2023: utilization of programme by department professors and researchers, and transfer of this knowledge to students, or to research projects (via internal marketing and incentives); integration of programme into interdisciplinary bachelor curriculum (via learning packages designed for use with students); national and international dissemination of the new model. How is the programme and model perceived among the professors and researchers? What is the models' relevance for public health?

Results

Preliminary results according to various professors, suggest that the programme is user-friendly and very useful. It has been integrated into the interdisciplinary bachelor curriculum. Researchers provided less feedback; however, ongoing incentives should result in its increased integration into research projects. Additional feedback is that the model is an innovative tool, and is relevant for health professionals at the international level. Its dissemination will begin in spring 2020, through its submission for publishing.

Conclusions

This e-learning programme and model are considered to be valuable and innovative. Upon publication, this systematic approach to improving the psychosocial health of target group(s) will be widely available for health professionals.

Key messages

An innovative action-model has been developed for the promotion of psychosocial health. A new understanding of how health promotion and prevention can applied to promote psychosocial health is offered.

Thyroid surgery in obese patients: A review of the literature

The incidence of obesity in the general population has tripled in the past four decades. The number of bariatric surgeries performed annually has quadrupled in the past ten years due to this obesity epidemic. Concomitantly, the number of patients who are obese or who have undergone bariatric surgery and have become candidates for thyroid surgery has also increased considerably. Among patients undergoing thyroidectomy in the French population, the proportion of obese patients currently represents 10 to 20%. In addition, the frequency of benign and malignant thyroid pathologies seems to be increased by obesity, with a Hazard Ratio of around 1.8 for thyroid cancers in obese women. While obesity does not seem to influence the specific post-operative morbidity of thyroidectomy, a history of malabsorptive bariatric surgery should encourage the greatest caution in patients who need to undergo thyroid surgery since it is associated with a significant risk of severe hypocalcemia (>60% in some studies) requiring intravenous calcium supplementation in about 20% of cases. In the latter situation, peri-operative vitamin D-calcium supplementation is essential. In addition, the replacement dose of Levothyroxine (T4) intended for replacement must also be adapted in obese patients, calculated not from the actual weight but from the ideal weight. The objective of this review is to discuss the influence of obesity on the evolution of nodular and neoplastic thyroid pathologies, on the morbidity of thyroid surgery as well as on post-operative drug treatments. The impact of bariatric surgery on these different aspects is also discussed.

The economic burden of schizophrenia in Germany: A population-based retrospective cohort study using genetic matching

Objective

Prior studies to determine the economic consequences of schizophrenia have largely been undertaken in clinical settings with a small number of cases and have been unable to analyze effects across different age cohorts. The aim of this study is to investigate the burden of schizophrenia in Germany.

Methods

Costs, service utilization, and premature mortality attributable to schizophrenia were estimated for the year 2008 using a retrospective matched cohort design. Therefore, 26,977 control subjects as well as 9411 individuals with a confirmed diagnosis of schizophrenia were drawn from a sickness fund claims database. To reduce conditional bias, the non-parametric genetic matching method was employed.

Results

The final study population comprised 8224 matched pairs. The annual cost attributable to schizophrenia was €11,304 per patient from the payers’ perspective and €20,609 from the societal perspective with substantial variations among age groups: direct medical expenses were highest among patients aged > 65 years, whereas younger individuals (< 25 years) incurred the greatest non-medical costs. The annual burden of schizophrenia from the perspective of German society ranges between €9.63 billion and €13.52 billion.

Conclusion

There are considerable differences in the distribution of costs and service utilization for schizophrenia. Because schizophrenia is characterized by an early age of onset and a long duration, research efforts should be targeted at particular populations to obtain the most beneficial outcomes, both clinically and economically.

Acute esophageal necrosis: Case report of an unknown entity

•

Acute esophageal necrosis is an unknown entity because it is a rare disease.

•

Management including different specialties.

•

Time is necessary and surgery is not the only therapy.

Introduction

Acute Esophageal Necrosis Syndrome (AENS) is a rare and unknown clinical entity, defined as a diffuse circumferential black-appearing friable esophageal mucosa going from the distal esophageal mucosa to the gastroesophageal (GE) junction. Esophagogastroduodenoscopy (EGD) remains the gold standard in making diagnosis.

