Are HIV Prevention Services Reaching all LGBTQ+ Youth? An Intersectional Analysis in a National Sample

Although research has examined disparities in HIV prevention behaviors, intersectional research is needed to understand who may be underserved. This study examines disparities in consistent condom use, HIV testing, and PrEP awareness and use across assigned sex, gender identity, sexual orientation, and racial/ethnic identity in a large sample of sexually active LGBTQ+ youth (mean age = 16.5) who completed the 2022 LGBTQ National Teen Survey. Four social identities were included as indicators in Chi-Square Automated Interaction Detection models to uncover disparate rates of HIV preventive behaviors. Generally, HIV testing and PrEP services were higher among gay/lesbian and queer youth assigned male, and lower among those assigned female. Certain LGBTQ+ youth may be systematically missed by these services, (e.g., those assigned female; those assigned male who also identify as bisexual, pansexual, asexual, questioning, or straight (and trans/gender diverse)). Providers should strive to serve populations who are not being reached by HIV prevention services.

[Precision medicine enhances personalized medicine in cardiology]

Personalized medicine and precision medicine, frequently used synonymously, shall be clearly differentiated. Accordingly, personalization in cardiac medicine is based on the clinical presentation of a patient, as well as his/her cardiovascular risk factors and comorbidities, electrocardiography, imaging, and biomarkers for myocardial load and ischemia. Personalization is based on large clinical trials with detailed subgroup analyses and is practiced on the basis of guidelines. Further in depth personalization is achieved by precision medicine, which is based on innovative imaging for myocardial structure, coronary morphology, and electrophysiology. From the clinical perspective, genome analyses are relevant for comparatively rare monogenetic cardiovascular diseases. While these as well as transcriptome and metabolome analyses play a significant role in cardiovascular research with great translation potential, they have not yet been broadly introduced in the diagnosis, prevention, and treatment of complex cardiovascular diseases. Furthermore, digital technologies have considerable potential in cardiovascular precision medicine. On the one hand, this is based on the frequency of the diseases with the availability of Big Data and, on the other hand, on the availability of bio-signals and sensors of those signals in cardiovascular diseases.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Clinical characteristics and patient-reported outcomes of chronic and episodic migraine patients at a US tertiary headache center: A retrospective observational study

OBJECTIVE

To describe differences in clinical and demographic characteristics between patients with episodic migraine (EM) or chronic migraine (CM) and determine the effect of migraine subtype on patient-reported outcome measures (PROM).

BACKGROUND

Prior studies have characterized migraine in the general population. While this provides a basis for our understanding of migraine, we have less insight into the characteristics, comorbidities, and outcomes of migraine patients who present to subspecialty headache clinics. These patients represent a subset of the population that bears the greatest burden of migraine disability and are more representative of migraine patients who seek medical care. Valuable insights can be gained from a better understanding of CM and EM in this population.

METHODS

We conducted a retrospective observational cohort study of patients with CM or EM seen in the Cleveland Clinic Headache Center between January 2012 and June 2017. Demographics, clinical characteristics, and patient-reported outcome measures (3-Level European Quality of Life 5-Dimension [EQ-5D-3L], Headache Impact Test-6 [HIT-6], Patient Health Questionnaire-9 [PHQ-9]) were compared between groups.

RESULTS

Eleven thousand thirty-seven patients who had 29,032 visits were included. More CM patients reported being on disability 517/3652 (14.2%) than EM patients 249/4881 (5.1%) and had significantly worse mean HIT-6 (67.3 ± 7.4 vs. 63.1 ± 7.4, p < 0.001) and median [interquartile range] EQ-5D-3L (0.77 [0.44-0.82] vs. 0.83 [0.77-1.00], p < 0.001), and PHQ-9 (10 [6-16] vs. 5 [2-10], p < 0.001).

CONCLUSIONS

There are multiple differences in demographic characteristics and comorbid conditions between patients with CM and EM. After adjustment for these factors, CM patients had higher PHQ-9 scores, lower quality of life scores, greater disability, and greater work restrictions/unemployment.

Unmasking systolic impairment in HFpEF by cardiovascular magnetic resonance derived hemodynamic force assessment: insights from the HFpEF stress trial

Background

The diagnosis of heart failure with preserved ejection fraction (HFpEF) remains challenging. Exercise-stress testing is recommended in case of uncertainty; however, this approach is time-consuming and costly. Since preserved EF does not represent normal systolic function, we evaluated cardiovascular magnetic resonance (CMR) comprehensive cardiac hemodynamic forces (HDF) analyses for an in-depth characterisation of cardiac function at rest.

Methods

The HFpEF Stress Trial (DZHK-17) prospectively recruited 75 patients with exertional dyspnea, preserved EF (≥50%) and signs of diastolic dysfunction (E/e' ≥8) on echocardiography. Patients underwent right heart catheterisation, echocardiography and CMR. 68 patients entered the final study cohort (HFpEF n=34 and non-cardiac dyspnea n=34 according to pulmonary capillary wedge pressure (PCWP)). HDF assessment included left ventricular (LV) longitudinal, systolic peak and impulse, systolic/diastolic transition, E-wave deceleration as well as A-wave acceleration forces. Two patients were lost to 24 months follow-up evaluating cardiovascular mortality and hospitalisation (CVH).

Results

HDF assessment revealed impairment of LV longitudinal force in HFpEF (15.8 vs. 18.3, p=0.035) attributable to impairment of systolic peak (38.6 vs 51.6, p=0.003) and impulse (20.8 vs. 24.5, p=0.009) forces as well as late diastolic filling (−3.8 vs −5.4, p=0.029). Impairment of early diastolic filling could be observed in HFpEF patients identified at rest only but not stress (7.7 vs. 9.9, p=0.004). Impaired systolic peak was associated to CVH (HR 0.95, p=0.016) and superior for CVH prediction compared to LV global longitudinal strain (AUC 0.76 vs. 0.61, p=0.048).

Conclusions

Assessment of HDF reveals impairment of LV systolic and diastolic function in HFpEF. The value of systolic HDF assessment exceeded that of conventional deformation imaging for CVH prediction.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Centre for Cardiovascular Research

Transforming Standard of Care for Spine Surgery: Integration of an Online Single-Session Behavioral Pain Management Class for Perioperative Optimization

Estimates suggest that 10-40% of lumbar spine surgery patients experience persistent post-surgical pain (PPSP). PPSP is associated with 50% greater healthcare costs, along with risks of emotional distress and impaired quality of life. In 2019, U.S. Health and Human Services identified brief and digital behavioral treatments as important for pain management after surgery. Indeed, brief behavioral pain treatments delivered in the perioperative period may offer patients a low burden opportunity to acquire essential pain coping strategies for enhanced surgical recovery. Additionally, the COVID-19 pandemic has diminished in-person pain treatment access during extended perioperative time frames, thus underscoring the need for on-line options and home based care. This report describes the integration of an online, live-instructor delivered single-session pain self-management intervention (Empowered Relief) into the standard of care for lumbar spine surgery. Here, we apply the RE-AIM framework; describe systems implementation of the Empowered Relief intervention in a large, academic medical center during the COVID-19 pandemic; describe operational challenges and financial considerations; and present patient engagement data. Finally, we discuss the scalable potential of Empowered Relief and other single-session interventions in surgical populations, their importance during extended perioperative periods, practical and scientific limitations, and new directions for future research on this topic.

Comparison of different sowtware solutions for AVC quantification using contrast enhanced MDCT

Funding Acknowledgements

Type of funding sources: None.

Aims

Estimating aortic valve calcification (AVC) derived from multi detector computed tomography (MDCT) scans in aortic stenosis (AS) patients has gained increasing interest for diagnostic and prognostic reasons. Little is known about the interchangeability of AVC obtained from different software solutions which, was systematically determined in consecutive patients undergoing contrast enhanced MDCT before TAVR.

Methods and results

50 randomly selected patients who underwent contrast enhanced MDCT for TAVR planning were included in the analysis. All MDCT data sets were analysed using three different software vendors (3 Mensio, CVI 42, Snygo.Via). AVC score was expressed as mm³. For analysing intra- and inter-observer variability a subset of 10 patients were analysed twice with at least 2 weeks in between the measurements. Intra- and inter-observer variability was quantified using the ICC reliability method, Bland-Altman analysis and coefficients of variation.

