Biallelic EPCAM deletions induce tissue-specific DNA repair deficiency and cancer predisposition

We report a case of Mismatch Repair Deficiency (MMRD) caused by germline homozygous EPCAM deletion leading to tissue-specific loss of MSH2. Through the use of patient-derived cells and organoid technologies, we performed stepwise in vitro differentiation of colonic and brain organoids from reprogrammed EPCAMdel iPSC derived from patient fibroblasts. Differentiation of iPSC to epithelial-colonic organoids exhibited continuous increased EPCAM expression and hypermethylation of the MSH2 promoter. This was associated with loss of MSH2 expression, increased mutational burden, MMRD signatures and MS-indel accumulation, the hallmarks of MMRD. In contrast, maturation into brain organoids and examination of blood and fibroblasts failed to show similar processes, preserving MMR proficiency. The combined use of iPSC, organoid technologies and functional genomics analyses highlights the potential of cutting-edge cellular and molecular analysis techniques to define processes controlling tumorigenesis and uncovers a new paradigm of tissue-specific MMRD, which affects the clinical management of these patients.

Position specific physical performance and running intensity fluctuations in elite women's football

The purpose of the present study was to investigate the physical performance of elite female football players during match play along with transient alterations in running performance following 1- and 5-min univariate peak periods. 54 elite female players from four top-level Norwegian teams were monitored for one season (n = 393 match observations), and physical performance data collected using STATSport GPS APEX. Results revealed significant differences in physical performance between the positions during full match play, particularly between wide and central players. Both full backs (FBs) and wide midfielders (WMs) covered more total distance (TD), high-speed running distance (HSRD), and sprint distance (SpD) than center backs (CBs) (p < 0.05-0.001), while WMs also covered more HSRD than both central midfielders (CMs) (p < 0.01) and forwards (FWs) (p < 0.05), and more acceleration -and deceleration distance (Acc_dist and Dec_dist ) than both CBs and CMs (p < 0.01-0.001). A similar pattern was observed for the peak period analysis, with FBs and WMs covering more SpD in peak 1 min than CBs and CM (p < 0.001) and more SpD in peak 5-min than CBs, CMs, and FWs (p < 0.001). Irrespective of the variable analyzed, greater distances were covered during the peak 5-min period than in the next-5 and mean 5-min periods (p < 0.001). Significant (p < 0.001), but small to trivial (Cohen's D_z : 0.07-0.20), decreases in distance covered were also observed for each variable following each univariate peak 5-min period. In conclusion, practitioners should account for differences in physical performance when developing training programs for female football players and be aware of transient reductions in physical performance following univariate peak 1- and 5-min periods. Specifically, the very high intensity in 1-min peak periods adds support to the principal of executing speed endurance activities during training to mirror and be prepared for the physical demands of match play.

Prognostic value of layer-specific global longitudinal strain in patients undergoing coronary artery bypass grafting

Background

Recent improvements in speckle tracking echocardiography have made sectionalized quantification of layer-specific global longitudinal strain (GLS) possible. Prior studies have reported prognostic value of GLS in several cardiac diseases, however, the use of layer-specific strain has not been investigated in patients undergoing coronary artery bypass grafting (CABG).

Purpose

To determine the prognostic value of layer-specific GLS for predicting all-cause mortality after CABG.

Methods

In this retrospective cohort study, consecutive patients undergoing isolated CABG between 2006 and 2011 were included. The patients were followed through nation-wide registries for the endpoint of all-cause mortality. Multivariable Cox regression models adjusted for clinical and echocardiographic baseline characteristics were used to assess the association between layer-specific GLS and all-cause mortality. Cumulative survival was stratified by clinical age and gender-dependent cut-off values for the layer-specific GLS, which was obtained from a large healthy population study.

Results

Of 641 patients included (mean age 67 years, 84% male), 70 (10.9%) died during follow-up (median 3.8 years [IQR: 2.7; 4.9 years]). Patients who died during follow-up were significantly older (71 years vs. 67 years, P = &lt;0.001) and had a lower LVEF (46% vs. 51% P = &lt;0.001). Endocardial GLS (GLSendo) (−14.2% vs. −16.3%, P&lt;0.001), whole wall GLS (−12.1% vs. −13.9%, P&lt;0.001), and epicardial GLS (GLSepi) (−10.6% vs. −12.2%, P&lt;0.001) were all reduced in patients who died during follow-up, and patients with GLS below cut-off had a more than two-fold increased risk of all-cause mortality (Figure 1). The risk of dying increased linearly with decreasing absolute GLS for all layers (p&lt;0.0002 for all layers), (Figure 2). In multivariable models, all layer-specific strain parameters remained significantly associated with all-cause mortality; GLSepi: HR=1.14 (1.05–1.23), p=0.002; GLS: HR=1.12 (1.04–1.20), p=0.002; GLSendo: HR=1.09 (1.03–1.16), p=0.003, per 1% absolute decrease. However, only GLSepi remained significantly associated with mortality when also adjusting for echocardiographic parameters (GLSepi: HR=1.12 (1.00–1.25), p=0.049, per 1% absolute decrease) and separately also after adjusting for the EuroScore II (GLSepi: HR=1.09 (1.00–1.18), p=0.043, per 1% absolute decrease).

Conclusion

Layer-specific GLS is an independent prognosticator of all-cause mortality after CABG. In multivariable models, GLSepi provided significant prognostic value after adjusting for echocardiographic parameters and EuroScore II.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Research grant from Herlev & Gentofte University Hospital's internal research funds. Figure 1. Kaplan-Meier survival estimatesFigure 2. Incidence rate of all-cause mortality

Effect of internet-delivered cognitive behavioral therapy on quality of life in patients with symptomatic atrial fibrillation

Background

Many patients with atrial fibrillation (AF) experience severe or disabling symptoms and suffer from impaired quality of life (QoL). AF symptoms are often not sufficiently alleviated by current treatments. Symptom preoccupation (fear of AF episodes, hypervigilance towards cardiac symptoms, worry about complications, avoidance of physical and social activities) plays an important role in AF disability and can be targeted by cognitive behavioural therapy (CBT). This is the first randomized controlled trial (RCT) evaluating internet-delivered CBT in patients with AF.