Presentation of case

We report here the case of a 45-year-old man with necrosis of the esophagus treated conservatively. Regression of the lesion but persistence of ulcerations were seen on the endoscopic follow-up. Distal esophageal stenosis was then diagnosed and treated by endoscopic dilation.

Discussion

Diagnosis of AENS must be considered when an old patient, with multiple comorbidities, presents an upper digestive hemorrhage. Upper endoscopy is mandatory. Treatment is in most of the cases conservative. Esophageal stenosis is a frequent complication.

Conclusion

Although AENS is a rare clinical entity, it should not be dismissed by doctors, avoiding useless surgical management. This pathology remains nevertheless associated with a considerable mortality rate.

Compact radio emission indicates a structured jet was produced by a binary neutron star merger

The binary neutron star merger event GW170817 was detected through both electromagnetic radiation and gravitational waves. Its afterglow emission may have been produced by either a narrow relativistic jet or an isotropic outflow. High-spatial-resolution measurements of the source size and displacement can discriminate between these scenarios. We present very-long-baseline interferometry observations, performed 207.4 days after the merger by using a global network of 32 radio telescopes. The apparent source size is constrained to be smaller than 2.5 milli-arc seconds at the 90% confidence level. This excludes the isotropic outflow scenario, which would have produced a larger apparent size, indicating that GW170817 produced a structured relativistic jet. Our rate calculations show that at least 10% of neutron star mergers produce such a jet.

The genetic basis for most patients with pustular skin disease remains elusive

BACKGROUND

Rare variants in the genes IL36RN, CARD14 and AP1S3 have been identified to cause or contribute to pustular skin diseases, primarily generalized pustular psoriasis (GPP).

OBJECTIVES

To better understand the disease relevance of these genes, we screened our cohorts of patients with pustular skin diseases [primarily GPP and palmoplantar pustular psoriasis (PPP)] for coding changes in these three genes. Carriers of single heterozygous IL36RN mutations were screened for a second mutation in IL36RN.

METHODS

Coding exons of IL36RN, CARD14 and AP1S3 were sequenced in 67 patients - 61 with GPP, two with acute generalized exanthematous pustulosis and four with acrodermatitis continua of Hallopeau. We screened IL36RN and AP1S3 for intragenic copy-number variants and 258 patients with PPP for coding changes in AP1S3. Eleven heterozygous IL36RN mutations carriers were analysed for a second noncoding IL36RN mutation. Genotype-phenotype correlations in carriers/noncarriers of IL36RN mutations were assessed within the GPP cohort.

RESULTS

The majority of patients (GPP, 64%) did not carry rare variants in any of the three genes. Biallelic and monoallelic IL36RN mutations were identified in 15 and five patients with GPP, respectively. Noncoding rare IL36RN variants were not identified in heterozygous carriers. The only significant genotype-phenotype correlation observed for IL36RN mutation carriers was early age at disease onset. Additional rare CARD14 or AP1S3 variants were identified in 15% of IL36RN mutation carriers.

CONCLUSIONS

The identification of IL36RN mutation carriers harbouring additional rare variants in CARD14 or AP1S3 indicates a more complex mode of inheritance of pustular psoriasis. Our results suggest that, in heterozygous IL36RN mutation carriers, there are additional disease-causing genetic factors outside IL36RN.

The Ionospheric Connection Explorer Mission: Mission Goals and Design

The Ionospheric Connection Explorer, or ICON, is a new NASA Explorer mission that will explore the boundary between Earth and space to understand the physical connection between our world and our space environment. This connection is made in the ionosphere, which has long been known to exhibit variability associated with the sun and solar wind. However, it has been recognized in the 21st century that equally significant changes in ionospheric conditions are apparently associated with energy and momentum propagating upward from our own atmosphere. ICON's goal is to weigh the competing impacts of these two drivers as they influence our space environment. Here we describe the specific science objectives that address this goal, as well as the means by which they will be achieved. The instruments selected, the overall performance requirements of the science payload and the operational requirements are also described. ICON's development began in 2013 and the mission is on track for launch in 2017. ICON is developed and managed by the Space Sciences Laboratory at the University of California, Berkeley, with key contributions from several partner institutions.

