Mikrozirkulationsstörungen der Haut: Microcirculation disorders of the skin

Veränderungen in der Mikrozirkulation der Haut sind ein häufig beobachtetes Begleitphänomen vieler Erkrankungen, weit über das Spektrum dermatologischer Krankheiten hinausreichend. Nicht alle dieser Veränderungen haben einen Krankheitswert, viele treten temporär auf, ohne schwerwiegende Folgen zu verursachen. Dies trifft für viele inflammatorische Erkrankungen wie die Psoriasis vulgaris oder das atopische Ekzem zu.

Daneben gibt es aber auch Erkrankungen, bei denen funktionell und morphologisch erkennbare Mikroangiopathien zu schwerwiegenden Krankheitsfolgen führen. Eine der wichtigsten Erkrankungen in diesem Zusammenhang ist die systemische Sklerose, eine autoimmune Systemerkrankung mit multiplen Organmanifestationen. Hier sind die Untersuchungen der kutanen Mikrozirkulation sowohl in der Erstdiagnose als auch in der Prognose‐ und Verlaufsbeurteilung von weitreichender Bedeutung.

Auch bei Erkrankungen der peripheren Hämodynamik wie der peripheren arteriellen Verschlusskrankheit (pAVK) und der chronisch venösen Insuffizienz (CVI) spielt das Verständnis von Mikrozirkulationsstörungen eine wichtige Rolle für die Therapie und die Erfolgskontrolle therapeutischer Interventionen.

Microcirculation disorders of the skin

Changes in the microcirculation of the skin are a frequently observed accompanying phenomenon of many diseases, far beyond the spectrum of dermatological diseases. Not all of these changes are pathological, many are transient and have no serious consequences. This is true for many inflammatory diseases such as psoriasis vulgaris or atopic eczema. However, there are also diseases in which functionally and morphologically recognizable microangiopathies lead to severe disease consequences. One of the most important diseases in this context is systemic sclerosis, an autoimmune systemic disease with multiple organ manifestations. Investigations of the cutaneous microcirculation are of great importance for the initial diagnosis as well as for prognosis and assessment of disease progression. In peripheral hemodynamic disorders such as peripheral arterial disease (PAD) and chronic venous insufficiency (CVI), understanding microcirculatory disturbances also plays an important role in therapy and in monitoring the success of therapeutic interventions.

Epidermolysis-Bullosa-Associated Squamous Cell Carcinomas Support an Immunosuppressive Tumor Microenvironment: Prospects for Immunotherapy

Cutaneous squamous cell carcinomas (SCCs) are a major complication of some subtypes of epidermolysis bullosa (EB), with high morbidity and mortality rates and unmet therapeutic needs. The high rate of endogenous mutations and the fibrotic stroma are considered to contribute to the pathogenesis. Patients with dystrophic EB (DEB) and Kindler EB (KEB) have the highest propensity for developing SCCs. Another patient group that develops high-risk SCCs is immunosuppressed (IS) patients, especially after organ transplantation. Herein, we interrogate whether immune checkpoint proteins and immunosuppressive enzymes are dysregulated in EB-associated SCCs as an immune resistance mechanism and compare the expression patterns with those in SCCs from IS patients, who frequently develop high-risk tumors and sporadic SCCs, and immunocompetent (IC) individuals. The expression of indoleamine 2,3-dioxygenase (IDO), programmed cell death protein-1 (PD-1), programmed cell death ligand-1 (PD-L1), T cell immunoglobulin and mucin-domain-containing protein-3 (TIM-3), lymphocyte activation gene-3 (LAG-3), and inflammatory infiltrates (CD4, CD8, and CD68) was assessed via immunohistochemistry and semi-quantitative analysis in 30 DEB-SCCs, 22 KEB-SCCs, 106 IS-SCCs, and 100 sporadic IC-SCCs. DEB-SCCs expressed significantly higher levels of IDO and PD-L1 in tumor cells and PD-1 in the tumor microenvironment (TME) compared with SCCs from IC and IS individuals. The number of CD4-positive T cells per mm2 was significantly lower in DEB-SCCs compared with IC-SCCs. KEB-SCCs showed the lowest expression of the exhaustion markers TIM-3 and LAG-3 compared with all other groups. These findings identify IDO, PD-1, and PD-L1 to be increased in EB-SCCs and candidate targets for combinatory treatments, especially in DEB-SCCs.

Arrhythmias among Older Adults Receiving Comprehensive Geriatric Care: Prevalence and Associated Factors

BACKGROUND

Cardiovascular diseases and arrhythmias are medical conditions that increase with age and are associated with significant morbidities and mortality. The aim of the present study was to investigate the prevalence of arrhythmias and clinical associations in the collective of older adults receiving comprehensive geriatric care (CGC).

METHODS

Holter ECG monitoring (HECG) of older patients hospitalized for CGC was analyzed. The prevalence of arrhythmias and the associations between the presence of arrhythmias, patients' characteristics and the functional status regarding basic activities of daily living (assessed by the Barthel index (BI)), walking ability (assessed by the timed up and go test (TUG)), and balance and gait (assessed by the Tinetti balance and gait test (TBGT)) were examined.

RESULTS

In the presented study, 626 patients were included (mean age: 83.9 ± 6.6 years, 67.7% were female). The most common arrhythmias detected in HECG were premature ventricular contractions (87.2%), premature atrial contractions (71.7%), and atrial fibrillation (22.7%). Atrial flutter was found in 1.0%, paroxysmal supraventricular tachycardia in 5.8%, non-sustained ventricular tachycardia in 12.5%, first-degree AV block in 0.8%, second-degree AV block type Mobitz I in 0.8%, second-degree AV block type Mobitz II in 0.3%, pause > 2.5 s any cause in 3.5%, and pause > 3 s any cause in 1.6% of the cases. Premature atrial contractions were associated with the female sex (74.8% vs. 65.3%, p = 0.018), whereas in male patients, the following arrhythmias were more common: premature ventricular contractions (91.6% vs. 85.1%, p = 0.029), ventricular bigeminus (8.4% vs. 3.8%, p = 0.021), and non-sustained ventricular tachycardia (17.3% vs. 10.1%, p = 0.014). Atrial fibrillation detected in HECG was more frequent in patients at high risk of falls, indicated by their TBGT score ≤ 18 (24.7% vs. 12.0%, p = 0.006), and premature ventricular contractions were more common in patients unable to walk (TUG score 5) compared to those with largely independent mobility (TUG score 1 or 2) (88.0% vs. 75.0%, p = 0.023). In a logistic regression analysis, atrial fibrillation detected in HECG was identified as a risk factor for a high risk of falls (odds ratio (OR): 2.35, 95% confidence interval (CI): 1.23-4.46).

CONCLUSION

In our study, investigation of HECG of older adults hospitalized for CGC revealed that premature atrial contractions, premature ventricular contractions, and atrial fibrillation were the most common arrhythmias. Premature atrial contractions were found to be more frequent in female patients, while male patients were more prone to premature ventricular contractions. In the investigated population, atrial fibrillation emerged as a risk factor associated with a high risk of falls.

Polysomnographic characteristics of sleep in adults with and without physician-diagnosed atopic dermatitis: results from the Study of Health in Pomerania

PURPOSE

To analyze sleep characteristics as measured with polysomnography (PSG) in adults from the general population with and without physician-diagnosed atopic dermatitis (AD).

METHODS

We analyzed data from participants from the German population-based Study of Health in Pomerania (SHIP) TREND-0. AD was diagnosed in a standardized skin examination. The following polysomnographic parameters were measured: total sleep duration (min), sleep latency (min), wake after sleep onset (WASO; min), rapid eye movement (REM) latency (min), sleep efficiency (%), total number of wakefulness and movement episodes, stages of sleep (%), and apnea-hypopnea index (AHI). Additionally, the subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). We compared sleep characteristics of participants with and without AD.