AVC scores were successfully obtained using all software solutions (3 Mensio 941 ± 623, CVI42 941 ± 637, Syngo.Via 948 mm³ ± 655) without significant differences (p = 0.455). There was excellent intra- (3 Mensio: ICC 0.999 [0.995 – 1.000], COV 3.86 %, mean difference -19.28 [± 45.07]; CVI 42: ICC 1.000 [0.999 – 1.000], COV 1.6 %, mean difference -10.28 [± 18.6]; Syngo.Via: ICC 0.998 [0.993 – 1.000], COV 4.13 %, mean difference -24.81 [± 48.52]) and inter-observer variability (3 Mensio: ICC 1.000 [0.999 – 1.000], COV 1.38 %, mean difference -7.14 [± 16.20]; CVI 42: ICC 1.000 [1.000 – 1.000], COV 1.01 %, mean difference -1.74 [± 11.83]; Syngo.Via: ICC 0.996 [0.985 – 0.999], COV 6.68 %, mean difference -0.65 [± 79.43]) for all software types. Best inter-vendor agreement was found between CVI 42 and Syngo.Via (ICC 0.997 [CI 0.995-0.998], COV 7.26 %, mean difference -7 [± 68.60]) followed by 3 Mensio / CVI 42 (ICC 0,996 [CI 0,922-0,998], COV 8.95 %, mean difference -0.06 [± 84.16]) and 3 Mensio / Syngo.Via (ICC 0,992 [CI 0,986-0,995], COV 12.19%, mean difference -7.06 [± 115.07]).

Conclusion

Contrast enhanced MDCT derived AVC scores are interchangeable between and reproducible within different commercially available software solutions. This is important since sufficient reproducibility, inter-changeability and valid results represent prerequisites for accurate TAVR planning and wide spread clinical use.

Aortic valve calcification and endomyocardial fibrosis determine adverse outcomes following transcatheter aortic valve replacement

Funding Acknowledgements

Type of funding sources: None.

Aims

There is evidence to suggest that subtype of aortic stenosis (AS), degree of myocardial fibrosis (MF) and level of aortic valve calcification (AVC) are associated with adverse cardiac outcome in AS. Since little is known about their respective contribution, we sought to investigate their relative importance and interplay as well as association with adverse cardiac events.

Methods

100 consecutive patients with severe AS and indication for transfemoral transcatheter aortic valve replacement (TAVR) were prospectively enrolled between January 2017 and October 2018. Patients underwent transthoracic echocardiography, multi detector computed tomography (MDCT) and left ventricular endomyocardial biopsy at the time of TAVR.

Results

The final study cohort consisted of 92 patients with completed study protocol comprising of 39 (42.4 %) normal ejection fraction high gradient (NEFHG), 13 (14.1 %) low EF high gradient (LEFHG), 25 (27.2 %) low EF (flow) low gradient (LEFLG) and 15 (16.3 %) paradoxical low flow low gradient (PLFLG) AS. The high gradient phenotypes (NEFHG and LEFHG) showed the largest amount of AVC (807 ± 421; 813 ± 281 mm³ respectively) as compared to the low gradient phenotypes (LEFLG and PLFLG; 503 ± 326; 555 ± 594 mm³ respectively, p &lt; 0.05). Conversely, MF was most prevalent in low output phenotypes (LEFLG &gt; LEFHG &gt; PLFLG &gt; HEFHG, p &lt; 0.05). This was paralleled by larger cardiovascular mortality within 600 days post TAVR (LEFLG n = 7 &gt; PLFLG n = 4 &gt; LEFHG n = 2 &gt; NEFHG n = 1). In Patients with high MF burden a higher AVC was associated with a lower mortality (p = 0.045, HR = 0.261, 95%CI 0.07-0.97). Within LEFLG AS, patients with larger AVC (&gt;476.8 mm³) had larger MF (40.2%) and higher cardiovascular mortality (n = 5) as compared to patients with lower AVC (£476.8 mm³, 17.1% MF, p = 0.027, cardiovascular mortality n = 2).

Conclusion

MF is associated with adverse cardiovascular outcome following TAVR which is most prevalent in low ejection fraction situations. In the presence of large MF burden patients with large AVC have better outcome following TAVR. Conversely worse outcome in large MF and relatively little AVC may be explained by a relative prominence of an underlying cardiomyopathy while better survival rates in large AVC patients may indicate severe AS associated pressure overload relief and subsequently improved survival following TAVR.

Optimal Methods for Reducing Proxy-Introduced Bias on Patient-Reported Outcome Measurements for Group-Level Analyses

BACKGROUND

Caregivers, or proxies, often complete patient-reported outcomes (PROs) on behalf of patients; yet, research has demonstrated proxies rate patient outcomes worse than patients rate their own outcomes. To improve interpretability of PROs in group-level analyses, our study aimed to identify optimal approaches for reducing proxy-introduced bias in the analysis of PROs.

METHODS

Data were simulated based on 200 patients with stroke and their proxies who both completed 9 PROMIS domains as part of a cross-sectional study. The sample size was varied as 50, 100, 200, and 500, and the proportion of patients with proxy-respondents was varied as 10%, 20%, and 50%. Six methods for handling proxy-completions were investigated: (1) complete case analysis; (2) proxy substitution; (3) Method 2 plus proxy adjustment; (4) Method 3 including inverse-probability of treatment weighting; (5) multiple imputation; (6) linear equating. These methods were evaluated by comparing average bias in PROMIS T-scores (estimated versus observed patient-only responses), as well as by comparing estimated regression coefficients to models using patient-only responses.

RESULTS

Overall mean T-score differences ranged from 0 to 1.75. The range of mean differences varied by the 6 methods with methods 1 and 5 providing estimates closest to the observed mean. In regression models, all but inverse-probability of treatment weighting resulted in low bias when proxy-completions were 10% to 20%. With 50% proxy-completions, method 5 resulted in less accurate estimations while methods 1 to 3 provided less proxy-introduced bias. Bias remained low across domain and varying sample sizes but increased with larger percentages of proxy-respondents.

CONCLUSIONS

Our study found modest proxy-introduced bias when estimating PRO scores or regression estimates across multiple domains of health. This bias remained low, even when sample size was 50 and there were large proportions of proxy-completions. While many of these methods can be chosen for including proxies in stroke PRO research with <20% proxy-respondents, proxy substitution with adjustment resulted in low bias with 50% proxy-respondents.

Patient-proxy agreement on change in acute stroke patient-reported outcome measures: a prospective study

Objectives

Research has indicated proxies overestimate symptoms on patients’ behalves, however it is unclear whether patients and proxies agree on meaningful change across domains over time. The objective of this study is to assess patient-proxy agreement over time, as well as agreement on identification of meaningful change, across 10 health domains in patients who underwent acute rehabilitation following stroke.

Methods

Stroke patients were recruited from an ambulatory clinic or inpatient rehabilitation unit, and were included in the study if they were undergoing rehabilitation. At baseline and again after 30 days, patients and their proxies completed PROMIS Global Health and eight domain-specific PROMIS short forms. Reliability of patient-proxy assessments at baseline, follow-up, and the change in T-score was evaluated for each domain using intra-class correlation coefficients (ICC(2,1)). Agreement on meaningful improvement or worsening, defined as 5+ T-score points, was compared using percent exact agreement.

Results

Forty-one patient-proxy dyads were included in the study. Proxies generally reported worse symptoms and functioning compared to patients at both baseline and follow-up, and reported less change than patients. ICCs for baseline and change were primarily poor to moderate (range: 0.06 (for depression change) to 0.67 (for physical function baseline)), and were better at follow-up (range: 0.42 (for anxiety) to 0.84 (for physical function)). Percent exact agreement between indicating meaningful improvement versus no improvement ranged from 58.5–75.6%. Only a small proportion indicated meaningful worsening.

Conclusions

Patient-proxy agreement across 10 domains of health was better following completion of rehabilitation compared to baseline or change. Overall change was minimal but the majority of patient-proxy dyads agreed on meaningful change. Our study provides important insight for clinicians and researchers when interpreting change scores over time for questionnaires completed by both patients and proxies.

Changes in Health-Related Quality of Life After Transient Ischemic Attack

IMPORTANCE

Numerous studies have found that patients diagnosed with TIA have decreased health-related quality of life, which has been interpreted as suggesting that patients with TIA have residual symptoms after the event. Studies assessing health status in the same patients before and after an event are lacking but may allow a direct determination of the association of TIA with postevent health status.

OBJECTIVE

To examine patient-reported health before transient ischemic attack (TIA) among individuals diagnosed with this event and evaluate change in patient-reported health after the event overall and by TIA characterization subgroups.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted among 236 patients with a clinical diagnosis of TIA from October 2015 to December 2017 in a large US health system that collects a patient-reported outcome measure in ambulatory setting as part of routine care. Included patients had patient-reported global health scale assessments completed as part of routine care before and after a TIA event. Data were analyzed from March through July 2020.