Percutaneous correction of second toe proximal deformity: Proximal interphalangeal release, flexor digitorum brevis tenotomy and proximal phalanx osteotomy

We report the results of a percutaneous technique to correct a proximal plantar flexion deformity of the second toe that combines several procedures: tenotomy of the Flexor Digitorum Brevis, plantar capsulotomy for release of the proximal interphalangeal joint and proximal phalangeal osteotomy. The goal of these procedures is to improve anatomical correction and preserve articular range of motion. From 2009 to 2011, 54 patients, mean age 64.4 years old (43-81) underwent surgery for a proximal deformity of the second toe. Associated tenotomy of the extensor digitorum longus and brevis was performed in the presence of an extension deformity of the metatarsophalangeal joint (24 cases). After a mean follow-up of 30.7 ± 8.9 months, the rate of satisfaction and morphological correction was high (89.5% in both cases), as well as the number of flexible toes (88%). Active plantar flexion was preserved in 86% of the cases. This seems to be an effective technique to correct proximal plantar flexion deformity of the second toe, while preserving active plantar flexion.

Treatment of Freiberg's disease by Gauthier's dorsal cuneiform osteotomy: Retrospective study of 30 cases

INTRODUCTION

Freiberg's disease is osteonecrosis of the dorsal side of a metatarsal head. The gold-standard surgical treatment is the osteotomy procedure first described by Gauthier.

HYPOTHESIS

Gauthier osteotomy for Freiberg's disease will restore the joint space and lead to long-term clinical improvement. A retrospective study was carried out to verify this hypothesis.

MATERIAL AND METHODS

This study involved 30 consecutive cases treated by a single surgeon in 28 patients having a mean age of 61.2 years. These patients underwent the Gauthier osteotomy procedure with one or two dorsal staples used for fixation. Patients were reviewed 15 days, 45 days and 3 months after the procedure, and then at the last follow-up to look for any complications and determine patient satisfaction, the AOFAS score, metatarsophalangeal range of motion (ROM), sphericity of the metatarsal head, bone union and metatarsal shortening.

RESULTS

The average follow-up was 6.5 years ± 2.2. The second metatarsal was affected in 27 cases and the third metatarsal in 3 cases. Discomfort related to the staples was noted in five cases; the staples were removed in three of them. There was one case of severe stiffening (< 20° ROM). At the last follow-up, 17 cases were very satisfied, 11 were satisfied and 2 were moderately satisfied. The average AOFAS score was 83.8 points ± 11.8 at the last follow-up. A mean loss of 15° plantar flexion and 10° dorsiflexion was noted. Bone union and metatarsal head sphericity were achieved in all cases. The average shortening was 2 mm ± 1.4.

CONCLUSIONS

The Gauthier osteotomy procedure results in recovery of the metatarsal head's sphericity in every case of this series, with good clinical results and low morbidity.

Direct bone morphogenetic protein 2 and Indian hedgehog gene transfer for articular cartilage repair using bone marrow coagulates

OBJECTIVE

Bone morphogenetic protein 2 (BMP-2, encoded by BMP2) and Indian hedgehog protein (IHH, encoded by IHH) are well known regulators of chondrogenesis and chondrogenic hypertrophy. Despite being a potent chondrogenic factor BMP-2 was observed to induce chondrocyte hypertrophy in osteoarthritis (OA), growth plate cartilage and adult mesenchymal stem cells (MSCs). IHH might induce chondrogenic differentiation through different intracellular signalling pathways without inducing subsequent chondrocyte hypertrophy. The primary objective of this study is to test the efficacy of direct BMP2 and IHH gene delivery via bone marrow coagulates to influence histological repair cartilage quality in vivo.

METHOD

Vector-laden autologous bone marrow coagulates with 10(11) adenoviral vector particles encoding BMP2, IHH or the Green fluorescent protein (GFP) were delivered to 3.2 mm osteochondral defects in the trochlea of rabbit knees. After 13 weeks the histological repair cartilage quality was assessed using the ICRS II scoring system and the type II collagen positive area.

RESULTS

IHH treatment resulted in superior histological repair cartilage quality than GFP controls in all of the assessed parameters (with P < 0.05 in five of 14 assessed parameters). Results of BMP2 treatment varied substantially, including severe intralesional bone formation in two of six joints after 13 weeks.

CONCLUSION

IHH gene transfer is effective to improve repair cartilage quality in vivo, whereas BMP2 treatment, carried the risk intralesional bone formation. Therefore IHH protein can be considered as an attractive alternative candidate growth factor for further preclinical research and development towards improved treatments for articular cartilage defects.