RESULTS

Among 1187 participants, 47 (4.0%) had AD. We found no differences between participants with and without AD in any of the analyzed PSG parameters except for the total number of wakefulness and movement episodes and the percentage of REM sleep. Participants with AD had a higher number of wakefulness and movement episodes, and a lower proportion of REM sleep compared to those without AD. Regarding subjective sleep parameters, no significant differences were found between participants with and without AD.

CONCLUSION

Our data do not provide evidence for poor sleep quality in individuals with AD. Major limitations of the study include the unavailability of data on AD severity and the small number of participants with AD. Larger-scaled longitudinal studies considering disease severity and specific AD symptoms with an effect on sleep are required.

European and multi-ancestry genome-wide association meta-analysis of atopic dermatitis highlights importance of systemic immune regulation

Atopic dermatitis (AD) is a common inflammatory skin condition and prior genome-wide association studies (GWAS) have identified 71 associated loci. In the current study we conducted the largest AD GWAS to date (discovery N = 1,086,394, replication N = 3,604,027), combining previously reported cohorts with additional available data. We identified 81 loci (29 novel) in the European-only analysis (which all replicated in a separate European analysis) and 10 additional loci in the multi-ancestry analysis (3 novel). Eight variants from the multi-ancestry analysis replicated in at least one of the populations tested (European, Latino or African), while two may be specific to individuals of Japanese ancestry. AD loci showed enrichment for DNAse I hypersensitivity and eQTL associations in blood. At each locus we prioritised candidate genes by integrating multi-omic data. The implicated genes are predominantly in immune pathways of relevance to atopic inflammation and some offer drug repurposing opportunities.

Comprehensive Geriatric Care in Older Adults: Walking Ability after an Acute Fracture

BACKGROUND/OBJECTIVES

Comprehensive Geriatric Care (CGC) is a specific multimodal treatment for older patients. In the current study, we aimed to investigate walking performance after CGC in medically ill patients versus those with fractures.

METHODS

The timed up and go test (TuG), a 5-grade scale assessment (1 = no walking impairment to 5 = no walking ability at all) for evaluating individual walking ability was performed in all patients who underwent CGC prior to and after treatment. Factors associated with improvement in walking ability were analyzed in the subgroup of patients with fractures.

RESULTS

Out of 1263 hospitalized patients, 1099 underwent CGC (median age: 83.1 years (IQR 79.0-87.8 years); 64.1% were female). Patients with fractures (n = 300) were older than those without (n = 799), (median 85.6 versus 82.4 years, p = 0.001). Improvement in TuG after CGC was found in 54.2% of the fracture patients compared to just 45.9% of those without fractures. In fracture group patients, TuG improved from median 5 on admission to median 3 on discharge (p = 0.001). In fracture patients, improvement in walking ability was associated with higher Barthel index values on admission (median 45 (IQR: 35-55) versus 35 (IQR: 20-50): p = 0.001) and Tinetti assessment scores (median 9 (IQR: 4-14.25) versus 5 (IQR: 0-13); p = 0.001) and was negatively associated with the diagnosis of dementia (21.4% versus 31.5%; p = 0.058).

CONCLUSION

CGC improved walking ability in more than half of all patients examined. Older patients in particular might benefit from undergoing the procedure after an acute fracture. A better initial functional status favors a positive result following the treatment.

Effects of Extracorporeal Photopheresis on Quality of Life and the Course of Diseases in Patients With Mycosis Fungoides and Graft-Versus-Host Disease: A Single-Center Analysis

INTRODUCTION

The aim of the study was to systematically analyze the influence of extracorporeal photopheresis (ECP) on the quality of life (LQ) and the course of the disease in patients with Mycosis Fungoides (MF), as well as with Graft-versus-Host Disease (GvHD).

METHODS

LQ was monitored retrospectively by using the dermatology life quality index (DLQI) and Skindex-29 test before ECP onset and after the last ECP. Disease parameters were assessed by objective criteria i.e. number of associated medical drugs taken, intervals between therapeutic cycles, gradual change of the disease, and eventual side-effects and complications of ECP therapy.

RESULTS

Fifty-one patients were treated with ECP during 2008-19; 19 out of 51 died, and follow-up was not completed in 13 patients. Finally, treatment protocols of 671 ECP procedures were evaluated in 19 patients (10 MF; 9 GvHD). MF and GvHD subpopulations did not differ in the individual scores of LQ questions, either before the outset or after the last ECP. DLQI and Skindex-29 scores were ameliorated by the ECP therapy (p= 0.001 and p< 0.001, respectively) due to improvement of individual scores of feelings, daily/social activities (p< 0.05), and functionality (p≤ 0.05). The median interval between ECP cycles was extended from two to eight weeks (p= 0.001). Needs of GvHD patients for drugs being received for the underlying disease were reduced (p= 0.035). Two of the 10 MF patients worsened from stage IIA to IIIA. Severe or minor side effects leading to a therapy interruption were not recorded.

CONCLUSION

Patients with GvHD experienced a notable decrease in the administration of drugs for their underlying condition, and there were no instances of severe side effects that resulted in the discontinuation of treatment. ECP is safe and effective for the treatment of MF and GvHD.

Comprehensive Geriatric Care in Older Hospitalized Patients with Depressive Symptoms

BACKGROUND/OBJECTIVES

Depressive symptoms (DS) may interfere with comprehensive geriatric care (CGC), the specific multimodal treatment for older patients. In view of this, the aim of the current study was to investigate the extent to which DS occur in older hospitalized patients scheduled for CGC and to analyze the associated factors. Furthermore, we aimed to investigate whether DS are relevant with respect to outcomes after CGC.

METHODS

For this retrospective study, all patients fulfilling the inclusion criteria were selected by reviewing case files. The main inclusion criterion was the completion of CGC within the defined period (May 2018 and May 2019) in the geriatrics department of the Diakonie Hospital Jung-Stilling Siegen (Germany). The Geriatric Depression Scale was used to asses DS in older adults scheduled for CGC (0-5, no evidence of DS; 6-15 points, DS). Scores for functional assessments (Timed Up and Go test (TuG), Barthel Index, and Tinetti Gait and Balance test) were compared prior to versus after CGC. Factors associated with the presence of DS were studied.

RESULTS

Out of the 1263 patients available for inclusion in this study, 1092 were selected for the analysis (median age: 83.1 years (IQR 79.1-87.7 years); 64.1% were female). DS (GDS > 5) were found in 302 patients (27.7%). The proportion of female patients was higher in the subgroup of patients with DS (85.5% versus 76.3%, p = 0.024). Lower rates of patients diagnosed with chronic pulmonary obstructive disease were detected in the subgroup of patients without DS (8.0% versus 14.9%, p = 0.001). Higher rates of dizziness were observed in patients with DS than in those without (9.9% versus 6.2%, p = 0.037). After CGC, TuG scores improved from a median of 4 to 3 (p < 0.001) and Barthel Index scores improved from a median of 45 to 55 (p < 0.001) after CGC in both patients with and without DS. In patients with DS, the Tinetti score improved from a median of 10 (IQR: 4.75-14.25) prior to CGC to 14 (IQR 8-19) after CGC (p < 0.001). In patients without DS, the Tinetti score improved from a median of 12 (IQR: 6-7) prior to CGC to 15 (IQR 2-20) after CGC (p < 0.001).

CONCLUSIONS

DS were detected in 27.7% of the patients selected for CGC. Although patients with DS had a poorer baseline status, we detected no difference in the degree of improvement in both groups, indicating that the performance of CGC is unaffected by the presence of DS prior to the procedure.

Effect of freezing and embalming of human cadaveric whole head specimens on bone conduction

BACKGROUND AND AIMS

Conserved specimens do not decay and therefore permit long-term experiments thereby overcoming limited access to fresh (frozen) temporal bones for studies on middle ear mechanics. We used a Thiel conservation method which is mainly based on a watery solution of salts. In contrast to pure Formalin, Thiel conservation aims to preserve the mechanical proprieties of human tissue. The aim of this study is to examine the effect of Thiel conservation on bone conduction in the same specimen before and after conservation.