Methods

We randomized patients to 10 weeks of CBT or routine care with AF-education (EDU) only. Inclusion criteria were ECG documented paroxysmal AF (≥1 episode/month); AF-care according to ESC guidelines; symptoms ≥EHRA IIb. Exclusion criteria were recent or planned ablation and severe medical or psychiatric illness. CBT was delivered over the internet by clinical psychologists. Main components were exposure to cardiac-related physical sensations and reduction of AF-related avoidance behavior. Patients were evaluated at baseline, post-CBT and 3 months (3M) post-CBT. The primary endpoint was AF-specific QoL (AFEQT) at 3M. Secondary endpoints were symptom preoccupation (CAQ), symptom frequency (SCL), symptom severity (SCL), general QoL (WHODAS) and AF-specific healthcare (AFSS) (abbreviations: see table legend). AF burden was measured by 5-day continuous ECG recording. After 3M, patients in the EDU group were offered CBT. The CBT group was further evaluated at 6M and 12M.

Results

127 patients (age 65.4±8.3; 58% female; AF duration 5.6±6.1 years) were randomized to CBT (n=65) or EDU (n=62). CBT significantly improved AF-specific QoL. The AFEQT score was 62.5±16.7 at baseline and increased by 21.0 in the CBT group compared to 6.0 in the EDU group resulting in an 15.0 points improvement (95% CI: 10.1–19.8; P&lt;.001). CBT also significantly improved the secondary outcomes (table). Results were sustained 12 months after treatment (AFEQT; figure). The results from ECG monitoring (AF burden) are currently being analyzed.

Conclusion

Internet delivered CBT significantly improved AF-specific QoL in patients with symptomatic paroxysmal AF already receiving routine AF care. The magnitude of QoL improvement was comparable to that obtained in recent rhythm control trials and the effects were sustained over 12 months. AF-specific CBT delivered via the internet has the potential to improve the well-being of a large group of patients who do not sufficiently improve from current treatment methods. Our data support the integration of psychological evaluation and treatment in a multifactorial approach to AF management.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was supported by grants from theSwedish Research Council (2016-01379), RegionStockholm (ALF project). Change in AFEQT score over study periodBetween group improvements

Reliability and agreement of proton density-weighted vs. gadolinium-enhanced T1-weighted MRI in hand osteoarthritis. An OMERACT MRI special interest group reliability exercise

OBJECTIVES

To compare reliabilities of assessing synovitis in hand osteoarthritis (OA) using Magnetic Resonance Imaging (MRI) with/without gadolinium (Gd).

METHODS

Three readers scored synovitis on non-enhanced two-dimensional (2D) proton density (PD)-weighted MRI and Gd-enhanced (3D) MRI of hand joints in 20 patients. Inter-reader reliabilities were examined.

RESULTS

Reliability was good for Gd-enhanced MRI, but poor for non-enhanced PD-weighted MRI (intraclass correlation coefficient 0.83 and 0.21, respectively). Agreement between the two sequences was poor (weighted kappa 0.18).

CONCLUSION

Gd-enhanced MRI was more reliable than PD-weighted MRI for assessing synovitis. Gd-enhancement, but also resolution and tissue contrast, might have contributed to this.

Systematic review and network meta-analysis of randomised controlled trials of interventions for depressive symptoms in patients with coronary artery disease

Funding Acknowledgements

Type of funding sources: None.

Objective

Depression is common in patients with coronary artery disease (CAD) and is associated with poor outcomes. Although different treatments are available, it is unclear which are best or most acceptable to patients, so we conducted a network meta-analysis of evidence from randomized controlled trials (RCTs) of different depression treatments to ascertain relative efficacy.

Methods

We searched for systematic reviews of RCTs of depression treatments in CAD and updated these with a comprehensive search for recent individual RCTs. RCTs comparing depression treatments (pharmacological, psychotherapeutic, combined pharmacological/psychotherapeutic, exercise, collaborative care) were included. Primary outcomes were acceptability (dropout rate) and change in depressive symptoms 8-weeks post-treatment commencement. Change in 26-week depression and mortality were secondary outcomes. Frequentist, random effects network meta-analysis synthesized the evidence. GRADE was used to assess evidence quality.

Results

Thirty-three RCTs (7240 participants) provided analysable data. All treatments were equally acceptable. At 8-weeks, combination therapy (1 study), exercise (1 study), and antidepressants (10 studies) yielded the strongest effects versus comparators. At 26-weeks, antidepressants were consistently effective, but psychotherapy was only effective versus usual care. There were no differences in treatment groups for mortality.  GRADE ratings ranged from very low to low.

Conclusions

All treatments were equally acceptable, while antidepressants appeared to have the most robust evidence base for post-CAD depression. The evidence base was limited and biased; conclusions based on this literature should be drawn cautiously and considered to be tentative. Rigorous, multi-arm intervention trials, including trials of combination therapies and exercise, are urgently needed.

Prognostic utility of early systolic lengthening by speckle tracking in patients undergoing coronary artery bypass graft

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Independent Research Fund Denmark

Background

Early systolic lengthening (ESL), a paradoxical stretch of myocardial fibers, has been linked to myocardial viability and contractile dysfunction. We assessed the long-term prognostic potential of ESL in coronary artery bypass graft (CABG) patients.

Methods

We retrospectively included patients (n = 709; mean age 68 years; 85% men) who underwent speckle tracking echocardiography (median 15 days) prior to CABG. Endpoints were cardiovascular death (CVD) and all-cause mortality. We assessed amplitude of ESL (%), defined as peak positive strain, and duration of ESL (ms), determined as time from Q-wave on the ECG to peak positive strain. We applied Cox proportional hazards models adjusted for the clinical risk tool, EuroSCORE II.

Results

During median follow-up of 3.8 years [IQR 2.7 to 4.9 years], 45 (6%) experienced CVD and 80 (11%) died. In survival analyses adjusted for EuroSCORE II, amplitude of ESL was associated with CVD (HR 1.37 [95%CI 1.13 to 1.66], P = 0.001) and all-cause mortality (HR 1.31 [95%CI 1.13 to 1.54], P = 0.001). Similar findings applied to duration of ESL and CVD (HR 1.17 [95%CI 1.08 to 1.26], P &lt; 0.001) and all-cause mortality (HR 1.14 [95%CI 1.07 to 1.21], P &lt; 0.001). The prognostic value of ESL amplitude was modified by sex (P interaction &lt; 0.05), such that it was greater in women for both endpoints (Figure 1A-B). When adding ESL duration to EuroSCORE II, the net reclassification index improved significantly for both CVD and all-cause mortality.

Conclusions

Assessment of ESL provides independent and incremental prognostic information in addition to the EuroSCORE II for CVD and all-cause mortality in CABG patients. The prognostic value was greater in women.

Abstract Figure. Prognostic value of ESL amplitude by sex

Longitudinal change in cardiac structure and function following acute coronary syndrome stratified by culprit coronary artery lesion site

Funding Acknowledgements

Type of funding sources: None.