Simulated glass-forming polymer melts: dynamic scattering functions, chain length effects, and mode-coupling theory analysis

We present molecular-dynamics simulations for a fully flexible model of polymer melts with different chain length N ranging from short oligomers (N = 4) to values near the entanglement length (N = 64). For these systems we explore the structural relaxation of the supercooled melt near the critical temperature T c of mode-coupling theory (MCT). Coherent and incoherent scattering functions are analyzed in terms of the idealized MCT. For temperatures T > T c we provide evidence for the space-time factorization property of the β relaxation and for the time-temperature superposition principle (TTSP) of the α relaxation, and we also discuss deviations from these predictions for T ≈ T c. For T larger than the smallest temperature where the TTSP holds we perform a quantitative analysis of the dynamics with the asymptotic MCT predictions for the late β regime. Within MCT a key quantity, in addition to T c, is the exponent parameter λ. For the fully flexible polymer models studied we find that λ is independent of N and has a value (λ = 0.735 ) typical of simple glass-forming liquids. On the other hand, the critical temperature increases with chain length toward an asymptotic value T c (∞) . This increase can be described by T c (∞) - T c(N) ∼ 1/N and may be interpreted in terms of the N dependence of the monomer density ρ, if we assume that the MCT glass transition is ruled by a soft-sphere-like constant coupling parameter Γ c = ρ c T c (-1/4), where ρ c is the monomer density at T c. In addition, we also estimate T c from a Hansen-Verlet-like criterion and MCT calculations based on structural input from the simulation. For our polymer model both the Hansen-Verlet criterion and the MCT calculations suggest T c to decrease with increasing chain length, in contrast to the direct analysis of the simulation data.

Pre-operative function, motivation and duration of symptoms predict sporting participation after total hip replacement

There is little in the literature on the level of participation in sports which patients undertake after total hip replacement (THR). Our aims in this study were to determine first, the level of sporting activity, second, the predictive factors for returning to sporting activity, and third, the correlation between participation in sports and satisfaction after THR. We retrospectively identified 815 patients who had undergone THR between 1995 and 2005. All were asked to complete a self-administered questionnaire regarding their sporting activity. A total of 571 patients (71%) met the inclusion criteria and completed the evaluation. At a mean follow-up of 9.8 years (sd 2.9), 366 patients (64%) returned to sporting activity as defined by a University of California at Los Angeles (UCLA) score of > 5. The main reasons that patients had for refraining from sports were fear of dislocation (65; 31.6%), avoiding wear (52; 25.4%), and the recommendation of the surgeon (34; 16.6%). There was a significant relationship between higher post-operative participation in sport in those patients with a higher pre-operative Harris hip score (HHS) (p = 0.0074), motivation to participate in sporting activities (p = 0.00022) and a shorter duration of symptoms (p = 0.0034). Finally, there was a correlation between age (p = 0.00013), UCLA score (p = 0.012) and pre-operative HHS (p = 0.00091) and satisfaction.

In conclusion, we found that most patients participate in sporting activity after THR, regardless of the advice of their surgeon, and that there is a correlation between the level of participation and pre-operative function, motivation, duration of symptoms and post-operative satisfaction.

Cite this article: Bone Joint J 2014;96-B:1041–6

A close-pair binary in a distant triple supermassive black hole system

Galaxies are believed to evolve through merging, which should lead to some hosting multiple supermassive black holes. There are four known triple black hole systems, with the closest black hole pair being 2.4 kiloparsecs apart (the third component in this system is at 3 kiloparsecs), which is far from the gravitational sphere of influence (about 100 parsecs for a black hole with mass one billion times that of the Sun). Previous searches for compact black hole systems concluded that they were rare, with the tightest binary system having a separation of 7 parsecs (ref. 10). Here we report observations of a triple black hole system at redshift z = 0.39, with the closest pair separated by about 140 parsecs and significantly more distant from Earth than any other known binary of comparable orbital separation. The effect of the tight pair is to introduce a rotationally symmetric helical modulation on the structure of the large-scale radio jets, which provides a useful way to search for other tight pairs without needing extremely high resolution observations. As we found this tight pair after searching only six galaxies, we conclude that tight pairs are more common than hitherto believed, which is an important observational constraint for low-frequency gravitational wave experiments.