METHODS

Nine ears of five defrosted whole heads were stimulated with a direct, electrically driven, bone anchored hearing system (Baha, Baha SuperPower). The motion produced by bone conduction stimulation was measured with a single point laser Doppler vibrometer (LDV) at the promontory, the ossicular chain, and the round window through a posterior tympanotomy. After the initial experiments, the entire whole heads were placed in Thiel solution. In order to enable direct comparison between fresh frozen and Thiel specimens, our Thiel conservation did not include intravascular and intrathecal perfusion. The measurements were repeated 3 and 12 months later. To determine the effect of freezing, defrosting, and embalming on the whole heads, CT scans were performed at different stages of the experimental procedure. Additionally, three extracted temporal bones were stimulated a Baha, motion of the promontory measured by LDV and embalmed in Thiel solution to investigate the direct impact of Thiel solution on the bone.

RESULTS

The averaged magnitude of motion on the promontory increased in whole head specimens by a mean of 10.3 dB after 3 months of Thiel embalming and stayed stable after 12 months. A similar effect was observed for motion at the tympanic membrane (+7.2 dB), the stapes (+9.5 dB), and the round window (+4.0 dB). In contrast to the whole head specimens, the motion of the extracted temporal bones did not change after 3 months of Thiel embalming (-0.04 dB in average). CT scans of the whole heads after conservation showed a notable brain volume loss mostly >50% as well as a remarkable change in the consistency and structure of the brain. Partial changes could already be observed before the Thiel embalming but after 1-2 days of defrosting. In an additional experiment, a substitution of brain mass and weight by Thiel fluid did not lead to new deterioration in sound transmission. In contrast, a frozen (non-defrosted) whole head showed a distinctively reduced magnitude of promontory motion before defrosting.

DISCUSSION

For our setup, the vibration of the ear due to bone conduction in the same whole head specimens significantly increased after Thiel conservation. Such an increase was not observed in extracted temporal bone specimens. Due to brain changes in the CT scans, we investigated the consequences of the brain volume changes and structure loss on the frozen brain before defrosting. The loss of brain volume alone could not explain the increase of ear vibrations, as we did not observe a difference when the volume was replaced with Thiel fluid. However, freezing and defrosting of the entire brain seems to have a major influence. Beside the destructive effect of freezing on the brain, the modified conservation method without perfusion changed the brain structure. In conclusion, bone conduction in whole heads depends on the physical condition of the brain, rather than on the conservation.

Hypertensive Blood Pressure and Its Impact on Functional Outcomes among Older Adults Receiving Comprehensive Geriatric Care

BACKGROUND

Comprehensive geriatric care (CGC) is a multiprofessional treatment for older people which considers medical conditions and functional status. The aim of the presented study is to investigate the impact of hypertensive blood pressure (BP) on functional outcomes among older adults receiving CGC.

METHODS

Functional status was documented by the Barthel index (BI), Tinetti test (TBGT), and timed up and go test (TUG) prior to and after CGC. The results were analyzed in relation to hypertensive BP, indicated by mean BP ≥ 130/80 mmHg determined by 24 h blood pressure monitoring (BPM) while hospitalized.

RESULTS

In the presented monocentric, retrospective, observational study, 490 patients were included (mean age (SD): 83.86 ± 6.17 years, 72.2% females). Hypertension in BPM was found in 302 (61.6%) individuals. Hypertensive BP was associated with the female sex (p < 0.001) and current fracture (p = 0.001), and inversely associated with heart failure (p < 0.001), coronary heart disease (p < 0.001), atrial fibrillation (p < 0.001), urinary tract infection (p = 0.022), and hypocalcemia (p = 0.014). After CGC, improvements in BI (p < 0.001), TBGT (p < 0.001), and TUG (p < 0.001) were observed in patients with both normotensive and hypertensive BP profiles. The proportion of patients with outcome improvements did not differ between the two groups (BI: 84.4% vs. 88.3%, p = 0.285; TBGT: 81.1% vs. 77.7%, p = 0.357; TUG: 50.3% vs. 48.4%, p = 0.711).

CONCLUSION

Patients both with and without hypertensive BP profiles benefited from comprehensive geriatric care with comparable outcome improvements. Particularly, normotensive BP was associated with chronic cardiovascular comorbidities, indicating increased awareness of the importance of BP management in patients diagnosed with cardiac diseases.

Comparison between incus short process and long process coupling of the vibrant soundbridge in human temporal bones

OBJECTIVE

The Vibrant Soundbridge (VSB) is one of the most widely used implantable hearing devices. It consists of a vibrating floating mass transducer (FMT) that is connected to a middle ear structure. The standard coupling devices for sensorineural hearing loss are short process (SP) or long process (LP) couplers.

DESIGN AND STUDY SAMPLE

This study directly compared the electro-mechanical performance of the SP- and LP-coupled FMT of the VSB in the same temporal bone specimen (n = 10). We measured velocity magnitudes and total harmonic distortions (THD) of the stapes (ST) and the round window (RW) using laser Doppler Vibrometry (LDV).

RESULTS

Comparison shows a maximally 10 dB higher magnitude for the LP coupler at ST and RW for frequencies below 600 Hz, whereas the SP coupler shows a maximally 20 dB higher magnitude at the ST and RW for frequencies above 600 Hz. THD show similar behaviour with less distortion at 500 Hz for the LP coupler and less distortions for the SP coupler in higher frequencies.

CONCLUSIONS

Our experiments showed that the SP coupling may be mechanically favourable, in terms of magnitude and distortion, for the transmission of FMT vibrations at higher frequencies.

Community-associated Methicillin-Resistant Staphylococcus aureus (ca-MRSA) as a Pandemic Pathogen: Risk Factors and Implications for Healthcare

Background A diversity of risk factors for ca-MRSA manifestations has been described so far. Up to date toxic contact dermatitis induced by plants has not been identified as one.

Patients and Methods After intense skin contact with poison ivy in the US a 24-year-old Afro-American showed pronounced bullous contact dermatitis on the back of the neck and subsequently massive ca-MRSA furunculitis with proof of Panton-Valentin-leukocidin (PVL). After travelling to Germany, his German girlfriend developed a subacute ca-MRSA, PVL-positive superinfection of a mosquito bite at her lower leg. Both infections required surgical intervention.

Results While the male patient displayed contact dermatitis by poison ivy, the female patient demonstrated two risk factors for ca-MRSA: contact with a ca-MRSA positive person and a predisposing skin lesion. Both cases underpin the role of ca-MRSA transmission and the potential severeness of wound infections in young and immunocompetent persons, just to be resolved by invasive intervention.

Conclusions Marked and recalcitrant skin or soft tissue infections in otherwise healthy young patients require instant microbiological analysis and surgical intervention flanked by adequate antibiotic therapy. Contact dermatitis induced by plant toxins should be taken into consideration as possible risk factor for the acquisition of ca-MRSA.

[Telemedical aftercare of patients with skin diseases]

BACKGROUND

Improved technologies, an increased need for medical healthcare as well as the shortage of specialist personnel lead to a growing importance of telemedical applications. Dermatology is especially suitable for telemedical applications because of the visual appearance of skin diseases. This can contribute to optimizing the care and aftercare of patients with skin diseases.

OBJECTIVE

An analysis of patient satisfaction with teledermatological aftercare at the University Hospital Greifswald using the teledermatological application Mobil Skin® (Infokom, Neubrandenburg, Germany) was carried out. Factors that influence patient satisfaction and the suitability of the teledermatological aftercare for different skin diseases were also analyzed.

MATERIAL AND METHODS

The evaluation of standardized questionnaires, analysis of demographic data of the patient collective and analysis of usage data concerning the teledermatological system Mobil Skin® were carried out.

RESULTS

A total of 91 out of 118 telemedically treated patients participated in the survey. The majority of the patients reported a high degree of satisfaction with the teledermatological aftercare. Patient satisfaction was independent of where the patients lived (minor center or middle center/main center). Patient satisfaction correlated with the frequency of use and the number of answers received through the teledermatological system. The aftercare with the teledermatological system Mobil Skin® was suitable for all diagnosis groups surveyed. Both older and younger patients as well as children benefited from this kind of aftercare.