MAIN OUTCOMES AND MEASURES

The main outcome was Patient-Reported Outcome Measurement Information System Global Health (PROMIS GH) scale score before and after TIA. A change of 5 or more points in this score is considered clinically relevant. The secondary outcomes included change in patient-reported global health by clinical impression of the probability of a TIA event, pattern of neurological deficits, and short-term risk of stroke, as assessed by the ABCD2 score.

RESULTS

Among 263 patients who experienced TIA, mean (SD) age was 67.9 (13.4) years and 138 (52.5%) were women. The median (interquartile range) time between patient-reported global health scores was 152 (94-284) days. Mean (SD) baseline patient-reported global physical health and mental health scale summary scores were 43.4 (8.2) and 47.7 (9.7), respectively, and were statistically significantly decreased compared with the general population mean (SD) scores of 50 (10; P < .001) for physical and mental health. The difference between physical health summary score among study participants and the general population was clinically relevant. Mean (SD) summary scores were not statistically significantly different after the event compared with before the event overall (physical health: 44.1 [8.2], for a mean [SE] improvement of 0.65 [0.38] points; P = .09; mental health: 47.4 [9.1], for a mean [SE] worsening of 0.25 [0.38] points; P = .51) or within subgroups.

CONCLUSIONS AND RELEVANCE

These findings suggest that impaired health status among patients diagnosed with TIA reflect, at least in part, an impaired premorbid state of health. This study did not find that TIA events were associated with worsening of health status overall or within subgroups.

[Guideline for the Diagnosis and Treatment of Asthma - Addendum 2020 - Guideline of the German Respiratory Society and the German Atemwegsliga in Cooperation with the Paediatric Respiratory Society and the Austrian Society of Pneumology]

The present addendum of the guideline for the diagnosis and treatment of asthma (2017) complements new insights into the diagnosis and management of asthma as well as for the newly approved drugs for the treatment of asthma. Current, evidence-based recommendations on diagnostic and therapeutic approaches are presented for children and adolescents as well as for adults with asthma.

Patient-Reported Outcomes Predict Future Emergency Department Visits and Hospital Admissions in Patients With Stroke

Background

Identification of stroke patients at increased risk of emergency department (ED) visits or hospital admissions allows implementation of mitigation strategies. We evaluated the ability of the Patient‐Reported Outcomes Information Measurement System (PROMIS) patient‐reported outcomes (PROs) collected as part of routine care to predict 1‐year emergency department (ED) visits and admissions when added to other readily available clinical variables.

Methods and Results

This was a cohort study of 1696 patients with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, or transient ischemic attack seen in a cerebrovascular clinic from February 17, 2015, to June 11, 2018, who completed the following PROs at the visit: Patient Health Questionnaire‐9, Quality of Life in Neurological Disorders cognitive function, PROMIS Global Health, sleep disturbance, fatigue, anxiety, social role satisfaction, physical function, and pain interference. A series of logistic regression models was constructed to determine the ability of models that include PRO scores to predict 1‐year ED visits and all‐cause and unplanned admissions. In the 1 year following the PRO encounter date, 1046 ED visits occurred in 548 patients; 751 admissions occurred in 453 patients. All PROs were significantly associated with future ED visits and admissions except PROMIS sleep. Models predicting unplanned admissions had highest optimism‐corrected area under the curve (range, 0.684–0.724), followed by ED visits (range, 0.674–0.691) and then all‐cause admissions (range, 0.628–0.671). PROs measuring domains of mental health had stronger associations with ED visits; PROs measuring domains of physical health had stronger associations with admissions.

Conclusions

PROMIS scales improve the ability to predict ED visits and admissions in patients with stroke. The differences in model performance and the most influential PROs in the prediction models suggest differences in factors influencing future hospital admissions and ED visits.

Cardiovascular magnetic resonance deformation imaging: method comparison and considerations regarding reproducibility

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Centre for Cardiovascular Research

Purpose

Myocardial Feature-Tracking (FT) deformation imaging is superior for risk-stratification compared to volumetric approaches. Since there is no clear recommendation regarding FT post-processing, we compared different FT-strain analyses with reference standard techniques, including tagging and strain encoded (SENC) magnetic resonance imaging.

Methods

FT software from 4 different vendors (TomTec/Medis/Circle(CVI)/Neosoft), tagging (Segment), and fastSENC (MyoStrain) were used to determine left ventricular global circumferential and longitudinal strains (GCS/GLS) in 12 healthy volunteers and 12 heart failure patients. Variability and agreements were assessed using intraclass correlation coefficients for absolute agreement (ICCa) and consistency (ICCc) as well as pearson correlation coefficients.

Results

For FT-GCS, consistency was excellent comparing different FT-vendors (ICCc = 0.84-0.97, r = 0.86-0.95) and compared to fSENC (ICCc = 0.78-0.89, r = 0.73-0.81). FT-GCS consistency was excellent compared to tagging (ICCc = 0.79-0.85, r = 0.74-0.77) except for TomTec (ICCc = 0.68, r = 0.72). Absolute FT-GCS agreements between FT-vendors were highest for CVI and Medis (ICCa = 0.96) and lowest for TomTec and Neosoft (ICCa = 0.32). Similarly, absolute FT-GCS agreements were excellent for CVI and Medis compared to both tagging and fSENC (ICCa = 0.84-0.88), good to excellent for Neosoft (ICCa = 0.77 and 0.64) and lowest for TomTec (ICCa = 0.41 and 0.47).

For FT-GLS, consistency was excellent (ICCc≥0.86, r≥0.76). Absolute agreements between FT-vendors were excellent (ICCa = 0.91-0.93) or good to excellent for TomTec (ICCa = 0.69-0.85). Absolute agreements (ICCa) were good (CVI 0.70, Medis 0.60) and fair (TomTec 0.41, Neosoft 0.59) compared to tagging but excellent compared to fSENC (ICCa = 0.77-0.90).

Conclusion

Although absolute agreements differ depending on deformation assessment approaches, consistency and correlation are consistently high irrespective of the method chosen, thus indicating reliable strain assessment. Further standardisation and introduction of uniform references is warranted for routine clinical implementation.

Fully automated artificial intelligence-based myocardial scar quantification for diagnostic and prognostic stratification in patients following acute myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background Myocardial infarct size (IS) remains one of the strongest predictors of adverse cardiac events following acute myocardial infarction (AMI). Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) can precisely quantify the extent of injury but requires manual post-processing. Whether novel user-independent artificial intelligence (AI) based fully-automated analyses may facilitate clinical workflow and deliver similar information for risk stratification is unknown.

Methods 913 AMI patients from two multi-center trials (AIDA-STEMI n = 704 with ST-elevation myocardial infarction [STEMI] and TATORT-NSTEMI n = 245 with non-ST-elevation-infarction [NSTEMI]) were included in this sub-study. IS was quantified manually using conventional software (Medis, Leiden Netherlands) and fully automated AI-based software (NeoSoft). All automatically detected IS were evaluated visually and corrected if necessary. Analyzed data were tested for agreement and prediction of major adverse clinical events (MACE) within one year after AMI.

Results Automated and manual IS were similarly associated with outcome in cox regression analyses (HR 1.05 [95% CI 1-02-1.07] p &lt; 0.001 for automated IS and HR 1.04 [95% CI 1.02-1.06]; p &lt; 0.001 for manual IS). Comparison of C-statistics derived area under the curve (AUC) resulted in equivalent MACE prediction (AUC 0.65 for automated vs. AUC 0.66 for manual, p = 0.53). Manual correction of the automated scar detection did not lead to an improved risk prediction of MACE (AUC 0.65 to 0.66, p = 0.43). There was good agreement of automated and manually derived IS (intraclass correlation coefficient [ICC] 0.75 [0.07-0.89]) which was further improved after manual correction of the underlying contours (ICC 0.98 [0.97-0.98]).

Conclusion AI-based software enables automated scar quantification with similar prognostic value compared to conventional methods in patients following AMI.

Fully automated cardiac assessment for diagnostic and prognostic stratification following myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiovascular magnetic resonance (CMR) imaging is considered the reference methodology for cardiac morphology and function but requires manual post-processing. Whether novel artificial intelligence (AI) -based automated analyses deliver similar information for risk stratification is unknown. Therefore, this study aimed to investigate feasibility and prognostic implications of AI-based analyses.

Methods

CMR data (n = 1017 patients) from two myocardial infarction multi-center trials were included. Analyses of biventricular parameters including ejection fraction (EF) were manually and automatically assessed using conventional and AI-based software. Obtained parameters entered regression analyses for prediction of major adverse clinical events (MACE) defined as death, reinfarction or congestive heart failure within one-year after the acute event.