Continuous-time random-walk approach to supercooled liquids. II. Mean-square displacements in polymer melts

The continuous-time random walk (CTRW) describes the single-particle dynamics as a series of jumps separated by random waiting times. This description is applied to analyze trajectories from molecular dynamics (MD) simulations of a supercooled polymer melt. Based on the algorithm presented by Helfferich et al. [Phys. Rev. E 89, 042603 (2014)], we detect jump events of the monomers. As a function of temperature and chain length, we examine key distributions of the CTRW: the jump-length distribution (JLD), the waiting-time distribution (WTD), and the persistence-time distribution (PTD), i.e., the distribution of waiting times for the first jump. For the equilibrium (polymer) liquid under consideration, we verify that the PTD is determined by the WTD. For the mean-square displacement (MSD) of a monomer, the results for the CTRW model are compared with the underlying MD data. The MD data exhibit two regimes of subdiffusive behavior, one for the early α process and another at later times due to chain connectivity. By contrast, the analytical solution of the CTRW yields diffusive behavior for the MSD at all times. Empirically, we can account for the effect of chain connectivity in Monte Carlo simulations of the CTRW. The results of these simulations are then in good agreement with the MD data in the connectivity-dominated regime, but not in the early α regime where they systematically underestimate the MSD from the MD.

Continuous-time random-walk approach to supercooled liquids. I. Different definitions of particle jumps and their consequences

Single-particle trajectories in supercooled liquids display long periods of localization interrupted by "fast moves." This observation suggests a modeling by a continuous-time random walk (CTRW). We perform molecular dynamics simulations of equilibrated short-chain polymer melts near the critical temperature of mode-coupling theory Tc and extract "moves" from the monomer trajectories. We show that not all moves comply with the conditions of a CTRW. Strong forward-backward correlations are found in the supercooled state. A refinement procedure is suggested to exclude these moves from the analysis. We discuss the repercussions of the refinement on the jump-length and waiting-time distributions as well as on characteristic time scales, such as the average waiting time ("exchange time") and the average time for the first move ("persistence time"). The refinement modifies the temperature (T) dependence of these time scales. For instance, the average waiting time changes from an Arrhenius-type to a Vogel-Fulcher-type T dependence. We discuss this observation in the context of the bifurcation of the α process and (Johari) β process found in many glass-forming materials to occur near Tc. Our analysis lays the foundation for a study of the jump-length and waiting-time distributions, their temperature and chain-length dependencies, and the modeling of the monomer dynamics by a CTRW approach in the companion paper [J. Helfferich et al., Phys. Rev. E 89, 042604 (2014)].

Placement of deep brain electrodes in the dog using the Brainsight frameless stereotactic system: a pilot feasibility study

Background

Deep brain stimulation (DBS) together with concurrent EEG recording has shown promise in the treatment of epilepsy. A novel device is capable of combining these 2 functions and may prove valuable in the treatment of epilepsy in dogs. However, stereotactic implantation of electrodes in dogs has not yet been evaluated.

Objective

To evaluate the feasibility and safety of implanting stimulating and recording electrodes in the brain of normal dogs using the Brainsight system and to evaluate the function of a novel DBS and recording device.

Animals

Four male intact Greyhounds, confirmed to be normal by clinical and neurologic examinations and hematology and biochemistry testing.

Methods

MRI imaging of the brain was performed after attachment of fiducial markers. MRI scans were used to calculate trajectories for electrode placement in the thalamus and hippocampus, which was performed via burr hole craniotomy. Postoperative CT scanning was performed to evaluate electrode location and accuracy of placement was calculated. Serial neurologic examinations were performed to evaluate neurologic deficits and EEG recordings obtained to evaluate the effects of stimulation.

Results

Electrodes were successfully placed in 3 of 4 dogs with a mean accuracy of 4.6 ± 1.5 mm. EEG recordings showed evoked potentials in response to stimulation with a circadian variation in time‐to‐maximal amplitude. No neurologic deficits were seen in any dog.

Conclusions and Clinical Importance

Stereotactic placement of electrodes is safe and feasible in the dog. The development of a novel device capable of providing simultaneous neurostimulation and EEG recording potentially represents a major advance in the treatment of epilepsy.