Background

Acute coronary syndrome (ACS) has adverse consequences for the myocardium and subsequent cardiac function and structure. No reports exist comparing the differences in impact of culprit coronary artery lesion site on longitudinal remodeling and changes left ventricular structure and function.

Method

A total of 299 ACS patients treated with PCI were included in the present study. All patients had two echocardiographic examinations performed. The first was performed median 2 (IQR: 1; 3) days following PCI, while the second was performed median 240 (IQR: 81; 881) days after the first. Patients were grouped based on culprit coronary artery lesion (left anterior descending artery (LAD), right coronary artery (RCA) and circumflex artery (Cx)). Patients with multiple lesions were excluded from the present study. Univariable linear regression analysis was utilised to assess the association between culprit coronary artery lesion site and longitudinal change in cardiac structure and function.

Results

Mean age was 63 ± 11 years and 77% were male. At follow-up, mean left ventricular ejection fraction was 42 ± 9% and global longitudinal strain (GLS) was -13 ± 4%. Culprit coronary artery lesion was allocated as follows; 168 ACS patients were treated in LAD, 95 patients were treated in RCA, and 36 patients were treated in Cx. In the linear regression analysis, LAD patients displayed a greater improvement in GLS (b =-0.116, p = 0.048) compared to the two other lesion sites. LAD patients had the poorest GLS at both baseline and follow-up echocardiography (Figure). RCA lesions were associated with the largest decrease in left atrial maximum volume (LAVmax) (b = -0.156, p = 0.011) and the largest increase in relative wall thickness (RWT) (b = 0.139, p = 0.030), consequently resulting in an LAVmax smaller and an RWT larger at follow-up than other lesion sites (Figure). Lastly, Cx lesions were significantly associated with the largest decrease in ratio between peak early diastolic transmitral flow velocity and peak early diastolic mitral annular tissue velocity (E/e’) (b = -0.262, P &lt;0.001). Cx lesion patients were observed to have elevated E/e’ at baseline, which generally normalised at follow-up (Figure).

Conclusion

The present study suggests that culprit coronary artery lesion site has a differential impact on cardiac remodeling. This information can potentially aid the clinical understanding of cardiac structure and function following ACS according to coronary artery lesion site.

Abstract Figure

Left ventricular end-diastolic pressure is associated with left atrial functional measures by echocardiography

Funding Acknowledgements

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

Background

Assessment of maximal LA volume (LAVmax) is recommended in imaging guidelines but evidence suggests additional value of functional LA measures. How extended measures of LA function associate to left ventricular filling pressure has not been fully explored.

Purpose

To investigate the association between functional LA measures and left ventricular end-diastolic pressure (LVEDP)

Methods

Patients suspected of coronary artery disease referred for angiography had simultaneous left heart catheterization performed for invasive pressure measurements. LVEDP &gt; 12mmHg was considered elevated. LA measurements by echocardiography included: LAVmax, minimal LA volume (LAVmin), total LA emptying fraction (total LAEF), passive LA emptying fraction (passive LAEF), and active LA emptying fraction (active LAEF).

Results

Of 43 patients, 28 (65%) had elevated LVEDP. These patients more frequently had coronary vessel disease (VD) and impaired LA mechanics by all accounts except by LAVmax.

All LA measures except LAVmax were associated with LVEDP in unadjusted linear regression analyses, however, only LA emptying fractions remained associated with LVEDP after adjusting for age and VD (2.6 (1.2-4.0) mmHg increase, p = 0.001, per 5% decrease in total LAEF; 1.4 (0.1-2.8) mmHg increase, p = 0.040, per 5% decrease in active LAEF; 1.8 (0.1-3.4) mmHg increase, p = 0.038, per 5% decrease in passive LAEF).

In logistic regression, passive LAEF was significantly associated with elevated LVEDP (figure), and this was also the case after adjusting for age and VD (OR = 1.11 (1.01-1.21), p = 0.023, per 1% decrease). Similar findings were made in subgroup analyses among patients without dilated LA and patients without conventional indicators of elevated filling pressure.

Conclusion

Left ventricular end-diastolic pressure is significantly associated with LA functional measures but not LA volumes. Additionally, passive LAEF is associated with elevated LVEDP. Future studies examining LA function should include all components of LAEF.

Abstract Figure.

Unsupervised machine learning generated clusters of left ventricular strain curves identifies patients in risk of heart failure and cardiovascular death following acute myocardial infarction

Background

Today myocardial deformation, also known as strain, is assessed by the global longitudinal strain (GLS) which only provides information about the maximal deformation during systole. Hence, a lot of information obtained from different patterns of deformation curves might be undiscovered. Unsupervised Machine leaning (uML) is capable of identifying similar patterns of deformation curves. Identifying different phenotypical patterns from myocardial deformation curves might provide insights into the pathophysiological development of cardiac disease and entail useful prognostic information.

Purpose

To investigate whether uML can group specific patterns of myocardial deformation curves which provide prognostic information on heart failure and/or cardiovascular death (HF/CVD) following ST-segment elevation myocardial infarction (STEMI).

Methods

A total of 319 STEMI patients had an echocardiogram performed at median 2 days after primary percutaneous coronary intervention (pPCI). Speckle tracking echocardiography analysis divided the left ventricle into 18 segments. Standardisation of the cardiac cycle was done using linear interpolation and complete strain data (mean of all segments) as function of time throughout the cardiac cycle was used as input for the uML algorithm. Clusters were identified using a K-means cluster analysis algorithm. Primary endpoint was the composite of heart failure (HF) and/or cardiovascular death (CVD). Median follow-up time was 1423 days (IQR: 91; 1660).

Results

Mean age was 62 years, 75% were male and 130 (41%) suffered incident HF/CVD during follow-up. The uML algorithm grouped patients into three clusters containing 97, 104, and 118 patients respectively. GLS curves of the three clusters are illustrated in the Figure 1. Incidence of HF/CVD increased significantly from cluster 1 through 3 (24% vs. 39% vs. 60%, P&lt;0.001). In multivariable Cox regressions adjusting for the variables in the score risk chart model all three clusters were significantly associated with future HF/CVD (Figure 1). Cluster models provided significant incremental prognostic information when comparing C-statistics (0.64 vs. 0.62, p=0.029)

Conclusion

Unsupervised Machine Learning clusters of left ventricular deformation curves identifies patients in risk of HF/CVD following STEMI treated with pPCI, and provides incremental prognostic information to the score risk chart model.

Figure 1. GLS curves of the three clusters

Funding Acknowledgement

Type of funding source: None

The prognostic value of myocardial deformational patterns is reduced in patients with heart failure

Background

Early systolic lengthening (ESL) and postsystolic shortening are considered highly specific for myocardial ischemia. We aimed to investigate the prognostic potential of both deformational patterns in patients with heart failure (HF) and to determine if a history of ischemic heart disease modified this relationship.