Results

Both manual and uncorrected automated volumetric assessments showed similar impact on outcome on univariate (LVEF HR 0.93, [95% CI 0.91-0.95]; p &lt; 0.001 for manual and HR 0.94 [0.92-0.96]; p &lt; 0.001 for automated) and multivariable analyses (LVEF HR 0.95, [0.92-0.98]; p = 0.001 for manual and HR 0.95 [CI 0.92-0.98]; p = 0.001 for automated). Manual correction of the automated contours did not lead to improved risk prediction (LVEF AUC 0.67 automated vs. 0.68 automated corrected, p = 0.49). There was acceptable agreement (bias: 2.6%, 95% limits of agreement [LOA] -9.1-14.2%, intraclass correlation coefficient [ICC] 0.88 [0.77-0.93] for LVEF) of manual and automated volumetric assessments.

Conclusions

User independent volumetric analyses performed by fully automated software are feasible and results are equally predictive of MACE compared with conventional analyses in patients following myocardial infarction.

CMR feature tracking remote myocardial strain analyses for optimized risk prediction following acute myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac magnetic resonance myocardial feature tracking (CMR-FT) derived global strain assessments provide incremental prognostic information in patients following acute myocardial infarction (AMI). Functional analyses of the remote myocardium (RM) are scarce and whether they provide an additional prognostic value in these patients is unknown.

Methods

1052 patients following acute myocardial infarction were included. CMR imaging and strain analyses as well as scar size quantification were performed after reperfusion by primary percutaneous coronary intervention. The occurrence of major adverse cardiac events (MACE) within 12 months after the index event was defined as primary clinical endpoint.

Results

Patients with MACE had significantly lower RM circumferential strain (CS) compared to those without MACE. A cut-off value for RM CS of -25.8% best identified high-risk patients (p &lt; 0.001 on log-rank testing) and impaired RM CS was a strong predictor of MACE (HR 1.05, 95% CI 1.07-1.14, p = 0.003). RM CS provided further risk stratification amongst patients considered at risk according to established CMR parameters for 1.) patients with reduced left ventricular ejection fraction (LVEF) ≤ 35 % (p = 0.002 on log-rank testing), 2.) patients with reduced global circumferential strain (GCS) &gt; -18,3 % (p = 0.015 on log-rank testing), and 3.) patients with large microvascular obstruction ≥ 1.46 % (p = 0.038 on log-rank testing).

Conclusion

CMR-FT derived RM CS is a useful parameter to characterize the response of RM and allows improved stratification following AMI beyond commonly used parameters, especially of high-risk patients.

The validity of proxy responses on patient-reported outcome measures: Are proxies a reliable alternative to stroke patients' self-report?

PURPOSE

Caregivers, or proxies, often complete patient-reported outcome measures (PROMs) on behalf of patients with stroke. The objective of our study was to assess the validity and responsiveness of proxy-responses compared to patient-responses across multiple domains of health.

METHODS

Stroke patients and their proxies were recruited to complete PROMs between 7/2018-11/2019. PROMs included Neuro-QoL cognitive function, PROMIS physical function, satisfaction with social roles, anxiety, fatigue, pain interference, sleep disturbance, Global Health, and PHQ-9. Internal consistency and convergent validity were compared between patient- and proxy-reported measures. Known-groups validity was assessed across levels of stroke disability. Internal responsiveness was evaluated using paired t-tests for a subset of patients who attended rehabilitation following stroke. Analyses were stratified by patients ≤ 3 vs > 3 months from stroke.

RESULTS

This cross-sectional study included 200 stroke patients (age 62.2 ± 13.3, 41.5% female) and their proxies (age 56.5 ± 13.9, 70% female, 72% spouses). PROMs had high internal consistency and were significantly correlated for patients and proxies. Patient- and proxy-reported measures worsened with increasing stroke disability. For 34 (17%) patients who attended rehabilitation, patients self-reported improvement on 5 domains whereas proxies reported no improvement. Compared to patient self-reports, validity was worse for proxy-reports on patients ≤ 3 months but better > 3 months from stroke.

CONCLUSIONS

Both patient- and proxy-reported PROMs demonstrated strong validity. Only patient-reported PROMs were responsive to change, and proxies had worse validity for patients ≤ 3 months from stroke but better validity for patients > 3 months from stroke. These findings justify the utilization of proxy responses in stroke patients > 3 months from stroke.

Physical Activity Monitoring Using a Fitbit Device in Ischemic Stroke Patients: Prospective Cohort Feasibility Study

Background

Continuous tracking of ambulatory activity in real-world settings using step activity monitors has many potential uses. However, feasibility, accuracy, and correlation with performance measures in stroke patients have not been well-established.

Objective

The primary study objective was to determine adherence with wearing a consumer-grade step activity monitor, the Fitbit Charge HR, in home-going ischemic stroke patients during the first 90 days after hospital discharge. Secondary objectives were to (1) determine accuracy of step counts of the Fitbit Charge HR compared with a manual tally; (2) calculate correlations between the Fitbit step counts and the mobility performance scores at discharge and 30 days after stroke; (3) determine variability and change in weekly step counts over 90 days; and (4) evaluate patient experience with using the Fitbit Charge HR poststroke.

Methods

A total of 15 participants with recent mild ischemic stroke wore a Fitbit Charge HR for 90 days after discharge and completed 3 mobility performance tests from the National Institutes of Health Toolbox at discharge and Day 30: (1) Standing Balance Test, (2) 2-Minute Walk Endurance Test, and (3) 4-Meter Walk Gait Speed Test. Accuracy of step activity monitors was assessed by calculating differences in steps recorded on the step activity monitor and a manual tally during 2-minute walk tests.

Results

Participants had a mean age of 54 years and a median modified Rankin scale score of 1. Mean daily adherence with step activity monitor use was 83.6%. Mean daily step count in the first week after discharge was 4376. Daily step counts increased slightly during the first 30 days after discharge (average increase of 52.5 steps/day; 95% CI 32.2-71.8) and remained stable during the 30-90 day period after discharge. Mean step count difference between step activity monitor and manual tally was –4.8 steps (–1.8%). Intraclass correlation coefficients for step counts and 2-minute walk, standing balance, and 4-meter gait speed at discharge were 0.41 (95% CI –0.14 to 0.75), –0.12 (95% CI –0.67 to 0.64), and 0.17 (95% CI –0.46 to 0.66), respectively. Values were similarly poor at 30 days.

Conclusions

The use of consumer-grade Fitbit Charge HR in patients with recent mild stroke is feasible with reasonable adherence and accuracy. There was poor correlation between step counts and gait speed, balance, and endurance. Further research is needed to evaluate the association between step counts and other outcomes relevant to patients, including patient-reported outcomes and measures of physical function.

Twelfth European Students’ Conference

N/A

Fourteenth European Students Conference

N/A

Real-time cardiac magnetic resonance tissue characterisation for fibrosis assessment in aortic stenosis

Background

Myocardial fibrosis is a major determinant of outcome in aortic stenosis (AS). Novel fast real-time (RT) cardiac magnetic resonance (CMR) mapping techniques allow comprehensive quantification of fibrosis but have not yet been adequately validated against standard techniques and histology.

Methods

Patients with severe AS underwent CMR before (n=110) and left ventricular (LV) endomyocardial biopsy (n=46) at transcatheter aortic valve replacement (TAVR). Midventricular short axis native, post-contrast T1 and extracellular volume fraction (ECV) maps were generated using commercially available 5(3)3 MOLLI and RT single-shot inversion recovery fast low-angle shot (FLASH) with radial undersampling. ECV and LV mass were used to calculate LV matrix volumes. Variability and agreements were assessed between RT, MOLLI and histology using intraclass correlation coefficients, coefficients of variation and Bland Altman analyses.

Results

RT and MOLLI derived ECV were similar for myocardium (26.2 vs. 26.5, p=0.073) and inter-ventricular septum (26.2 vs. 26.5, p=0.216). MOLLI native T1 time was in median 20 ms longer compared to RT (p&lt;0.001). Agreement between RT and MOLLI was best for ECV (ICC &gt;0.91), excellent for post-contrast T1 times (ICC &gt;0.81) and good for native T1 times (ICC &gt;0.62). Diffuse collagen volume fraction by biopsies was in median 7.8%. ECV (RT r=0.345, p=0.039; MOLLI r=0.40, p=0.010) and LV matrix volumes (RT r=0.45, p=0.005; MOLLI r=0.43, p=0.007) were the only parameters associated with histology.