Visualization of Temporal Similarity in Field Data

This paper presents a visualization approach for detecting and exploring similarity in the temporal variation of field data. We provide an interactive technique for extracting correlations from similarity matrices which capture temporal similarity of univariate functions. We make use of the concept to extract periodic and quasiperiodic behavior at single (spatial) points as well as similarity between different locations within a field and also between different data sets. The obtained correlations are utilized for visual exploration of both temporal and spatial relationships in terms of temporal similarity. Our entire pipeline offers visual interaction and inspection, allowing for the flexibility that in particular time-dependent data analysis techniques require. We demonstrate the utility and versatility of our approach by applying our implementation to data from both simulation and measurement.

Electrical and pharmacological manipulations of the nucleus accumbens core impair synaptic plasticity in the dentate gyrus of the rat

The interest on the physiology of the nucleus accumbens (NAcc) has grown in recent years given its relationship to addictive behaviours, and the possibility to treat them by interacting with NAcc function. We have shown that the prior stimulation of the core region blocks induction of long-term potentiation (LTP) at the dentate gyrus in anaesthetized rats, while the shell facilitated it. In the present study we have confirmed and expanded those results testing the effects of core and shell stimulation in freely moving rats, as well as the effect of blocking D1 receptors in the NAcc. Our results show that shell stimulation had no effect on baseline recordings of the field excitatory postsynaptic potential (fEPSP) or the population spike amplitude (PSA) for 24 h. Core stimulation did not modify baseline-fEPSP, but significantly depressed PSA up to 8 h. LTP maintenance was not modified; neither by core nor shell stimulation after its induction, but LTP induction was impaired (both in the fEPSP and PSA) by core stimulation 15 min before induction. Shell stimulation showed a slight facilitating effect. Previous, topical application of a dopaminergic-receptor antagonist (SCH23390) into the NAcc produced a significantly depressed baseline fEPSP and PSA, as well as LTP measured in both components of the evoked potentials. Our results confirm a dual role of stimulation of NAcc sub-regions on hippocampal baseline synaptic transmission, and LTP induction when activated before induction. In contrast, stimulation of the NAcc had no influence on an already ongoing dentate gyrus LTP. A role for dopaminergic innervation to the NAcc, modifying susceptibility for synaptic plasticity outside the NAcc is also suggested by our results.

Chemosensory event-related potentials in relation to side of stimulation, age, sex, and stimulus concentration

OBJECTIVE

For chemosensory event-related potentials (ERP) significant effects of age and sex have been demonstrated. The aim of the present study was to assess the effects of stimulus concentration, side of stimulation, and sex on the topographical distribution of chemosensory ERP in a large group of subjects stratified for different age groups. In addition, psychophysical measures of both olfactory and trigeminal function should be assessed in greater detail compared to previous work.

METHODS

A total of 95 healthy subjects participated in the study. Olfactory functions were tested using the 'Sniffin' Sticks' comprising tests of odor identification, odor discrimination, and odor threshold. Trigeminal sensitivity was assessed on a psychophysical level using a lateralization paradigm. ERP to the olfactory stimulant H2S and the trigeminal irritant CO2 were recorded; stimuli were presented in different concentrations to the left and right nostril.

RESULTS

Olfactory thresholds exhibited an age-related increase while the outcome of psychophysical trigeminal tests was not significantly affected by age. In contrast, there was no significant main effect of the factor 'sex' for olfactory tests, while women scored higher than men in the trigeminal task. ERP to olfactory and trigeminal stimuli exhibited a relationship to stimulus concentration, age, and sex with youngest women showing largest amplitudes and shortest latencies. There was no significant main effect of left- or right-sided stimulation on ERP. Measures of olfactory function were found to correlate with parameters of olfactory ERP even when controlling for the subject's age. In addition, correlations between scores in the lateralization task and parameters of the trigeminal ERP were found.

CONCLUSIONS

Based on electrophysiological data obtained in a large sample size the present results established an age-related loss of olfactory and trigeminal function, which appears to be almost linear. Further, the present results emphasize that responses to chemosensory stimuli are related to sex, while the side of stimulation does not play a major role in the presently used paradigm. Finally, these data establish the lateralization paradigm as a psychophysical tool to investigate intranasal trigeminal function.

SIGNIFICANCE

The present results obtained in a representative group of healthy subjects establishes a comprehensive set of data, which will serve as reference for future work in this area of research.