Comparison of 18F-FDG PET/CT and ultrasound in staging of patients with malignant melanoma

OBJECTIVE

To evaluate the sensitivity and specificity of 2-18fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) and ultrasound (US) for staging patients with malignant melanoma.

METHODS

In total, 258 patients (112 men and 146 women; mean age, 61 ± 16years) met the primary inclusion criteria for malignant melanoma without further malignancy proven by histopathology. This was a retrospective study of the diagnostic accuracy. All data were obtained from the hospital's patient and radiology information system. Patients formed a consecutive series and were examined by 18F-FDG PET/CT and 176 additionally by US (US as a whole [wUS], peripheral lymph nodes [pUS], abdomen [aUS]), with a total of 584 18F-FDG PET/CT and 697 US. 18F-FDG PET/CT and US revealed 824 and 726 lesions, respectively. Per-patient, per-examination, and per-lesion analyses were also performed. The reference standards used were histopathology or resection of lesions, and follow-up controls using other imaging methods.

RESULTS

Significant differences (P < .05) were found in the per-examination for the sensitivity of 18F-FDG PET/CT (0.80) compared to wUS (0.63) and pUS (0.61), and the specificity of 18F-FDG PET/CT (0.96) compared to wUS (0.98) and aUS (0.99). In the PLA, there were significant differences in sensitivity and specificity for 18F-FDG PET/CT (0.83, 0.91) compared to wUS (0.61, 0.98), pUS (0.60, 0.98), and aUS (0.61, 0.99).

CONCLUSION

18F-FDG PET/CT is preferable to US for detecting both lymph node and abdominal metastases.

Phosphorylation of MSI-1 is implicated in the regulation of associative memory in Caenorhabditis elegans

The Musashi family of RNA-binding proteins controls several biological processes including stem cell maintenance, cell division and neural function. Previously, we demonstrated that the C. elegans Musashi ortholog, msi-1, regulates forgetting via translational repression of the Arp2/3 actin-branching complex. However, the mechanisms controlling MSI-1 activity during the regulation of forgetting are currently unknown. Here we investigated the effects of protein phosphorylation on MSI-1 activity. We showed that MSI-1 function is likely controlled by alterations of its activity rather than its expression levels. Furthermore, we found that MSI-1 is phosphorylated and using mass spectrometry we identified MSI-1 phosphorylation at three residues (T18, S19 and S34). CRISPR-based manipulations of MSI-1 phosphorylation sites revealed that phosphorylation is necessary for MSI-1 function in both short- and long-term aversive olfactory associative memory. Thus, our study provides insight into the mechanisms regulating memory-related MSI-1 activity and may facilitate the development of novel therapeutic approaches.

Understanding neural circuits and molecular mechanisms underlying learning and memory are the major challenges of neuroscience. It is a generally accepted model that a learning event causes modification of synapses; strengthening some within a circuit and weakening others (termed “synaptic plasticity”). A plastic nervous system requires not only the ability to acquire and store but also to forget new inputs. While learning and memory is widely investigated, clear-cut evidence for mechanisms involved in forgetting is still sparse. Previously, we demonstrated the role of the protein Musashi (MSI-1) in the active regulation of forgetting in the nematode C. elegans. Here we investigated the role of protein modification (phosphorylation) as a possible regulatory mechanism of the MSI-1 protein activity. We found that MSI-1 protein is modified at different positions and all of these modifications at the protein level contribute to the correct activity of the protein leading to active forgetting of short and long-term memories.

Ultra-high-frequency ECG assessment of QRS fragmentation predicts sudden cardiac death risk in inherited arrhythmia syndromes

Background

Fragmentation of the QRS complex, as a surrogate for scar or functionally disrupted ventricular activation, has been postulated as a risk factor for malignant ventricular arrhythmias across a range of cardiac diagnoses including cardiomyopathies, channelopathies and myocardial infarction. Fragmentation is subtle on the conventionally filtered 12-lead ECG and can easily be missed or over-diagnosed. Isolation of high-frequency (HF) QRS components could overcome this to demonstrate easily identifiable fragmentation but this has previously been limited by technological constraints resulting in a limited range of measured frequencies (150–300Hz). Ultra-high-frequency ECG (UHF-ECG) is a novel technology that utilises amplification and signal-averaging techniques to reliably measure frequencies up to 1000Hz.

Purpose

We explored the use of UHF-ECG in arrhythmia risk stratification.

Methods

We recruited 60 participants to undergo UHF-ECG recordings, including 23 healthy volunteers and 37 patients with inherited arrhythmia syndromes: 25 hypertrophic cardiomyopathy (HCM), 5 Brugada syndrome, 4 arrhythmogenic cardiomyopathy, 3 idiopathic ventricular fibrillation, 2 long QT syndrome and 1 non-ischaemic dilated cardiomyopathy.

The arrhythmia risk status of patients with inherited disease was classified, by two independent researchers, into high or low risk based on their history of cardiac arrest, sustained ventricular arrhythmia, appropriate therapy, syncope and programmed ventricular stimulation result. A third researcher adjudicated disagreement. Two further researchers, blinded to aforementioned risk status, independently assessed the UHF-ECG recordings of all participants.

Results

40 patients were classified as low risk, and 20 as high. Healthy volunteer UHF-ECGs showed uniform ventricular activation with single HF peaks in each lead. High-risk patients' UHF-ECGs showed multiple HF peaks, representing QRS fragmentation. The maximum number of HF peaks in any lead was used to measure severity of fragmentation. Example UHF-ECGs are shown in Figure 1. Fragmentation severity (number of peaks) correlated with arrhythmia risk status (chi-square statistic = 8.95, p-value = 0.03) across all participants (Figure 2) and when comparing high to low risk patients with inherited disease.

UHF-ECG fragmentation could be observed even when the 12-lead ECG did not show any observable fragmentation. Among patients with inherited disease, patients with HCM showed the largest difference in UHF-ECG fragmentation between high and low risk. UHF-ECG fragmentation analysis showed excellent reproducibility with no difference in number of peaks identified between two independent assessors.

Conclusion

We demonstrate proof-of-concept that a novel ultra-high-frequency tool for measuring a broad range of high frequency QRS components can be used for sudden death risk stratification in patients with inherited cardiac conditions.

Funding Acknowledgement

Type of funding sources: None.

A systematic review and meta-analysis of upgrade to biventricular or conduction system pacing approaches

Introduction

Chronic RV pacing has been recognised as being harmful to cardiac function. Patients undergoing a de novo pacemaker implant with even mild LV impairment are recommended to instead receive a physiological pacing strategy (biventricular or conduction system pacing [CSP]). No corresponding guideline recommendation exists for patients who already have a pacemaker.

Methods

We undertook a random-effects meta-analysis of all RCTs and observational studies covering device upgrade to biventricular pacing or conduction system pacing.

Results

6 RCTs assessing effect of upgrade to BiV pacing randomising 161 patients were eligible for analysis. Eligible observational studies included 46 of BiV upgrade and 7 of CSP upgrade totalling 2795 patients.

Mean LVEF improved by +8.3% from 34.4% in BiV upgrade RCTs (p=0.001) and +8.3% from 25.7% in BiV upgrade observational studies (p&lt;0.001).

In observational studies of upgrade to CSP, LVEF increased by +10.1% from 38.4% (p=0.001) despite less severe LV impairment at baseline (p=0.004 vs mean EF in BiV RCTs and p&lt;0.0001 vs mean EF in BiV observational studies).

LVESV decreased significantly by −25.4 ml, −23.7 ml, and −19.8 ml in BiV RCTs, BiV observational studies and CSP observational studies. Significant changes were also seen in NYHA class (decreased by −0.4, −0.8 and −1.0 respectively).

Minnesota Heart Failure Score (−6.9 points) and peak oxygen uptake (+1.1 ml/kg/min) increased significantly in RCTs of BiV upgrade. This was also seen in observational studies of BiV upgrade (−21.0 points and +2.63 ml/kg/min respectively).