Method

A total of 884 patients with systolic HF (66±12 years, male 73%, mean ejection fraction 28±9%) underwent speckle tracking echocardiography. Of these, 61% suffered from ischemic cardiomyopathy (ICM). Patients were followed for all-cause mortality. We assessed the ESL index: [−100x (peak positive strain/maximal strain)] and the postsystolic index (PSI): [100x (postsystolic strain/maximal strain)]. Both parameters were averaged across 18 myocardial segments.

Results

During a median follow-up of 3.4 years [interquartile range 1.9 to 4.8], 132 patients (15%) died. In multivariable survival analyses adjusted for potential confounders (age, sex, BMI, mean arterial pressure, cholesterol, heart rate, CABG/PCI, left ventricular ejection fraction and mass index, left atrial volume index, tricuspid annular plane systolic excursion, E-wave, E/e', deceleration time, and global longitudinal strain) neither the ESL index (HR 1.02 per 1% increase [0.97 to 1.08], P=0.40) nor PSI (HR 1.00 per 1% increase [0.98 to 1.01], P=0.69) were associated with all-cause mortality. ICM modified the relationship (P interaction unadjusted/adjusted=0.001/0.008; Figure) such that per 1% increase in ESL index in patients with ICM was significantly associated with all-cause mortality (unadjusted: HR 1.09 [1.04 to 1.15], P&lt;0.001 and adjusted: HR 1.06 [1.00 to 1.13], P=0.045) but not in those without (unadjusted: HR 1.02 [1.01 to 1.03], P=0.002 and adjusted: HR 0.99 [0.90 to 1.09], P=0.086). ICM did not modify the relationship between PSI and all-cause mortality (P interaction unadjusted/adjusted=0.15/0.13).

Conclusion

Our results indicate that in this cohort of undifferentiated HF patients with reduced ejection fraction the prognostic value of deformational patterns was reduced. However, the ESL index may provide some information on prognosis in patients with ICM.

ESL and interaction with ICM

Funding Acknowledgement

Type of funding source: None

Right ventricular speckle tracking in patients with heart failure – a comparison of right ventricular measures

Background

RV dysfunction is associated with increased mortality and morbidity in patients with heart failure. Due to the complex shape and position of the RV, assessing RV function from echocardiographic images remains a challenge.

Purpose

We have previously found that global longitudinal strain from 2DSTE is superior to left ventricular ejection fraction (LVEF) in identifying HFrEF patients with high risk of mortality. In this study we wanted to examine RV 2DSTE in patients with HFrEF and compare its prognostic value to conventional RV measures.

Methods and results

Echocardiographic examinations were retrieved from 701 patients with HFrEF. RV estimates were analysed offline, and end point was all-cause mortality. During follow-up (median 39 months) 118 patients (16.8%) died. RV GLS and RV FWS remained associated with mortality after multivariable adjustment, independent of TAPSE (RV GLS: HR 1.07, 95% CI 1.02–1.13, p=0.010, per 1% decrease) (RV FWS: HR 1.05, 95% CI 1.01–1.09, p=0.010, per 1% decrease). This seemed to be caused by significant associations in men as TAPSE remained as the only independent prognosticator in women. All RV estimates provided prognostic information incremental to established risk factors and significantly increased C-statistics (TAPSE: 0.74 to 0.75; RVFAC: 0.74 to 0.75; RVFWS: 0.74 to 0.77; RVGLS: 0.74 to 0.77).

Conclusions

RV strain from 2DSTE was associated with mortality in patients with HFrEF, independent of TAPSE and established risk factors. Our results indicate that RV strain is particularly valuable in male patients, whereas in women TAPSE remains a stronger prognosticator.

RV GLS and the risk of mortality

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): PGJ reports receiving lecture fee from Novo Nordisk.

Correlation between work impairment, scores of rhinitis severity and asthma using the MASK-air® App

BACKGROUND

In allergic rhinitis, a relevant outcome providing information on the effectiveness of interventions is needed. In MASK-air (Mobile Airways Sentinel Network), a visual analogue scale (VAS) for work is used as a relevant outcome. This study aimed to assess the performance of the work VAS work by comparing VAS work with other VAS measurements and symptom-medication scores obtained concurrently.

METHODS

All consecutive MASK-air users in 23 countries from 1 June 2016 to 31 October 2018 were included (14 189 users; 205 904 days). Geolocalized users self-assessed daily symptom control using the touchscreen functionality on their smart phone to click on VAS scores (ranging from 0 to 100) for overall symptoms (global), nose, eyes, asthma and work. Two symptom-medication scores were used: the modified EAACI CSMS score and the MASK control score for rhinitis. To assess data quality, the intra-individual response variability (IRV) index was calculated.

RESULTS

A strong correlation was observed between VAS work and other VAS. The highest levels for correlation with VAS work and variance explained in VAS work were found with VAS global, followed by VAS nose, eye and asthma. In comparison with VAS global, the mCSMS and MASK control score showed a lower correlation with VAS work. Results are unlikely to be explained by a low quality of data arising from repeated VAS measures.

CONCLUSIONS

VAS work correlates with other outcomes (VAS global, nose, eye and asthma) but less well with a symptom-medication score. VAS work should be considered as a potentially useful AR outcome in intervention studies.

0216 Is There a Daily Rhythm in Alcohol Craving and Does It Vary by Circadian Timing?

Introduction

People with later circadian timing tend to consume more alcohol, potentially due to altered rhythms in when and how much they crave alcohol throughout the day. However, whether circadian factors play a role in alcohol craving has received scant attention. Here, we investigated if the daily rhythm of alcohol craving varied by circadian timing in two independent studies of late adolescent and young adult drinkers.

Methods

In Study 1, 32 participants (18–22 years of age; 61% female; 69% White) completed momentary reports of alcohol craving five times a day for 14 days. Participants wore wrist actigraphs and completed two in-lab assessments of dim light melatonin onset (DLMO). Average actigraphically-assessed midpoint of sleep on weekends and average DLMO were used as indicators of circadian timing. In Study 2, 231 participants (21–35 years of age; 28% female; 71% White) completed momentary reports of alcohol craving six times a day for 10 days. Average midpoint of self-reported time-in-bed on weekends was used to estimate circadian timing.

Results

Multilevel cosinor analysis revealed a 24-hour daily rhythm in alcohol craving which was moderated by circadian timing in both studies (p’s&lt;0.05). In both Study 1 and 2, people with later circadian timing had a later timed peak of craving. In Study 1, but not Study 2, later circadian timing predicted a blunted amplitude in craving.