Conclusions

RT mapping offers precise T1 and ECV assessments with similar agreement with histology as compared to conventional MOLLI techniques. Single-shot real time techniques may be advantageous in sicker patients prone to dyspnoea or arrhythmia.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German Research Foundation

Structural and functional reverse myocardial remodeling following transcatheter aortic valve replacement

Background

Myocardial reverse remodeling determines outcome in patients with severe aortic stenosis (AS) following transcatheter aortic valve replacement (TAVR). However, little is known about the interplay of myocardial function and structure after TAVR. Since cardiac magnetic resonance (CMR) imaging allows comprehensive quantification of both structure and function we aimed to assess changes in myocardial tissue composition and deformation before and following TAVR.

Methods

CMR imaging was performed in 40 prospectively enrolled patients with severe AS before and one year after TAVR. Myocardial function was characterized using volumetry and CMR-feature-tracking (FT) deformation imaging of left ventricular (LV) global longitudinal strain (GLS) and atrial function (atrial reservoir ES, conduit Ee and booster pump strain EA). Myocardial structure was assessed using T1 mapping and late gadolinium enhancement (LGE) analysis. LV cellular and matrix volumes were calculated based on extra cellular volume fraction (ECV) and LV mass. CMR-FT results were compared to a control group of twenty patients with normal biventricular function. Moreover, biomarkers (NT-proBNP), functional (six-minute-walking-test) and clinical status (NYHA, Minnesota LIVING WITH HEART FAILURE score) were determined at baseline and one-year follow-up.

Results

Regression of both cellular (−20.6%, p&lt;0.001) and matrix volumes (−12.3%, p=0.003) and subsequently increased ECV (+9.0%, p=0.001) were documented one year after TAVR. Ventricular and atrial strains were impaired at baseline (GLS p=0.004, Es p&lt;0.001, Ee p&lt;0.001) and recovered during follow-up (GLS p&lt;0.001, Es p=0.005, Ee p=0.001). These changes were paralleled by improvements in NYHA (p&lt;0.001) and Minnesota (p&lt;0.001) scores as well as decline in NT-proBNP levels (p=0.001). There was a significant association of LV fibrosis as defined by matrix volume and extent of LGE and ventricular and atrial functional impairment (correlation of matrix volume and: GLS r=0.57, p&lt;0.001, Es r=−0.44, p=0.009; correlation of LGE%LV and: GLS r=0.41, p=0.015, Es: r=−0.4, p=0.02, and Ea: r=−0.41, p=0.02).

Conclusion

Regression of fibrosis and cellular hypertrophy determine improved myocardial function and recovery from heart failure following TAVR. Prognostic implications of the observed changes will need to be explored next to identify makers and therapeutic targets for optimized management of these patients.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German Research Foundation (DFG, CRC 1002, D1)

Performance of different myocardial tissue tracking algorithms and acquisition-based strain imaging to characterise myocardial pathology

Background

Myocardial deformation imaging is superior in risk-stratification compared to volumetric approaches. Myocardial Feature-Tracking (FT) allows easy post-processing of routinely acquired cine images. Since there is no clear recommendation regarding FT post-processing we sought to compare different FT-strains with reference standard techniques including tagging and strain encoded (SENC) magnetic resonance imaging.

Methods

CMR-FT software from 4 different vendors (TomTec, Medis, Circle, Neosoft), CMR tagging (Segment) and fastSENC (MyoStrain) were used to determine left ventricular (LV) global longitudinal and circumferential strains (GLS and GCS) in 12 healthy volunteers and 12 heart failure patients. Variability and agreements were assessed using intraclass correlation coefficients, coefficients of variation and Bland Altman plots.

Results

Compared to tagging, FT-based strain was software independently significantly higher except for GCS using Medis (p=0.178). Compared to fSENC, mean-differences of GLS were smaller within a range of ±1.5%. For GCS this only applied to CVI and Medis (&lt;1.5%) but not TomTec (&gt;7%) or Neosoft (&gt;4%). Absolute agreements comparing FT to tagging were best for CVI (GLS ICC0.70) and Medis (GCS ICC0.85). Compared to fSENC agreement of GLS was generally excellent (ICC&gt;0.77), but only CVI and Medis revealed excellent agreement for GCS (ICC0.88 and 0.85). Consistency and correlation of GLS were software independently high compared with tagging and fSENC (ICC&gt;0.86, r&gt;0.76) while being lower for GCS (ICC&gt;0.68, r&gt;0.72).

Conclusion

Although agreement differs between deformation assessment approaches, consistency and correlation are high irrespective of the method chosen, thus indicating reliable strain assessment. Further standardisation and introduction of uniform references is warranted for clinical routine implementation.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): DZHK - German Centre for Cardiovascular Research

Frequency and prognostic impact of right ventricular involvement in acute myocardial infarction

Background

Right ventricular (RV) involvement complicating myocardial infarction (MI) is thought to impact prognosis, but potent RV markers for risk stratification are lacking.

Purpose

To assess the frequency and prognostic implications of concomitant structural and functional RV injury in MI.

Methods

Cardiac magnetic resonance (CMR) was performed in 1235 patients with MI (STEMI: n=795; NSTEMI: n=440) 3 days after reperfusion by primary percutaneous coronary intervention. Central core laboratory-masked analyses included structural (edema representing reversible ischemia, irreversible infarction, microvascular obstruction [MVO]) and functional (ejection fraction, global longitudinal strain [GLS]) RV alterations. The clinical endpoint was the 12-month rate of major adverse cardiac events (MACE).

Results

RV ischemia and infarction were observed in 19.6% and 12.1% of patients, respectively, suggesting complete myocardial salvage in one-third of patients. RV ischemia was associated with a significantly increased risk of MACE (10.1% versus 6.2%; p=0.035), while patients with RV infarction showed only numerically increased event rates (p=0.075). RV MVO was observed in 2.4% and not linked to outcome (p=0.894). Stratification according to median RV GLS (10.2% versus 3.8%; p&lt;0.001) but not RV ejection fraction (p=0.175) resulted in elevated MACE rates. Multivariable analysis including clinical and left ventricular MI characteristics identified RV GLS as an independent predictor of outcome (hazard ratio 1.05, 95% confidence interval 1.00–1.09; p=0.034) in addition to age (p=0.001), Killip class (p=0.020), and left ventricular GLS (p=0.001), while RV ischemia was not independently associated with outcome.

Conclusions

RV GLS is a predictor of post-infarction adverse events over and above established risk factors, while structural RV involvement was not independently associated with outcome.

Funding Acknowledgement

Type of funding source: None

Magnitude and Variability of Stroke Patient-Proxy Disagreement Across Multiple Health Domains

OBJECTIVES

To quantify the extent and variability of bias introduced when caregivers, or proxies, complete patient-reported outcome measures (PROM) on behalf of stroke patients.

DESIGN

Cross-sectional survey study conducted between July 2018 and November 2019.

SETTING

Ambulatory clinic of a cerebrovascular center or rehabilitation unit.

PARTICIPANTS

A consecutive sample of stroke patients (N=200) and their proxies who were able and willing to complete PROMs. Proxies completed PROMs as they believed the patient would answer.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

PROMs included Neuro-QoL cognitive function, PROMIS physical function, social role satisfaction, anxiety, fatigue, pain interference, sleep disturbance, Patient Health Questionnaire-9 translated to PROMIS Depression, and PROMIS Global Health.

RESULTS

The study included 200 stroke patients (age, 62.2±13.3; 41.5% women) and their proxies (age 56.5±13.9; 70% women, 72% spouses). Proxies reported worse functioning and more symptoms across all PROM domains compared with patients (average difference, 0.3-3.0 T score points). Reliability between dyad responses was moderate across all domains (intraclass correlation coefficients (2,1), 0.49-0.76) and effect sizes were small (d=0.04-0.35). Cognitive function, anxiety, and depression had the lowest agreement, whereas physical function, pain, and sleep had the highest agreement based on the Bland-Altman method. At the individual level, a large proportion of dyads had meaningfully different scores across domains (range, 40%-57%; dyads differed >5 T score points). Few predictors of disagreement were identified through multinomial regression models.

CONCLUSIONS

At the aggregate level, small differences were detected between stroke patient-proxy pairs, with lower agreement on more subjective domains. At the individual level, a large proportion of dyads reported meaningfully different scores on all domains, affecting the interpretability of proxy responses on PROMs in a clinical setting.

Pain in Patients With Type 2 Diabetes-Related Polyneuropathy Is Associated With Vascular Events and Mortality

PURPOSE

Type 2 diabetes-related polyneuropathy (DPN) is associated with increased vascular events and mortality, but determinants and outcomes of pain in DPN are poorly understood. We sought to examine the effect of neuropathic pain on vascular events and mortality in patients without DPN, DPN with pain (DPN + P), and DPN without pain (DPN-P).