Conclusions

RCTs and observational studies of upgrade to BiV pacing show significant physiological and symptomatic benefit. Observational studies of CSP upgrade show similar benefit with significant improvements in LVEF, LVESV and NYHA class in patients with an even milder degree of baseline LV impairment.

Funding Acknowledgement

Type of funding sources: None.

Childhood maltreatment is not associated with atopic dermatitis in adults: results from a cross-sectional population-based cohort study

BACKGROUND

Childhood maltreatment (CM) is related to poor physical and mental health outcomes in adults. Knowledge on the impact of CM on skin diseases is limited, and no study has previously addressed the association of CM with atopic dermatitis (AD) in adult age.

OBJECTIVES

To analyze the prevalence of CM in individuals with physician-diagnosed AD, and to examine the relationship between different types of CM with physician-diagnosed AD in a general population sample of German adults.

METHODS

Data from 2973 participants from the cross-sectional population-based Study of Health in Pomerania (SHIP) TREND-0 were analyzed (aged 20 to 83 years; 51.4% female). We administered the Childhood Trauma Questionnaire (CTQ) assessing emotional, physical and sexual abuse, and emotional and physical neglect. AD was diagnosed by dermatologists in a standardized clinical examination. We conducted logistic regression analyses adjusted for age, sex and school education to investigate the association of CM types with AD.

RESULTS

Among all individuals with AD, 20.6% reported to have experienced at least one type of moderate or severe CM. Emotional and physical neglect were the most frequently reported CM types. Overall, the prevalence of CM types among individuals with AD did not differ from those among individuals without AD. We found no association of CM type with AD.

CONCLUSIONS

This is the first study investigating the association of CM with AD in adults. CM was common in the present general population sample, emphasizing that CM is an important public health problem. Our findings suggest that CM is not a risk factor for AD. It might be hypothesized that AD severity is a crucial outcome, and that CM history is a factor with impact on disease severity and course rather than a risk factor for the development of AD. Longitudinal studies are required to address this question.

Improvement of occupational leg edema and discomforts (RCT)

BACKGROUND: Edema and subjective leg complaints (e.g. pain, heaviness) after long standing or sitting, are defined as orthostatic leg complaints or occupational edema. Compression hosiery should help to prevent or decrease those symptoms. OBJECTIVE: Assess the effects on leg discomforts and leg volume and wearing comfort in two medical below-knee compression stocking types (A vs. B) with an interface pressure of 18 –20 mmHg and a below-knee-low-pressure support stocking (LPSS) with an interface pressure of 8–10mmHg (C). METHODS: Two different types of below-knee medical compression stockings and a LPSS were examined in this randomized, blinded, crossover trial in volunteers having leg discomforts and edema after being in an upright position during the day. Participants were divided into two cohorts, and each type of stocking was worn for three consecutive days in one week with a subsequent washout phase. The assessment of effects and wearing comfort was ascertained by questionnaires. Volume changes in the lower leg were measured with the Bodytronic 600® (Bauerfeind AG, Zeulenroda, Germany). RESULTS: A significant reduction of lower leg volume (mean stocking A: 204.7 ml; mean stocking B: 153.5 ml; mean stocking C: 48.2 ml) and a significant reduction of the life-quality dimension leg-complaints (p <  0.0001) was achieved by all three types of stockings. Compared to the LPSS both compression stockings decreased the lower leg volume significantly more (p <  0.001) and had a significant better fit (p <  0.001). CONCLUSION: Below-knee medical compression stockings with an interface pressure 18–21mmHg and LPSS with an interface pressure of 8–10 mmHg reduce significantly occupational orthostatic edema and leg discomforts which are due to long standing and sitting activities.

Preparing railway stakeholders against CBRNe threats through better cooperation with security practitioners

This paper presents partial results from the Horizon2020 PROACTIVE project, following a set of literature reviews and surveys conducted with first responder organisations and rail security experts. Qualitative and quantitative data from two surveys are being presented. The results provide an overview of the CBRNe (Chemical, Biological, Radiological, Nuclear and explosive) preparedness and response capabilities of railway stakeholders and how these relate to a wider context represented by CBRNe first responders. The results highlight a set of challenges as well as five core skills that railway staff need to develop or improve: 1) understand the specific characteristics of the CBRNe threat, 2) develop basic response measures, 3) cooperate with authorities and train with specialised first responders, 4) improve public awareness about this threat, and 5) optimise crisis communication. In line with these, project PROACTIVE will further help update rail crisis management plans with practical recommendations concerning the CBRNe threat.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Contact Force Guided Radiofrequency Current Application at Developing Myocardium: Summary and Conclusions

BACKGROUND

Catheter contact is one key determinant for lesion size in radiofrequency catheter ablation (RFA). Monitoring of contact force (CF) during RFA has been shown to improve efficacy of RFA in experimental settings as well as in adult patients. Coronary artery narrowing after RFA has been described in experimental settings as well as in children and adults and may be dependent from catheter contact. Value of CF monitoring concerning these issues has not been systematically yet.

OBJECTIVE

Value of high versus low CF during RFA in piglets was studied to assess lesion size and potential coronary artery involvement mimicking RFA in small children.

ANIMALS AND METHODS

RFA with continuous CF monitoring was performed in 24 piglets (median weight 18.5 kg) using a 7F TactiCath Quartz RF ablation catheter (Abbott, Illinois, USA). A total of 7 lesions were induced in each animal applying low (10-20 g) or high (40-60 g) CF. RF energy was delivered with a target temperature of 65 °C at 30 W for 30 seconds. Coronary angiography was performed prior and immediately after RF application. Animals were assigned to repeat coronary angiography followed by heart removal after 48 h (n=12) or 6 months (n=12). Lesions with surrounding myocardium were excised, fixated and stained. Lesion volumes were measured by microscopic planimetry.

RESULTS

A total of 148 RF lesions were identified in the explanted hearts. Only in the subset of lesions at the AV annulus 6 month after ablation, lesion size and number of lesions exhibiting transmural extension were higher in the high CF group compared to low CF. In all other locations CF had no impact on lesion size and mural extension after 48 h as well as after 6 months. Additional parameters as Lesion Size Index and Force Time Integral were also not related to lesion size. Coronary artery damage was present in 2 animals after 48 h and in 1 after 6 months and was not related to CF. This article is protected by copyright. All rights reserved.

Improvement of dynamic venous function after thermal ablation with steam vein occlusion - 6-weeks and 1-year follow-up after 167 treatments

BACKGROUND

In this paper, the method of steam vein occlusion for the treatment of the great/small saphenous vein (GSV/SSV) was analyzed in terms of a therapeutic influence on the dynamic parameters of global vein function, its effects on subjective symptoms based on chronic venous insufficiency (CVI) and the side effects of the steam vein sclerosis (SVS). It has been questioned whether the effects of this method lead to a recommendation for routine clinical practice.

METHODS

The venous drainage and the venous refilling time (T0) of the leg treated were determined by photoplethysmography (Elcat, Wolfratshausen, Germany) before, six weeks and one year after the intervention to examine the effects on global venous function. Further changes of clinical symptoms and findings were assessed by the Venous Clinical Severity Score (VCSS), preoperatively and after one year, and the complication rate at 6-week follow-up was monitored.

RESULTS

The SVS was performed on 167 veins (GSV: 124; SSV: 43) in a total of 156 patients. Eight patients (5.1%) did not attend the 6-week follow-up, while 29 patients (18.6%) were lost in the 1-year follow-up. Patients were suffering from symptoms such as leg pain and leg edema, which resulted in a VCSS of 9.4 (cumulated mean score of all patients) preoperatively. The T0 was reduced to mean values of 20.6 s (GSV cohort) and 21 s (SSV cohort). The VCSS improved to 6.0 after one year. This correlated with the hemodynamic parameters. The T0 increased in the GSV cohort after six weeks to 31.8 s, p <  0.001, and showed a nonsignificant improvement to 32.2 s, p = 0.509, in the 1-year check. The T0 also increased in the SSV cohort significantly after 6 weeks to 30.1 s, p <  0.001, and showed a nonsignificant reduction after one year, p = 0.289. A total of 71%of the GSV and 69.8%of the SSV of the patients involved no complications following the treatment. Light complications (grade 1) occurred (reddening, hematoma, hyperpigmentation) in the majority: 24.2%of the GSV and 18.6%of the SSV. We noticed one grade 3 complication with thrombosis in the SSV cohort, which led to a pulmonary embolism. Forty-seven complete questionnaires were analyzed (responder rate: 28.1%); 40.4%of the patients had light complaints after the treatment, such as pain, warmth or local pressure sensations (Fig. 7); 63%of those patients noticed only slight pain at a maximum of 3 out of 10. The majority (91%) would recommend this procedure.