Conclusion

Findings support a daily rhythm in craving that varies by individual differences in circadian timing. Because craving is an important predictor of future alcohol use, the findings implicate circadian factors as a useful area to advance alcohol research and potentially improve interventions.

Support

R21AA023209; R01DA044143; K01AA021135; ABMRF/The Foundation for Alcohol Research.

Scoring magnetic resonance imaging (MRI) inflammation and structural lesions in sacroiliac joints of patients with axial spondyloarthritis: assessment of all MRI slices of the cartilaginous compartment versus standardized six or five slices

Objectives: The Spondyloarthritis Research Consortium of Canada (SPARCC) sacroiliac joint (SIJ) scoring system assesses six or five (6/5) semicoronal magnetic resonance imaging (MRI) slices for inflammation/structural lesions in patients with axial spondyloarthritis (axSpA). However, the cartilaginous SIJ compartment may be visible in a few additional slices. The objective was to investigate interreader reliability, sensitivity to change, and classification of MRI scans as positive or negative for various lesion types using an 'all slices' approach versus standard SPARCC scoring of 6/5 slices.Method: Fifty-three axSpA patients were treated with the tumour necrosis factor inhibitor golimumab and followed with serial MRI scans at weeks 0, 4, 16, and 52. The most anterior and posterior slices covering the cartilaginous compartment and the transitional slice were identified. Scores for inflammation, fat metaplasia, erosion, backfill, and ankylosis in the cartilaginous SIJ compartment were calculated for the 'all slices' approach and the 6/5 slices standard.Results: By the 'all slices' approach, three readers scored mean 7.2, 7.7, and 7.0 slices per MRI scan. Baseline and change scores for the various lesion types closely correlated between the two approaches (Pearson's rho ≥ 0.95). Inflammation score was median 13 (interquartile range 6-21, range 0-49) for 6/5 slices versus 14 (interquartile range 6-23, range 0-69) for all slices at baseline. Interreader reliability, sensitivity to change, and classification of MRI scans as positive or negative for various lesion types were similar.Conclusion: The standardized 6/5 slices approach showed no relevant differences from the 'all slices' approach and, therefore, is equally suited for monitoring purposes.

P1868Risk of arrhythmias after myocardial infarction in patients with left ventricular systolic dysfunction according to mode of revascularization: a CARISMA substudy

Introduction

The CARISMA trial was the first study to use continuous monitoring for documentation of long-term arrhythmias in post-infarction patients with left ventricular dysfunction. During the study duration (2000–2005), primary PCI (pPCI) as treatment of acute myocardial infarction was introduced approximately midway (2002) on the enrolling centres.

Purpose

The aim of this study was to describe the influence of mode of revascularization after myocardial infarction (AMI) on long-term risk of risk of new onset atrial fibrillation, ventricular tachyarrhythmias and brady arrhythmias.

Methods

The study is a sub-study on the CARISMA study population that consisted of patients with AMI and left ventricular ejection fraction ≤40%, which received an implantable loop recorder and was followed for 2 years. After exclusion of 15 patients who refused device implantation and 26 with pre-existing arrhythmias, 268 of the 312 patients were included. Choice of revascularization was made by the treating team independently of the trial and was retrospectively divided into primary percutaneous intervention (pPCI), subacute PCI (24 hours to 2 weeks after AMI), primary thrombolysis or no revascularization.

Endpoints were new-onset of arrhythmias and major cardiovascular events (MACE). The Kaplan-Meier (figure 1) and Mantel-Byar methods were used for time to first event risk analysis.

Results

A total of 77 patients received no revascularization, whereas 49 received thrombolysis only and 142 received PCI. At two-years follow up patients treated with any PCI had a significant lower risk (0.40, n=63) of any arrhythmia compared to patients treated with trombolysis (0.60, n=30) or no revascularization (0.68, n=16) (p<0.001, unadjusted) (figure 1). Risk of MACE was significant higher in patients with any arrhythmia (0.25, n=76) compared to no arrhythmia (0.11, n=93) at two years follow-up (p=0.004, unadjusted).

Figure 1

Conclusion(s)

The long-term risk of new onset arrhythmias after AMI was significantly lower in patients treated with any PCI compared to patients not revascularized or treated with thrombolysis. Risk of MACE was significantly higher in patients with new onset arrhythmias compared to patients with no arrhythmias.

1096Diastolic myocardial dysfunction by tissue doppler imaging predicts outcome following isolated coronary artery bypass grafting

Background

Myocardial tissue velocities by tissue Doppler imaging (TDI) have proven superior predictors of outcome to left ventricular ejection fraction (LVEF) in ischemic heart disease, with early diastolic myocardial relaxation velocity (e') being an early sign of LV dysfunction in the ischemic cascade.

Purpose

We hypothesized that e' predicts outcome after coronary artery bypass grafting (CABG).

Methods

We included patients treated with isolated CABG (n=679). Before surgery, all patients had an echocardiogram performed with TDI to measure tissue velocities: systolic (s'), e' and late diastolic (a'). Endpoint was all-cause mortality retrieved from national registries. We performed Cox regressions and C-statistics. Net reclassification index was used to test improvement of EuroSCOREII.

Results

Of 679 patients, 79 (n=12%) died during follow-up (median: 3.8 years (IQR: 2.8; 5.0y). Follow-up was 100%. Mean age was 68 years, LVEF 50%, and 86% were male. All tissue velocities were univariable predictors of outcome (s': HR=1.46 [1.21; 1.78], p<0.001; e': HR=1.55 [1.33; 1.81], p<0.001; a': HR=1.19 [1.06; 1.33], p=0.004, per 1cm/s decrease for all). Overall, e' provided the highest C-statistics of all the tissue velocities (c-stat=0.69). In multivariable adjustments, e' remained an independent predictor after adjusting for clinical, biochemical and echocardiographic confounders (HR=1.24 [1.03; 1.49], p=0.022, per 1cm/s decrease). LVEF <40% modified the relationship between e' and outcome, so e' did not predict outcome in these patients (p for interaction = 0.013). However, e' was an independent predictor after multivariable adjustments in patients with LVEF >40% (HR=1.39 [1.11; 1.74], p=0.005, per 1cm/s decrease). When split by the median (−4.95cm/s), patients in the lowest group had a 3-fold increased risk of death (HR=3.31 [1.98; 5.56], p<0.001) compared to patients in the highest group (figure).

The e' improved the net reclassification improvement index when added to EuroSCOREII, with a net reclassification of 39%.

Conclusion

After CABG, e' is a strong predictor of all-cause mortality and improves the predictive value of the established prediction model, the EuroSCOREII. We identified a possible effect modifier in LVEF, such that e' was a strong predictor in patients with LVEF >40% and not when LVEF is below 40%.