METHODS

A retrospective cohort study was conducted within a large health system of adult patients with type 2 diabetes from January 1, 2009 through December 31, 2016. Using an electronic algorithm, patients were classified as no DPN, DPN + P, or DPN-P. Primary outcomes included number of vascular events and time to mortality. Independent associations with DPN + P were evaluated using multivariable negative binomial and Cox proportional hazards regression models, adjusting for demographics, socioeconomic characteristics, and comorbidities.

RESULTS

Of 43 945 patients with type 2 diabetes (age 64.6 ± 14.0 years; 52.1% female), 13 910 (31.7%) had DPN: 9104 DPN + P (65.4%) vs 4806 DPN-P (34.6%). Vascular events occurred in 4538 (15.1%) of no DPN patients, 2401 (26.4%) DPN + P, and 1006 (20.9%) DPN-P. After adjustment, DPN + P remained a significant predictor of number of vascular events (incidence rate ratio [IRR] = 1.55, 95% CI, 1.29-1.85), whereas no DPN was protective (IRR = 0.70, 95% CI, 0.60-0.82), as compared to DPN-P. Compared to DPN-P, DPN + P was also a significant predictor of mortality (hazard ratio = 1.42, 95% CI, 1.25-1.61).

CONCLUSIONS

Our study found a significant association between pain in DPN and an increased risk of vascular events and mortality. This observation warrants longitudinal study of the risk factors and natural history of pain in DPN.

Clinical Symptom Profiles After Mild-Moderate Stroke

Background

There is heterogeneity in the severity of domains affected in patients with stroke, resulting in differences in health‐related quality of life (hrQoL). Identifying different clinical profiles of stroke patients may provide a means for selecting patients for tailored interventions to improve hrQoL.

Methods and Results

This was an observational study of 496 patients with ischemic stroke or intracerebral hemorrhage seen in a cerebrovascular clinic from October 12, 2015, through June 11, 2018, who completed patient‐reported outcome measures using Patient‐Reported Outcome Measurement Information System (PROMIS) tools within 1 month of stroke. Latent profile analysis identified groups based on PROMIS domain scores—pain, depression, cognitive function, fatigue, social role satisfaction, and physical function—as well as clinician‐reported modified Rankin Scale (mRS). Five distinct profiles were identified. Group 1 (“excellent hrQoL,” n=106) had fewer symptoms in all domains than the general population. Group 2 (“disabled with mixed hrQoL,” n=17) had fewer symptoms than the general population in all domains except social role satisfaction and physical function, despite having moderate disability (median mRS score: 3). Group 3 (“mild limitations with average hrQoL,” n=189) had scores similar to the general population for all domains and minimal disability (median mRS score: 1). Group 4 (“mild limitations with poor hrQoL,” n=152) also had a median mRS score of 1 but had worse scores than group 3 on all domains. Group 5 (“disabled with poor hrQoL,” n=32) had worse symptoms than patients in the other profiles and a median mRS score of 3.

Conclusions

Patients with recent stroke have distinct clinical symptom profiles, even with similar levels of clinician‐reported disability. Symptom profiles provide a means of understanding patterns of outcomes in patients with stroke.

Differences in right ventricular-pulmonary vascular coupling and clinical indices between repaired standard tetralogy of Fallot and repaired tetralogy of Fallot with pulmonary atresia

PURPOSE

The purpose of this study was to compare ventricular vascular coupling ratio (VVCR) between patients with repaired standard tetralogy of Fallot (TOF) and those with repaired TOF-pulmonary atresia (TOF-PA) using cardiovascular magnetic resonance (CMR).

MATERIALS AND METHODS

Patients with repaired TOF aged>6 years were prospectively enrolled for same day CMR, echocardiography, and exercise stress test following a standardized protocol. Sanz's method was used to calculate VVCR as right ventricle (RV) end-systolic volume/pulmonary artery stroke volume. Regression analysis was used to examine associations with exercise test parameters, New York Heart Association (NYHA) class, RV size and biventricular systolic function.

RESULTS

A total of 248 subjects were included; of these 222 had repaired TOF (group I, 129 males; mean age, 15.9±4.7 [SD] years [range: 8-29 years]) and 26 had repaired TOF-PA (group II, 14 males; mean age, 17.0±6.3 [SD] years [range: 8-29 years]). Mean VVCR for all subjects was 1.54±0.64 [SD] (range: 0.43-3.80). Mean VVCR was significantly greater in the TOF-PA group (1.81±0.75 [SD]; range: 0.78-3.20) than in the standard TOF group (1.51±0.72 [SD]; range: 0.43-3.80) (P=0.03). VVCR was greater in the 68 NYHA class II subjects (1.79±0.66 [SD]; range: 0.75-3.26) compared to the 179 NYHA class I subjects (1.46±0.61 [SD]; range: 0.43-3.80) (P<0.001).

CONCLUSION

Non-invasive determination of VVCR using CMR is feasible in children and adolescents. VVCR showed association with NYHA class, and was worse in subjects with repaired TOF-PA compared to those with repaired standard TOF. VVCR shows promise as an indicator of pulmonary artery compliance and cardiovascular performance in this cohort.

564 Cardiac magnetic resonance myocardial feature tracking for optimized risk assessment after acute myocardial infarction in patients with type 2 diabetes

Objective

Type 2 diabetes mellitus (T2DM) associates with worse cardiovascular outcome following acute myocardial infarction (AMI) as compared to non-diabetic patients. Since the mechanisms behind these observations are not fully understood we aimed to quantify the underlying pathophysiology on ventricular and atrial levels and study their prognostic implications using cardiovascular magnetic resonance (CMR) quantitative feature-tracking (FT) and tissue characterization.

Research Design and Methods:

A total of 1147 consecutive patients with AMI (n = 265 with diabetes; n = 882 without diabetes) undergoing cardiac magnetic resonance (CMR) imaging in median 3 days after AMI were included in this multicenter study. Left ventricular (LV) function and volumetry included LV ejection fraction (LV-EF), global longitudinal (GLS), radial (GRS) and circumferential strain (GCS) as well as left atrial (LA) strain and strain rate parameters of LA reservoir, conduit and booster pump function. LV damage assessment included infarct size (IS), edema and microvascular obstruction (MO). The clinical study endpoint was the rate of major adverse cardiovascular events (MACE) at 12 months.

Results

T2DM patients had impaired LA reservoir (19.8 vs. 21.2%, p &lt; 0.01) and conduit strains 7.6 vs. 9.0%, p &lt; 0.01) but no differences in ventricular function or myocardial damage. They were at higher risk of MACE than non-diabetic patients (10.2% vs. 5.8%, p &lt; 0.01) with the majority of MACE occurring in patients with LVEF ≥ 35%. Whilst LVEF was an independent predictor of adverse events in non-diabetic patients (p = 0.04 on multivariable analysis), LV GLS as well as LA strain emerged as independent predictors of poor prognosis in patients with diabetes (p &lt; 0.02 on multivariable analysis). Considering patients with diabetes and LVEF ≥35% (n = 237), GLS and LA reservoir strain below median were significantly associated with higher 12-month event rates.

Conclusions

In patients with diabetes, LA and LV longitudinal strain permit optimized risk assessment early after reperfused AMI with incremental prognostic value over and above LVEF.

565 Impact of right atrial physiology on heart failure and adverse events after myocardial infarction

Background

Right ventricular (RV) function is a known predictor of adverse events in heart failure and following acute myocardial infarction (AMI). While right atrial (RA) involvement is well characterized in pulmonary arterial hypertension, its relative contributions to adverse events following AMI especially in patients with heart failure and congestion needs further evaluation.

Methods

1235 MI patients underwent CMR after primary percutaneous coronary intervention (PCI) in 15 centers across Germany (n = 795 with ST-elevation MI and 440 with non ST-elevation MI). Right atrial (RA) performance was evaluated using cardiac magnetic resonance myocardial feature tracking (CMR-FT) for the assessment of RA reservoir (total strain εs), conduit (passive strain εe), booster pump function (active strain εa) and associated strain rates (SR) in a blinded core-laboratory. The primary clinical endpoint was the occurrence of major adverse cardiac events (MACE) 12 months post MI.

Results

RA reservoir (εs p = 0.061, SRs p = 0.049) and conduit functions (εe p = 0.006, SRe p = 0.030) were impaired in patients with MACE as opposed to RA booster pump (εa p = 0.579, SRa p = 0.118) and RA volume index (p = 0.866). RA conduit function was associated with clinical onset of heart failure and MACE independently of RV systolic function (multi-variable analysis HR 0.95, 95% CI 0.91-0.99, p = 0.006) while RV systolic function was no independent prognosticator (HR 0.98, 95% CI 0.96-1.00, p = 0.055). Furthermore, RA conduit strain identified low- and high-risk groups within patients with relatively preserved and reduced RV and LV systolic functions (p &lt; 0.019 on log rank testing).