CONCLUSION

The SVS revealed endoluminal catheter-based intervention to abolish venous reflux of the G/SSV as safe. As one therapeutic target is to eliminate venous reflux, effectiveness of a method cannot be based on sonographic data alone; one must further assess patients' symptoms and dynamic venous function. This data shows an improvement of patients' symptoms which correlated well with the improvement of the venous function in digital photoplethysmography. The SVS can be recommended as a catheter-based treatment in the future.

Rare variant analysis in eczema identifies exonic variants in DUSP1, NOTCH4 and SLC9A4

Previous genome-wide association studies revealed multiple common variants involved in eczema but the role of rare variants remains to be elucidated. Here, we investigate the role of rare variants in eczema susceptibility. We meta-analyze 21 study populations including 20,016 eczema cases and 380,433 controls. Rare variants are imputed with high accuracy using large population-based reference panels. We identify rare exonic variants in DUSP1, NOTCH4, and SLC9A4 to be associated with eczema. In DUSP1 and NOTCH4 missense variants are predicted to impact conserved functional domains. In addition, five novel common variants at SATB1-AS1/KCNH8, TRIB1/LINC00861, ZBTB1, TBX21/OSBPL7, and CSF2RB are discovered. While genes prioritized based on rare variants are significantly up-regulated in the skin, common variants point to immune cell function. Over 20% of the single nucleotide variant-based heritability is attributable to rare and low-frequency variants. The identified rare/low-frequency variants located in functional protein domains point to promising targets for novel therapeutic approaches to eczema.

Genetic studies of eczema to date have mostly explored common genetic variation. Here, the authors perform a large meta-analysis for common and rare variants and discover 8 loci associated with eczema. Over 20% of the heritability of the condition is attributable to rare variants.

Nosocomial or not? A combined epidemiological and genomic investigation to understand hospital-acquired COVID-19 infection on an elderly care ward

Background

COVID-19 has the potential to cause outbreaks in hospitals. Given the comorbid and elderly cohort of patients hospitalized, hospital-acquired COVID-19 infection is often fatal. Pathogen genome sequencing is becoming increasingly important in infection prevention and control (IPC).

Aim

To inform the understanding of in-hospital SARS-CoV-2 transmission in order to improve IPC practices and to inform the future development of virological testing for IPC.

Methods

Patients detected COVID-19 positive by polymerase chain reaction on Ward A in April and May 2020 were included with contact tracing to identify other potential cases. Genome sequencing was undertaken for a subgroup of cases. Epidemiological, genomic, and cluster analyses were performed to describe the epidemiology and to identify factors contributing to the outbreak.

Findings

Fourteen cases were identified on Ward A. Contact tracing identified 16 further patient cases; in addition, eight healthcare workers (HCWs) were identified as being COVID-19 positive through a round of asymptomatic testing. Genome sequencing of 16 of these cases identified viral genomes differing by two single nucleotide polymorphisms or fewer, with further cluster analysis identifying two groups of infection (a five-person group and a six-person group).

Conclusion

Despite the temporal relationship of cases, genome sequencing identified that not all cases shared transmission events. However, 11 samples were found to be closely related and these likely represented in-hospital transmission. This included three HCWs, thereby confirming transmission between patients and HCWs.

Micro-CT imaging of Thiel-embalmed and iodine-stained human temporal bone for 3D modeling

Introduction

This pilot study explores whether a human Thiel-embalmed temporal bone is suitable for generating an accurate and complete data set with micro-computed tomography (micro-CT) and whether solid iodine-staining improves visualization and facilitates segmentation of middle ear structures.

Methods

A temporal bone was used to verify the accuracy of the imaging by first digitally measuring the stapes on the tomography images and then physically under the microscope after removal from the temporal bone. All measurements were compared with literature values.

The contralateral temporal bone was used to evaluate segmentation and three-dimensional (3D) modeling after iodine staining and micro-CT scanning.

Results

The digital and physical stapes measurements differed by 0.01–0.17 mm or 1–19%, respectively, but correlated well with the literature values. Soft tissue structures were visible in the unstained scan. However, iodine staining increased the contrast-to-noise ratio by a factor of 3.7 on average. The 3D model depicts all ossicles and soft tissue structures in detail, including the chorda tympani, which was not visible in the unstained scan.

Conclusions

Micro-CT imaging of a Thiel-embalmed temporal bone accurately represented the entire anatomy. Iodine staining considerably increased the contrast of soft tissues, simplified segmentation and enabled detailed 3D modeling of the middle ear.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40463-021-00522-0.

Laser doppler derived peripheral perfusion can distinguish haemodynamically tolerated VT from haemodynamically compromised VT

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): NIHR Imperial Biomedical Research Centre

Introduction

Implantable Cardioverter-Defibrillators (ICDs) cannot distinguish between ventricular tachycardia (VT) with haemodynamic compromise from haemodynamically tolerated VT to ensure that therapies are delivered only when necessary. Currently, unnecessary therapies are reduced by longer duration thresholds and higher rate thresholds. This can result in ICDs withholding or delaying therapies during haemodynamically compromising VT while potentially still providing therapies during rapid or prolonged VT that is haemodynamically well tolerated.

Laser doppler perfusion monitoring (LDPM) allows assessment of peripheral blood flow as a surrogate for haemodynamic status. We have previously demonstrated that laser doppler perfusion signals, analysed using an electro-mechanical coupling algorithm (SafeShock), can reliably identify loss of perfusion during ventricular fibrillation (VF), as well as discriminate VF from simulated lead fractures and T wave over-sensing. The utility of LDPM signals in VT, however, has not been established.

Purpose

In this study we assessed the utility of LDPM using the SafeShock algorithm to discriminate haemodynamically tolerated VT from VT with haemodynamic compromise.

Methods

Recruited participants underwent a rapid ventricular pacing protocol to simulate VT at different rates. Pacing was performed using the right ventricular lead of an implanted pacing device or a temporary pacing wire in the right ventricular apex. 3-lead ECG, blood pressure (either invasively using a radial artery catheter or non-invasively using beat-by-beat finometry) and LDPM signal were continuously recorded during the protocol. LDPM signals during simulated VT were analysed using the SafeShock electro-mechanical algorithm and compared to blood pressure change from baseline intrinsic rhythm to simulated VT.

Results

We obtained 588 recordings of simulated VT in 56 patients at rates of 100 bpm, 120 bpm, 140 bpm, 160 bpm, 180 bpm and 200 bpm. Percentage change in systolic blood pressure from baseline to VT correlated with LDPM-derived perfusion value during VT (Spearman’s Rho = 0.7786, p &lt; 0.0001).

Using a cut-off of 5 units, perfusion value predicted a 20% drop in systolic blood pressure in VT with an accuracy of 89.4% (sensitivity 94.8%, specificity 83.6%, p value &lt;0.0001).

Conclusions

Peripheral perfusion measurements, analysed using an electro-mechanical algorithm, can accurately discriminate haemodynamically tolerated VT from VT with haemodynamic compromise. ICDs with integrated LDPM sensors and algorithms could make therapy decisions based on the circulatory status of patients with arrhythmias not just rate and duration parameters. This could reduce unnecessary therapies while facilitating prompt treatment of compromising arrhythmias. Abstract Figure 1

Non-selective and selective His bundle pacing both preserve left ventricular activation time and pattern

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): British Heart Foundation

Background: His bundle pacing can be achieved in two ways

selective His bundle pacing, where the His bundle is captured alone, and non-selective His bundle pacing, where local myocardium is also captured resulting a pre-excited ECG appearance. We assessed the impact of this ventricular pre-excitation on left and right ventricular dys-synchrony.