P4628A multiple biomarker approach for risk assessment after ST-segment elevation myocardial infarction

Background

Several biomarkers independently predict outcome following ST-segment elevation myocardial infarction (STEMI). We hypothesized that combining information from multiple circulating biomarkers with numerous pathophysiological pathways may improve biomarker risk stratification following a STEMI.

Method

This was a prospective study of 735 patients with STEMI treated with primary percutaneous coronary intervention. Seventeen biomarkers were drawn before revascularization, including adrenalin, noradrenalin, C-reactive protein (CRP), neutrophil gelatinase-associated lipocalin (NGAL), pro-atrial natriuretic peptide (pro-ANP), alfa-defensin, adiponectin, troponin I, hemoglobin, thrombocyte, and total leukocyte count. The primary outcome was a composite of cardiovascular death or heart failure (CVD/HF) identified by national registries. In the effort to identify the best model, the population was randomly split into two equally sized groups, a derivation cohort and a validation cohort. We used classification and regression tree (CART) analysis to develop a risk model. The identified risk model was hereafter applied to the whole cohort.

Results

Mean age was 63 years, 74% were male and 33% had hypertension. During a median follow-up time of 5.0 years (3.2; 5.0), we observed 185 primary events. After including all biomarkers in the initial model, the CART analysis created a risk model including pro-ANP, NGAL, and CRP (Figure 1a). The risk of CVD/HF increased incrementally with increasing risk group (Figure 1b). The risk remained significantly higher in groups 3 and 4 after multivariable adjustments (hazard ratio (HR)=3.38 [95% confidence interval (CI): 1.60; 7.16] p=0.001 and HR=6.55 [95% CI: 2.73; 15.76] p<0.001, respectively) when compared with group 1.

Figure 1

Conclusion

We developed a risk model based on multiple biomarkers (NGAL, CRP, and pro-ANP) determined from a CART analysis which may ease risk stratification after STEMI.

Acknowledgement/Funding

Sif Rasmussen received a scholarship grant from Herlev & Gentofte Hospital and the P. Carl Petersens Fond during preparation of this manuscript.

P623Regional Longitudinal Strain for Prediction of Left Ventricular Thrombus Formation following Acute Myocardial Infarction

Background

Left ventricular thrombus (LVT) formation is a dangerous complication to acute myocardial infarction (MI).

Purpose

We hypothesized that regional strain impairment was predictive of LVT formation.

Methods

We included 373 prospectively enrolled patients with ST-segment elevation MI treated with primary percutaneous intervention. All patients had an echocardiogram performed a median of 2 days post-MI. Using logistic regression, we investigated the predictive value of left ventricular (LV) speckle tracking, conventional echocardiographic measures and well-known echocardiographic features of LVT formation including LV smoke, aneurysm and valvular regurgitations.

Results

Overall, the mean age was 62 years, 75% were male, 5% had prior MI, and 48% had anterior infarcts. Mean LVEF was 46% and absolute global longitudinal strain (GLS) was 12%.

Of 373 patients, 31 (8%) developed LVT in follow-up echocardiograms. Patients with LVT more frequently had anterior infarcts, prior MI, lower LVEF, lower e', lower GLS and regional strain, and these were all univariable predictors of LVT formation.

In multivariable analysis (including anterior infarcts, prior MI, LVEF, e'), GLS and regional strain remained independent predictors of LVT formation (GLS: OR: 1.17 [1.00; 1.36], midventricular strain: OR: 1.19 [1.03; 1.38], apical strain: 1.12 [1.00; 1.25], p<0.05 for all) (figure)

In a combined diagnostic model, including anterior infarct, impaired LVEF (<42%) and apical strain (<8%), the sensitivity and negative predictive value was 100%, with a specificity and positive predictive value of 38 and 13%, respectively.

Regional strain and risk of LVT

Conclusion

In MI patients, anterior infarct, LVEF and apical strain were strong predictors of LVT formation. Reduced apical strain indicates a markedly increased LVT risk.

P6399Left atrial function determined by echocardiography predicts incident heart failure in STEMI patients treated with primary percutaneous coronary intervention

Objectives

To assess the comparative effectiveness of LA functional parameters (LAEF and MinLAVI) with that of LA volume index (LAVI) in predicting HF following STEMI.

Background

Heart failure (HF) is common following STEMI. Enlarged left atrial (LA) volume determined by echocardiography is associated with adverse outcome following STEMI. However, whether echocardiographic parameters of LA function, such as the LA emptying fraction (LAEF) and the minimal LA volume index (MinLAVI), are superior to LAVI for predicting prognosis following STEMI is unknown.

Methods

A total of 369 STEMI patients without atrial fibrillation or heart failure treated with primary percutaneous coronary intervention (pPCI) were prospectively enrolled in the period September 2006 to December 2008. Patients underwent echocardiography shortly after STEMI. The maximal and minimal LA volume were measured using the biplane area-length method. LAVI, MinLAVI (minimal LA volume indexed to body surface area) and LAEF [(maximal LA volume − minimal LA volume) / maximal LA volume] were calculated. End-point was incident HF.

Results

During a median follow-up of 66 months (interquartile-range: 50–73 months), 68 patients (18%) were admitted for HF. In univariable analysis, both reduced LAEF and increased MinLAVI were significantly associated with an increased risk of HF (LAEF: HR 1.18, 95% CI 1.08–1.29, per 5% decrease, p<0.001) (MinLAVI: HR 1.35, 95% CI 1.09–1.67, per 5 mL/m2 increase, p=0.006) (Figure). In contrast, LAVI was not significantly associated with the development of HF (HR 1.03, 95% CI 0.87–1.22, per 5 mL/m2 increase, p=0.73) (Figure). Following adjustment for clinical, biochemical and echocardiographic variables, LAEF and MinLAVI remained independent predictors of HF, while the lack of association between LAVI and HF persisted (LAEF: HR 1.14, 95% CI 1.02–1.27, per 5% decrease, p=0.019) (MinLAVI: HR 1.31, 95% CI 1.02–1.69, per 5 mL/m2 increase, p=0.036) (LAVI: HR 1.05, 95% CI 0.86–1.29, per 5 mL/m2 increase, p=0.61). These results were replicated when treating death from all causes as a competing event in competing risk regression.

PY, person-years

Conclusion

In STEMI patients treated with pPCI, LAEF and MinLAVI measured by echocardiography shortly after infarction are superior to LAVI for predicting incident HF.