Conclusions

Right atrial impairment is a distinct feature and independent risk factor in patients following AMI and can be easily assessed using CMR-FT derived quantification of RA strain.

P1838 Defining the Optimal Temporal and Spatial Resolution for Cardiovascular Magnetic Resonance Imaging Feature Tracking

Background

Myocardial deformation analyses using cardiovascular magnetic resonance feature tracking (CMR-FT) have incremental value in the assessment of cardiac function beyond volumetric analyses. Since guidelines do not recommend specific imaging parameters, we aimed to define optimal spatial and temporal resolutions for CMR cine images to enable reliable post-processing.

Methods

Intra- and inter-observer reproducibility was assessed in 12 healthy volunteers. Cine images were acquired with differing temporal (20, 30, 40 and 50 frames/cardiac cycle) and spatial resolutions (high in-plane 1.5x1.5mm through-plane 5mm, standard 1.8x1.8x8mm and low 3.0x3.0x10mm). CMR-FT analyses comprised left ventricular (LV) global longitudinal strain (GLS) and systolic strain rate (SRs) as well as LV circumferential and radial strains (GCS and GRS) and right ventricular (RV) GLS. Intra- and inter-observer reproducibility was assessed in all subjects.

Results

Temporal but not spatial resolution did impact absolute strain and SR. Maximum absolute changes between lowest and highest temporal resolution were as follows: 2.3% LV GLS, 2.2%

GCS, 7.2% GRS, 1.7% RV GLS and 0.32s-1 SRs. Changes of time-integrated (strain) values occurred predominantly comparing 20 and 30 frames/cardiac cycle including LV GLS, GCS and GRS (p = 0.034, p = 0.008 and p = 0.034) in highest spatial resolution settings. In contrast, time-derivatives values (SRs) changed significantly from lower temporal resolutions to 40 frames/cardiac cycle and beyond (20 to 30 p = 0.002; 30 to 40 p = 0.018; 40 to 50 frames/cardiac cycle p = 0.075) in highest spatial resolution settings. Strain reproducibility was not affected by either temporal or spatial resolution. SRs variability as assessed by coefficient of variation decreased with higher temporal resolutions.

Conclusion

Temporal but not spatial resolutions significantly affect strain and SR in CMR-FT deformation analyses. Clinical CMR-FT strain and SR analyses require minimum temporal resolutions of 30 and 40frames/cardiac cycle, respectively to ensure precise quantification of myocardial function.

Inflammatory response to magnesium-based biodegradable implant materials

Biodegradability and mechanical properties of magnesium alloys are attractive for orthopaedic and cardiovascular applications. In order to study their cytotoxicity usually bone cells are used. However, after implantation, diverse and versatile cells are recruited and interact. Among the first ones coming into play are cells of the immune system, which are responsible for the inflammatory reaction. Macrophages play a central role in the inflammatory process due to the production of cytokines involved in the tissue healing but also in the possible failure of the implants. In order to evaluate the in vitro influence of the degradation products of magnesium-based alloys on cytokine release, the extracts of pure magnesium and two magnesium alloys (with gadolinium and silver as alloying elements) were examined in an inflammatory in vitro model. Human promonocytic cells (U937 cells) were differentiated into macrophages and further cultured with magnesium-based extracts for 1 and 3 days (simulating early and late inflammatory reaction phases), either at 37 °C or at 39 °C (mimicking normal and inflammatory conditions, respectively). All extracts exhibit very good cytocompatibility on differentiated macrophages. Results suggest that M1 and even more M2 profiles of macrophage were stimulated by the extracts of Mg. Furthermore, Mg-10Gd and Mg-2Ag extracts introduced a nuancing effect by rather inhibiting macrophage M1 profile. Magnesium-based biomaterials could thus induce a faster inflammation resolution while improving tissue repair. STATEMENT OF SIGNIFICANCE: Macrophage are the key-cells during inflammation and can influence the fate of tissue healing and implant performance. Magnesium-based implants are biodegradable and bioactive. Here we selected an in vitro system to model early and late inflammation and effect of pyrexia (37 °C versus 39 °C). We showed the beneficial and nuancing effects of magnesium (Mg) and the selected alloying elements (silver (Ag) and gadolinium (Gd)) on the macrophage polarisation. Mg extracts exacerbated simultaneously the macrophage M1 and M2 profiles while Mg-2Ag and Mg-10Gd rather inhibited the M1 differentiation. Furthermore, 39 °C exhibited protective effect by either decreasing cytokine production or promoting anti-inflammatory ones, with or without extracts. Mg-based biomaterials could thus induce a faster inflammation resolution while improving tissue repair.

567 Interplay of infarct territory related myocardial mechanics and prognostic implications following acute myocardial infarction

Background

Prognosis in acute myocardial infarction (AMI) depends on the amount of infarct related artery (IRA) subtended myocardium and associated damage but has not been described in great detail. Consequently, we sought to describe IRA associated pathophysiological consequences using cardiac magnetic resonance (CMR).

Methods

1235 AMI patients (n = 795 ST-elevation (STEMI) and 440 non-STEMI) underwent CMR following percutaneous coronary intervention. Blinded core-laboratory data were compared according to left anterior descending (LAD), left circumflex (LCx) and right coronary artery (RCA) regarding major adverse clinical events (MACE) within 12 months. Left ventricular (LV) global longitudinal/circumferential/radial (GLS/GCS/GRS) as well as left atrial (LA) total (εs), passive (εe) and active (εa) strains were determined using CMR-feature tracking. Tissue characterisation included infarct size (IS) and microvascular obstruction.

Results

LAD and LCx were associated with higher mortality compared to RCA lesions (4.6% and 4.4% vs 1.6%). LAD lesions showed largest IS (16.8%), largest ventricular (LV ejection fraction (EF) 47.4%, GLS -13.2%, GCS -20.8%) and atrial (εs 20.2%) impairment. There was less impairment in LCx (IS 11.8%, LVEF 50.8%, GLS -17.4%, GCS -25.0%, εs 20.7%) followed by RCA lesions (IS 11.3%, LVEF 50.8%, GLS -19.1%, GCS -26.6%, εs 21.7%). In AUC analyses εs (LAD, RCA) and GLS (LCx) best predicted MACE (AUC &gt; 0.69). Multivariate analyses identified εs (p = 0.017) in LAD and GLS (p = 0.034) in LCx infarcts as independent predictors of MACE.

Conclusions

CMR allows IRA specific phenotyping and characterisation of morphologic and functional changes. These alterations carry infarct specific prognostic implications and may represent novel diagnostic and therapeutic targets following AMI.

566 Myocardial left ventricular mechanical uniformity and adverse cardiac events following myocardial infarction

Background

Despite limitations as a standalone parameter, left ventricular ejection fraction (LVEF) is the preferred measure of myocardial function and marker for post-infarction risk stratification. LV myocardial uniformity may provide superior prognostic information after acute myocardial infarction (AMI), which was subject of this study.

Methods and Results:

Consecutive patients with AMI (n = 1082; median age 63 years; 75% male) undergoing cardiac magnetic resonance (CMR) in median 3 days after infarction were included in this multicenter, observational study. Circumferential and radial uniformity ratio estimates (CURE and RURE) were derived from CMR feature-tracking as markers of mechanical uniformity (values between 0 and 1 with 1 reflecting perfect uniformity). The clinical endpoint was the 12-month rate of major adverse cardiac events (MACE), consisting of all-cause death, re-infarction, and new congestive heart failure.

Patients with MACE (n = 73) had significantly impaired CURE [0.76 (IQR 0.67-0.86) versus 0.84 (IQR 0.76-0.89); p &lt; 0.001] and RURE [0.69 (IQR 0.60-0.79) versus 0.76 (IQR 0.67-0.83); p &lt; 0.001] compared to patients without events. While uniformity estimates did not provide independent prognostic information in the overall cohort, CURE below the median of 0.84 emerged as an independent predictor of outcome in post-infarction patients with LVEF &gt;35% (n = 959) even after adjustment for established prognostic markers (hazard ratio 1.99; 95% confidence interval 1.06-3.74; p = 0.033 in stepwise multivariable Cox regression analysis). In contrast, LVEF was not associated with adverse events in this subgroup of AMI patients.

Conclusions

CMR-derived estimates of mechanical uniformity are novel markers for risk assessment after AMI and CURE provides independent prognostic information in patients with preserved or only moderately reduced LVEF.

P5249Comprehensive invasive and non-invasive assessment of coronary artery lesions with and without hemodynamic significance

Background

There is limited knowledge about specific morphological parameters beyond the degree of stenosis to further characterize hemodynamically relevant coronary lesions.