Methods

We recruited patients who displayed both selective and non-selective His bundle pacing. We performed non-invasive epicardial electrical mapping to determine left and right ventricular activation times and patterns.

Results

In the primary analysis (n = 20, all patients), non-selective His bundle pacing did not prolong LVAT compared to select His bundle pacing by a pre-specified non-inferiority margin of 10ms (LVAT prolongation: -5.5ms, 95% confidence interval (CI): -0.6 to -10.4, non-inferiority p &lt; 0.0001). Non-selective His bundle pacing did not prolong right ventricular activation time (4.3ms, 95%CI: -4.0 to 12.8, p = 0.296) but did prolong QRS duration (22.1ms, 95%CI: 11.8 to 32.4, p = 0.0003).

In patients with narrow intrinsic QRS (n = 6), non-selective His bundle pacing preserved left ventricular activation time (-2.9ms, 95%CI: -9.7 to 4.0, p = 0.331) but prolonged QRS duration (31.4ms, 95%CI: 22.0 to 40.7, p = 0.0003) and mean right ventricular activation time (16.8ms, 95%CI: -5.3 to 38.9, p = 0.108) compared to selective His bundle pacing.

Activation pattern of the left ventricular surface was unchanged between selective and non-selective His bundle pacing. Non-selective His bundle pacing produced early basal right ventricular activation, which was not observed with selective His bundle pacing.

Conclusions

Compared to selective His bundle pacing, local myocardial capture during non-selective His bundle pacing produces right ventricular pre-excitation resulting in prolongation of QRS duration. However, non-selective His bundle pacing preserves the left ventricular activation time and pattern of selective His bundle pacing. When choosing between selective and non-selective His bundle pacing, left ventricular dyssynchrony is not an important factor. Abstract Figure: Selective vs Non-Selective HBP

Effect of conservation method on ear mechanics for the same specimen

BACKGROUND AND AIMS

As an alternative to fresh temporal bones, Thiel conserved specimens can be used in the study of ear mechanics. Conserved temporal bones do not decay, permit long-term experiments and overcome problems with limited access to fresh (frozen) temporal bones. Air conduction motion of the tympanic membrane (TM), stapes (ST) and round window (RW) in Thiel specimens is similar to that of fresh specimens according to reports in the literature. Our study compares this motion directly before and after conservation for the same specimens.

METHODS

The magnitude of motion of TM, ST and RW elicited by acoustic stimulation via the external auditory canal was measured using single point laser Doppler vibrometry (LDV) accessed through a posterior tympanotomy. For the initial measurements (10 ears), fresh frozen whole heads were thawed for at least 24 h. Afterwards, the entire whole heads were embalmed according to the Thiel embalming method and measurements were repeated 3 and 12 months later.

RESULTS

The magnitudes of TM, ST and RW motion before and after Thiel conservation differed maximally 10 dB on average. A significant increase in TM motion was observed at low frequencies only after long term conservation (12 months). ST motions decreased significantly between 161 and 5300 Hz after 3 months of Thiel conservation. Over the same time period RW motions decreased significantly between 100 and 161 Hz and 489-788 Hz. The ST and RW motions across all measured frequencies were lower after 3 months by 5.7 dB and 7.1 dB, respectively, without further changes after 12 months of conservation. The mean phase shift between ST and RW motion was only 2.1° for frequencies below 450 Hz.

DISCUSSION AND CONCLUSION

Thiel embalming changes motion of TM after long term conservation. ST and RW motion changed mainly after short term conservation. The phase shifts close to 180° between ST and RW motion indicates that the cochlea was still filled with liquid without air bubbles. The results show that Thiel conserved specimens can be used as an alternative model to fresh frozen preparations with some limitations when studying mechanics of the normal human ear, for example, in implant design.

The course of Kaposi's sarcoma, a marker disease for the initial diagnosis of AIDS, under ongoing cART

While Kaposi's sarcoma (KS) was common in the 1980s and early 1990s in HIV-positive patients and one of the most common AIDS-defining diseases, its prevalence today has decreased significantly due to the early and widespread use of chimeric antigen receptor T-cell (cART) therapy. The rapid initiation of cART or, if occurring during ongoing cART, an optimization of antiretroviral therapy leads to a healing of this tumour disease in most patients. The aim of the therapy is immune reconstitution, as the immunodeficiency resulting from the HIV disease (reduced CD4+-T helper cells) promotes the development and spread of KS. This case report describes the course of KS in the first diagnosis of AIDS in a 36-year-old patient. The HIV copy count was below the detection limit and the CD3+/CD4+ T-helper cell count was only slightly below the normal value in the six-month follow-up after initial diagnosis and initiation of cART therapy. However, the clinical findings in the one-year follow-up showed only a partial response, whereby it was noted that new tumour lesions also developed focally in addition to individual progressive lesions. This was demonstrated clinically, dermatoscopically and by laser Doppler fluxmetry measurements of the lesions. Such a progression was observed in about one-third of the patients affected in various studies and is called Immune Reconstitution Inflammatory Syndrome. Other therapies in addition to cART are necessary here to suppress this immunological phenomenon (including cytostatic drugs). Promising studies are currently underway, including utilising checkpoint inhibitors. These are of great therapeutic interest due to the high immunological activity of KS itself and usually of systemic inflammatory response syndrome.

Dual Role of an mps-2/KCNE-Dependent Pathway in Long-Term Memory and Age-Dependent Memory Decline

Activity-dependent persistent changes in neuronal intrinsic excitability and synaptic strength are underlying learning and memory. Voltage-gated potassium (K_v) channels are potential regulators of memory and may be linked to age-dependent neuronal disfunction. MinK-related peptides (MiRPs) are conserved transmembrane proteins modulating K_v channels; however, their possible role in the regulation of memory and age-dependent memory decline are unknown. Here, we show that, in C. elegans, mps-2 is the sole member of the MiRP family that controls exclusively long-term associative memory (LTAM) in AVA neuron. In addition, we demonstrate that mps-2 also plays a critical role in age-dependent memory decline. In young adult worms, mps-2 is transcriptionally upregulated by CRH-1/cyclic AMP (cAMP)-response-binding protein (CREB) during LTAM, although the mps-2 baseline expression is CREB independent and instead, during aging, relies on nhr-66, which acts as an age-dependent repressor. Deletion of nhr-66 or its binding element in the mps-2 promoter prevents age-dependent transcriptional repression of mps-2 and memory decline. Finally, MPS-2 acts through the modulation of the K_v2.1/KVS-3 and K_v2.2/KVS-4 heteromeric potassium channels. Altogether, we describe a conserved MPS-2/KVS-3/KVS-4 pathway essential for LTAM and also for a programmed control of physiological age-dependent memory decline.

Psychosocial stress of dermatology inpatients and their relatives - Comparison of patients with and without cancer

BACKGROUND

In the clinical treatment pathways of certified oncological centers, psychotherapeutic services are mandatory. Although patients with somatic, non-oncological illnesses show an equally high prevalence of psychosocial stress, these guidelines do not exist for the general hospital sector. Are these patients really less burdened and is psychological support only needed in individual cases? The example of dermatological patients will be used to show whether the need for psychosocial care and the desire for support vary between individuals with and without malignant disease.

PATIENTS AND METHODS

Using the Hornheider screening instrument and distress thermometer, 216 dermatological inpatients assessed their psychosocial stress and that of a close relative. In addition, they were asked about their desire for support and preferred support provider.

RESULTS

i) Patients without skin cancer were more frequently and more severely distressed than cancer patients. ii) Patients of both groups assessed their relatives to be approximately equally distressed. Compared with their own distress, cancer patients assessed their relatives as more frequently and on average more severely distressed. More than 50 % of all patients regarded their own disease as the cause of their relatives' distress. iii) The desire for support in both groups was about 18 %. iv) Doctors and psychologists were usually named as potential contact persons.