Prevalence and predictors of weight loss maintenance: a retrospective population-based survey of European adults with overweight and obesity

BACKGROUND

The prevalence of weight loss attempts has increased worldwide, although the extent to which sustained weight loss is achieved is unknown. There is insufficient research into weight loss maintenance (WLM) in individuals with overweight or obesity who have recently lost clinically significant amounts of weight (≥5%), particularly in the European general population. The present study aimed to determine the prevalence and retrospective predictors of WLM in population-based samples of European adults with overweight or obesity who had made a recently completed weight loss attempt.

METHODS

Participants (N = 2000) in UK, Denmark and Portugal completed an online survey about loss and regain in their most recent completed weight loss attempt, features of their attempt (duration, self-weighing, lapses, strategies), as well as loss of control and binge eating. Multiple regression analysis was used to determine factors retrospectively associated with WLM in those who achieved clinically significant weight loss (n = 1272).

RESULTS

Mean (SD) self-reported weight loss was 9% (8%) and mean (SD) regain was 96.3% (9%) of participants' start weight. Twenty-three percent of the total sample had maintained weight loss of ≥5% for at least 1 month. Controlling for weight loss and time since attempt, predictors of better WLM were avoidance of a temporary lapse, infrequent/absent loss of control and binge eating, and use of a greater number of dietary strategies for WLM (r²  = 0.338, P < 0.001).

PRINCIPAL CONCLUSIONS

Factors associated with recent successful WLM indicate the importance of the continued use of dietary and other strategies for WLM, particularly in the face of a lapse, as well as the need to manage dysfunctional eating behaviours.

Structural progression rate decreases over time on serial radiography and magnetic resonance imaging of sacroiliac joints and spine in a five-year follow-up study of patients with ankylosing spondylitis treated with tumour necrosis factor inhibitor

OBJECTIVE

To investigate temporal changes in structural progression assessed by serial conventional radiography and magnetic resonance imaging (MRI) of the sacroiliac joints (SIJs) and spine in patients with ankylosing spondylitis (AS) treated with tumour necrosis factor (TNF) inhibitor for 5 years.

METHOD

Forty-two patients were included and 33 patients were followed for 5 years in a prospective investigator-initiated study. Conventional radiographs were required four times and MRI seven times. The modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS); Spondyloarthritis Research Consortium of Canada (SPARCC) MRI SIJ and Spine Inflammation, and SPARCC MRI SIJ Structural Score (SSS) for Fat, Erosion, Backfill, and Ankylosis; and the Canada-Denmark MRI scores for Spine Inflammation, Fat, Erosion, and New Bone Formation (NBF) were applied.

RESULTS

Compared with baseline, MRI Inflammation had decreased significantly at week 22 (spine)/week 46 (SIJ) and thereafter. MRI SIJ Fat (from week 22), SIJ Ankylosis, Spine NBF, and mSASSS had increased significantly at week 46 and thereafter. SIJ Erosion had decreased from year 2. The annual progression rate in mSASSS was significantly higher during weeks 0-46 compared to week 46 to year 3. In multivariate regression analyses, baseline SIJ Inflammation and Backfill were independent predictors of 5 year progression in SIJ Ankylosis. Spine Erosion predicted progression in Spine NBF. Longitudinally, Ankylosing Spondylitis Disease Activity Score, Bath Ankylosing Spondylitis Disease Activity Index, MRI Spine Inflammation, Fat, and Erosion scores were significantly associated with mSASSS. SIJ Inflammation, Fat, Erosion, and Backfill scores were longitudinally associated with SIJ Ankylosis. Structural progression was not associated with body mass index, smoking, or Assessment of SpondyloArthritis international Society Non-Steroidal Anti-Inflammatory Drug Index.

CONCLUSION

In a 5 year follow-up study of patients with AS treated with TNF inhibitor, structural progression decreased over time.

Fat metaplasia on MRI of the sacroiliac joints increases the propensity for disease progression in the spine of patients with spondyloarthritis

Objective

We tested the hypothesis that fat metaplasia on MRI of the sacroiliac joints (SIJ) increases the propensity for new bone formation in the spine of patients with spondyloarthritis.

Methods

We assessed baseline T1-weighted and short τ inversion recovery SIJ MRIs from patients in the Follow Up Research Cohort in Ankylosing Spondylitis (FORCAST). Radiographic progression was assessed using the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). Structural and inflammatory lesions were scored using the Spondyloarthritis Research Consortium of Canada (SPARCC) SIJ structural and SPARCC SIJ inflammation scores, respectively. Radiographic progression was compared in cases with and without definite MRI lesions (score ≥2 or <2) and the extent of MRI lesions at baseline was compared in patients with and without radiographic progression. The predictive capacity of MRI SIJ lesions for radiographic progression in the spine was assessed in univariate and multivariate regression analyses.

Results

The extent of MRI structural lesions in the SIJ at baseline was significantly greater in those patients who had spinal radiographic progression on follow-up (p=0.003, 0.02, 0.003 for fat metaplasia, backfill and ankylosis, respectively). Also, radiographic progression was significantly greater in cases with definite baseline SIJ ankylosis (p=0.008). In multivariate regression that included all types of MRI lesions and was adjusted for age, sex, symptom duration, duration of follow-up, CRP, baseline mSASSS and treatment, the extent of SIJ fat metaplasia and ankylosis at baseline were independently associated with radiographic progression.

Conclusions

SIJ ankylosis and fat metaplasia but not inflammatory lesions increase the propensity for radiographic progression in the spine.

Monitoring total-body inflammation and damage in joints and entheses: the first follow-up study of whole-body magnetic resonance imaging in rheumatoid arthritis

OBJECTIVE

To investigate changes in whole-body magnetic resonance imaging (WBMRI) inflammatory and structural lesions in most joints and entheses in patients with rheumatoid arthritis (RA) treated with adalimumab.

METHODS

WBMRI was obtained at weeks 0, 6, 16, and 52 in a 52 week follow-up study of 37 RA patients starting treatment with adalimumab. Readability and reliability of WBMRI were investigated for 76 peripheral joints, 23 discovertebral units, the sacroiliac joints, and 33 entheses. Changes in WBMRI joint and entheses counts were investigated.

RESULTS

The readability of peripheral and axial joints was 82-100%, being less for elbows and small joints of the feet. For entheses, 72-100% were readable, except for entheses at the anterior chest wall, elbow, knee, and plantar fascia. The intrareader agreement was high for bone marrow oedema (BMO), bone erosion (80-100%), and enthesitis (77-100%), and slightly lower for synovitis and soft tissue inflammation (50-100%). All synovitis, BMO, and soft tissue inflammation counts decreased numerically during treatment. The 26-joint synovitis WBMRI count decreased significantly during the first 16 weeks for patients with a good European League Against Rheumatism (EULAR) response (from median 6 to 4, p < 0.05), but not for patients with a moderate or no EULAR response. There were no overall changes in structural lesions.