CONCLUSIONS

The expansion of psychosocial support services for non-tumor patients and their relatives seems necessary. The establishment of appropriate screening methods should be considered. Further studies in other clinical areas are required.

Evolutionary conserved role of neural cell adhesion molecule-1 in memory

The neural cell adhesion molecule 1 (NCAM-1) has been implicated in several brain-related biological processes, including neuronal migration, axonal branching, fasciculation, and synaptogenesis, with a pivotal role in synaptic plasticity. Here, we investigated the evolutionary conserved role of NCAM-1 in learning and memory. First, we investigated sustained changes in ncam-1 expression following aversive olfactory conditioning in C. elegans using molecular genetic methods. Furthermore, we examined the link between epigenetic signatures of the NCAM1 gene and memory in two human samples of healthy individuals (N = 568 and N = 319) and in two samples of traumatized individuals (N = 350 and N = 463). We found that olfactory conditioning in C. elegans induced ncam-1 expression and that loss of ncam-1 function selectively impaired associative long-term memory, without causing acquisition, sensory, or short-term memory deficits. Reintroduction of the C. elegans or human NCAM1 fully rescued memory impairment, suggesting a conserved role of NCAM1 for memory. In parallel, DNA methylation of the NCAM1 promoter in two independent healthy Swiss cohorts was associated with memory performance. In two independent Sub-Saharan populations of conflict zone survivors who had faced severe trauma, DNA methylation at an alternative promoter of the NCAM1 gene was associated with traumatic memories. Our results support a role of NCAM1 in associative memory in nematodes and humans, and might, ultimately, be helpful in elucidating diagnostic markers or suggest novel therapy targets for memory-related disorders, like PTSD.

A method to assess heart rate variability in neonate rats: validation in normotensive and hypertensive animals

Several studies have focused on the heart rate variability (HRV) of murine species, while studies discussing HRV in murine neonates and infants remain scarce, since recording hemodynamic signals through invasive methods in small animals has been found to be quite challenging. Thus, this study aimed at describing and validating a novel method to assess HRV in newborn rats. An electrocardiogram (ECG) system was used to determine RR intervals in awake newborns and evaluate HRV in normotensive (Wistar) and hypertensive (SHR) neonate rats. After birth, ECG was recorded in the awake newborns, and they were allowed to rest on a heated surface, restricted only by the weight of the adhesive ECG electrodes. The electrodes were cut and adapted to provide more comfort to the animal, and gently placed on the newborn's skin. RR intervals were recorded over a 30-min period using an ECG system together with LabChart software (4 KHz). Three sequences of 5 min each from the ECG recording period were analyzed in time and frequency domains, using CardioSeries software. ECG data resulted in a clearly interpretable signal that was used to generate an RR interval sequence through time for the analysis of HRV. SHR neonates presented increased cardiac sympathovagal balance compared to Wistar neonates (low frequency/high frequency: 3.85±0.71 vs 0.90±0.09). In conclusion, the ECG setup here described may be used to record RR intervals to assess HRV in neonate rats, thus detecting early impairment of HRV in hypertensive newborns.

P1449Anti-thrombotic management for electrophysiological procedures: results of the European Heart Rhythm Association (EHRA) young investigators survey

Funding Acknowledgements

none

Background

Electrophysiological studies (EPS), with or without ablation, require percutaneous introduction of catheters into the heart to record local electrical activity. Instrumentation of catheters within the blood causes activation of the clotting cascade, increasing the risk of thrombus formation. To date, the electrophysiological community lacks international guidelines on the use of anti-thrombotic therapies before, during and after EPS.

Purpose

To survey the current practice regarding the use of anti-thrombotic therapies across member countries of the European Heart Rhythm Association (EHRA).

Methods

The survey was conducted in February 2019. Electrophysiologists from EHRA member countries were contacted to complete the survey by e-mail, utilizing the EHRA Young EP network. They were asked to answer a questionnaire containing information on anti-thrombotic and anticoagulation management before, during and after left-sided EPS and ablation: atrial tachycardia (AT), accessory pathway (AP) and ventricular tachycardia (VT).

Results

We obtained 41 answers responses from 40 centers in 15 European EHRA member countries. Regarding of antiaggregation, the most used antiplatelet is aspirin (100% before, during and after ablation). The most used anticoagulant was novel oral anticoagulants (NOAC) before ablation (47.1%), during hospitalization (85.2%) and at discharge (70.3%). The administration of anti-thrombotic therapy depended on the procedure time only in 10 cases (24.4%).

For AP, before ablation, only 4 centers (9.7%) administered anti-platelets and 2 (4.9%) anticoagulants. During ablation, heparin was used by 85.4% of respondents maintaining ACT target 300-350 s in 36.6% of cases. At discharge, antiaggregation therapy was prescribed by 22 colleagues (53.7%) and anticoagulation only by one (2.4%).

In patients with AT, before ablation, antiaggregation prophylaxis was prescribed by only 4 centers (19.5%) and anticoagulation by 11 (26.8%). During procedure, almost all centers (40, 97.6%) used heparin with ACT target 300-350 s in 58.5% of cases. At discharge, antiplatelet therapy was recommended by 12 colleagues (29.3%) and anticoagulation by 24 (58.5%).

Regarding VT, before procedure, 8 centers (19.5%) prescribed antiaggregation and 5 (12.2%) anticoagulation prophylaxis. During ablation, all centers used heparin, maintaining ACT target 300-350 s in 58% of cases. The use of antiaggregation or anticoagulation depended on the left ventricle (LV) access in 15 centers (37.5%) and on LV ejection fraction in 11 (26.8%). At discharge, anti-thrombotic therapy was recommended by 16 colleagues (39%) and anticoagulation by 13 (31.7%).

Conclusion

Our survey showed that there is considerable variation in the management of anti-thrombotic therapy surrounding left-sided EPS and ablation. Further studies are necessary to evaluate the right approach to these procedures.

A rare case of a patient with PPP syndrome presenting pancreatic pseudocysts, panniculitis, and symptoms of polyarthritis. A radicular cyst of the upper jaw could be another manifestation of the syndrome

In rare cases, pancreatic enzymes can enter the bloodstream and cause fat necrosis in the bone and tissue leading to a disorder called pancreatitis, panniculitis, and polyarthritis syndrome. Clinicians should have this syndrome in mind when treating patients with pancreatitis.

Multimodal Imaging With Positron Emission Tomography/Computed Tomography and Magnetic Resonance Imaging to Detect Extracapsular Extension in Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

To assess the ability of specific positron emission tomography/computed tomography (PET/CT) and magnetic resonance imaging (MRI) features to detect extracapsular extension (ECE) in head and neck squamous cell carcinoma (HNSCC) patients.

STUDY DESIGN

Retrospective study in a tertiary certified university cancer institute.

METHODS

We performed a review of patients with advanced HNSCC at Bern University Hospital between 2014 and 2018. Patients with pretherapeutic PET/CT and/or MRI who underwent neck dissection were included, with 212 patients fulfilling inclusion criteria. Blinded evaluation of specific PET/CT and MRI features with respect to presence of ECE was performed. Histopathological examination of neck dissection specimens was used as the gold standard to determine ECE status.

RESULTS

Out of the 212 included patients, 184 had PET/CT, 186 MRI, and 158 both modalities. Overall clinical stage IV (odds ratio [OR]: 2.26, 95% confidence interval [CI]: 2.25-11.74), ill-defined margins in both PET/CT and MRI (OR: 3.48, 95% CI: 1.21-9.98 and OR: 2.14, 95% CI: 0.94-4.89, respectively), and a maximum standardized uptake value ≥ 10 (OR: 5.44, 95% CI: 1.21-9.98) were all significant independent predictors of ECE. When combined, these four features led to a cumulative score able to predict ECE status with an accuracy of 91.43%.

CONCLUSIONS

The current findings indicate specific features in PET/CT and MRI are potential predictors of ECE status and may help in pretherapeutic stratification in HNSCC.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E163-E169, 2021.