CONCLUSIONS

WBMRI allows simultaneous monitoring of most axial and peripheral joints and entheses in RA patients and can visualize a decrease in inflammatory counts during treatment. This first WBMRI follow-up study of patients with RA encourages further investigation of the usefulness of WBMRI in RA.

ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA—disseminated and implemented in over 70 countries globally—is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.

Scaling up strategies of the chronic respiratory disease programme of the European Innovation Partnership on Active and Healthy Ageing (Action Plan B3: Area 5)

Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) focuses on the integrated care of chronic diseases. Area 5 (Care Pathways) was initiated using chronic respiratory diseases as a model. The chronic respiratory disease action plan includes (1) AIRWAYS integrated care pathways (ICPs), (2) the joint initiative between the Reference site MACVIA-LR (Contre les MAladies Chroniques pour un VIeillissement Actif) and ARIA (Allergic Rhinitis and its Impact on Asthma), (3) Commitments for Action to the European Innovation Partnership on Active and Healthy Ageing and the AIRWAYS ICPs network. It is deployed in collaboration with the World Health Organization Global Alliance against Chronic Respiratory Diseases (GARD). The European Innovation Partnership on Active and Healthy Ageing has proposed a 5-step framework for developing an individual scaling up strategy: (1) what to scale up: (1-a) databases of good practices, (1-b) assessment of viability of the scaling up of good practices, (1-c) classification of good practices for local replication and (2) how to scale up: (2-a) facilitating partnerships for scaling up, (2-b) implementation of key success factors and lessons learnt, including emerging technologies for individualised and predictive medicine. This strategy has already been applied to the chronic respiratory disease action plan of the European Innovation Partnership on Active and Healthy Ageing.

Establishing a community-wide DNA barcode library as a new tool for arctic research

DNA sequences offer powerful tools for describing the members and interactions of natural communities. In this study, we establish the to-date most comprehensive library of DNA barcodes for a terrestrial site, including all known macroscopic animals and vascular plants of an intensively studied area of the High Arctic, the Zackenberg Valley in Northeast Greenland. To demonstrate its utility, we apply the library to identify nearly 20 000 arthropod individuals from two Malaise traps, each operated for two summers. Drawing on this material, we estimate the coverage of previous morphology-based species inventories, derive a snapshot of faunal turnover in space and time and describe the abundance and phenology of species in the rapidly changing arctic environment. Overall, 403 terrestrial animal and 160 vascular plant species were recorded by morphology-based techniques. DNA barcodes (CO1) offered high resolution in discriminating among the local animal taxa, with 92% of morphologically distinguishable taxa assigned to unique Barcode Index Numbers (BINs) and 93% to monophyletic clusters. For vascular plants, resolution was lower, with 54% of species forming monophyletic clusters based on barcode regions rbcLa and ITS2. Malaise catches revealed 122 BINs not detected by previous sampling and DNA barcoding. The insect community was dominated by a few highly abundant taxa. Even closely related taxa differed in phenology, emphasizing the need for species-level resolution when describing ongoing shifts in arctic communities and ecosystems. The DNA barcode library now established for Zackenberg offers new scope for such explorations, and for the detailed dissection of interspecific interactions throughout the community.

EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice

A taskforce comprised of an expert group of 21 rheumatologists, radiologists and methodologists from 11 countries developed evidence-based recommendations on the use of imaging in the clinical management of both axial and peripheral spondyloarthritis (SpA). Twelve key questions on the role of imaging in SpA were generated using a process of discussion and consensus. Imaging modalities included conventional radiography, ultrasound, magnetic resonance imaging, computed tomography (CT), positron emission tomography, single photon emission CT, dual-emission x-ray absorptiometry and scintigraphy. Experts applied research evidence obtained from systematic literature reviews using MEDLINE and EMBASE to develop a set of 10 recommendations. The strength of recommendations (SOR) was assessed by taskforce members using a visual analogue scale. A total of 7550 references were identified in the search process, from which 158 studies were included in the systematic review. Ten recommendations were produced using research-based evidence and expert opinion encompassing the role of imaging in making a diagnosis of axial SpA or peripheral SpA, monitoring inflammation and damage, predicting outcome, response to treatment, and detecting spinal fractures and osteoporosis. The SOR for each recommendation was generally very high (range 8.9–9.5). These are the first recommendations which encompass the entire spectrum of SpA and evaluate the full role of all commonly used imaging modalities. We aimed to produce recommendations that are practical and valuable in daily practice for rheumatologists, radiologists and general practitioners.

Abstract P3-03-02: Na+,HCO3--cotransport is the major mechanism of cellular acid extrusion in human and murine breast cancer

High metabolism and insufficient blood supply are characteristics of cancer tissue, which in combination with biochemical changes favor glycolytic metabolism and result in prominent intracellular acid production. Although extracellular pH at the core of malignant tumors is as low as one unit below normal, intracellular pH (pHi) in tumor cells is typically normal or even slightly alkaline. Thus, cancer cells must possess efficient mechanisms of acid extrusion to eliminate the excess acid load.

We investigated the role of the Na+,HCO3–cotransporter NBCn1 (SLC4A7), which in recent genome-wide association studies has been linked to human breast cancer. Based on immunohistochemistry of tumor slices and immunoblotting of enzymatically isolated epithelial organoids, we found that NBCn1 expression is upregulated in human and murine primary breast carcinomas and metastases compared to normal breast tissue. The upregulation of NBCn1 was of similar or greater magnitude than that observed for the Na+/H+-exchanger NHE1, which has previously been implicated in cell migration, proliferation and malignancy. Measurements of pHi from slices of human and murine breast cancers and from malignant and normal breast epithelial organoids showed that Na+,HCO3–cotransport is the major mechanism of acid extrusion in the near-physiological pHi range. Na+/H+-exchange was important for acid extrusion only at very low pHi values. We furthermore found that Na+,HCO3–cotransport activity was substantially greater in malignant compared to normal breast epithelial organoids of both human and murine origin, while no apparent difference in Na+/H+-exchange activity was detected between cancer and normal breast tissue. Steady-state pHi was higher in the breast cancer tissue compared to normal breast epithelium in the presence of CO2/HCO3- but not in its nominal absence.

We propose that NBCn1 plays a major role for cellular acid extrusion and pHi regulation in human and murine breast cancer. The upregulated expression of NBCn1 and the functional importance of Na+,HCO3–cotransport for pHi regulation support a causative role for NBCn1 in breast cancer development or progression.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-03-02.