Objective

The goal of this study was to identify certain morphological or molecular characteristics that distinguish hemodynamically significant from non-significant coronary lesions using various invasive and non-invasive measures.

Methods

This clinical study included patients with symptoms suggestive of CAD who underwent native T1-weighted CMR and gadofosveset-enhanced CMR as well as invasive coronary angiography between 2015 and 2016. OCT of the culprit vessel to determine the plaque type was performed in a subset of patients. Functional relevance of all lesions was examined using quantitative flow reserve (QFR-Angio). Hemodynamically significant lesions were defined as lesions with a QFR <0.8. Signal intensity (contrast-to-noise ratios; CNRs) on native T1-weighted CMR and gadofosveset-enhanced CMR was defined as a measure for intraplaque hemorrhage and endothelial permeability respectively.

Results

Overall 13 patients (n=28 coronary segments) were included, whose invasive coronary angiograms projections were eligible for QFR analysis. Segments containing lesions with a QFR <0.8 (n=9) were associated with significantly higher signal enhancement on Gadofosveset-enhanced CMR as compared to segments containing a hemodynamically non-relevant lesions (lesion-QFR>0.8; n=19) (7.0±4.9 vs. 3.0±2.6; p=0.02). No differences in signal enhancement were seen on native T1-weighted CMR (2.1±4.3 vs. 3.3±4.1; p=0.24). 66,7% (4 out of 6) of all vulnerable plaque and 33.3% (2 out of 6) of all non-vulnerable plaque (fibroatheroma) as assessed by OCT were hemodynamically significant lesions.

Conclusion

The findings of this small feasibility study suggest that hemodynamically significant lesions are more advanced and associated with a higher grade of endothelial permeability while the presence of intraplaque hemorrhage may not be associated with hemodynamically relevant coronary lesions.

P5284Fully automated quantification of biventricular volumes and function in cardiovascular magnetic resonance: applicability to clinical routine settings

Background

Cardiovascular magnetic resonance (CMR) represents the clinical gold standard for the assessment of biventricular morphology and function. Since manual post-processing is time-consuming and prone to observer variability, efforts have been directed towards automated volumetric quantification. In this study, we sought to validate the accuracy of a novel approach providing fully automated quantification of biventricular volumes and function in a “real-world” clinical setting.

Methods

Three-hundred CMR examinations were randomly selected from the local data base. Fully automatic quantification of left ventricular (LV) mass, LV and right ventricular (RV) end-diastolic and systolic volumes (EDV/ESV), stroke volume (SV) and ejection fraction (EF) were performed overnight using commercially available software. Parameters were compared to manual assessments. Sub-group analyses were further performed according to image quality, scanner field strength, the presence of implanted aortic valves and repaired Tetralogy of Fallot (ToF).

Results

Biventricular automatic segmentation was feasible in all 300 cases. Overall agreement between fully automated and manually derived LV parameters was good (LV-EF: intra-class correlation coefficient [ICC] 0.95; bias −2.5% [SD 5.9%]), whilst RV agreement was lower (RV-EF: ICC 0.72; bias 5.8% [SD 9.6%]). Lowest agreement was observed in case of severely altered anatomy, e.g. marked RV dilation but normal LV dimensions in repaired ToF (LV parameters ICC 0.73–0.91; RV parameters ICC 0.41–0.94) and/or reduced image quality (LV parameters ICC 0.86–0.95; RV parameters ICC 0.56–0.91), which was more common on 3.0T than on 1.5T.

Conclusions

Fully automated assessment of biventricular morphology and function is robust and accurate in a clinical routine setting with good image quality and can be performed without any user interaction. However, in case of demanding anatomy (e.g. repaired ToF, severe LV hypertrophy) or reduced image quality, quality check and manual re-contouring is still required.

Acknowledgement/Funding

DZHK - German Centre for Cardiovascular Research

P5255Culprit vessel related myocardial mechanics and prognostic implications following acute myocardial infarction

Background

Prognosis in acute myocardial infarction (AMI) depends on the amount of infarct related artery (IRA) subtended myocardium and associated damage but has not been described in great detail. Consequently, we sought to describe IRA associated pathophysiological consequences using cardiac magnetic resonance (CMR).

Methods

1235 AMI patients (n=795 ST-elevation (STEMI) and 440 non-STEMI) underwent CMR following percutaneous coronary intervention. Blinded core-laboratory data were compared according to left anterior descending (LAD), left circumflex (LCx) and right coronary artery (RCA) regarding major adverse clinical events (MACE) within 12 months. Left ventricular (LV) global longitudinal/circumferential/radial (GLS/GCS/GRS) as well as left atrial (LA) total (εs), passive (εe) and active (εa) strains were determined using CMR-feature tracking. Tissue characterisation included infarct size (IS) and microvascular obstruction.

Results

LAD and LCx were associated with higher mortality compared to RCA lesions (4.6% and 4.4% vs 1.6%). LAD lesions showed largest IS (16.8%), largest ventricular (LV ejection fraction (EF) 47.4%, GLS −13.2%, GCS −20.8%) and atrial (εs 20.2%) impairment. There was less impairment in LCx (IS 11.8%, LVEF 50.8%, GLS −17.4%, GCS −25.0%, εs 20.7%) followed by RCA lesions (IS 11.3%, LVEF 50.8%, GLS −19.1%, GCS −26.6%, εs 21.7%). In AUC analyses εs (LAD, RCA) and GLS (LCx) best predicted MACE (AUC>0.69). Multivariate analyses identified εs (p=0.017) in LAD and GLS (p=0.034) in LCx infarcts as independent predictors of MACE.

Conclusions

CMR allows IRA specific phenotyping and characterisation of morphologic and functional changes. These alterations carry infarct specific prognostic implications and may represent novel diagnostic and therapeutic targets following AMI.

Acknowledgement/Funding

DZHK - German Centre for Cardiovascular Research

P3097Atrioventricular mechanical coupling and major adverse cardiac events in female patients following acute ST elevation myocardial infarction

Background

Data on sex-specific outcomes following myocardial infarction (MI) are inconclusive with some evidence suggesting association of female sex and increased major adverse clinical events (MACE). Since underlying mechanisms remain elusive, we aimed to quantify the underlying phenotype using cardiovascular magnetic resonance (CMR) quantitative deformation imaging and tissue characterisation.

Methods

Amongst 8 centres across Germany, 795 ST-elevation MI (STEMI) patients underwent post-interventional CMR imaging. CMR feature-tracking (FT) was performed in a blinded core-laboratory. Left ventricular function was quantified using ejection fraction (LVEF) and global longitudinal/circumferential/radial strains (GLS/GCS/GRS). Left atrial function was assessed by reservoir (εs), conduit (εe) and booster pump function (εa). Tissue characterisation included infarct size (IS), microvascular obstruction (MO), area at risk and myocardial salvage index (MSI). Primary endpoint was the occurrence of major adverse clinical events (MACE) within 1 year.

Results

Female sex was associated with increased MACE (HR 1.96, 95% CI 1.13–3.42, p=0.017) but not independently of baseline confounders (p=0.526) with women being older, more often diabetic and hypertensive (p<0.001) and of higher Killip-class (p=0.010). Tissue characterisation was similar between sexes. Women showed impaired atrial (εs p=0.011, εe p<0.001) but increased systolic ventricular mechanics (GLS p=0.001, LVEF p=0.048). Ventricular strain was associated with MACE irrespective of all univariate significant baseline characteristics (GLS HR 1.08, 95% CI 1.01–1.16, p=0.036 and GCS HR 1.07, 95% CI 1.00–1.14, p=0.040).

Conclusion

Atrial function is reduced in women following STEMI, while ventricular systolic function is increased. This may reflect ventricular diastolic failure with systolic compensation, which is independently associated with MACE and may add to sex-specific prognosis evaluation.

Acknowledgement/Funding

DZHK - German Centre for Cardiovascular Research

P11.26 Genome-wide shRNA screen identifies candidate genes driving glioblastoma invasion

BACKGROUND

A major hallmark of glioblastoma (GBM) is its highly invasive capacity, contributing to its aggressive behaviour. Since invasive cells cannot be easily removed by surgery or irradiation, they are left behind and eventually result in lethal recurrence. Therefore, a better understanding of the invasion process and of the key molecular players underlying the invasive capacities of GBM may lead to the identification of new therapeutic targets for GBM patients.

MATERIAL AND METHODS

To identify candidate genes responsible for invasion, a genome-wide shRNA screen was performed in patient-derived GBM sphere cultures. The phenotype of the most promising candidate was validated in in vitro invasion assays, ex vivo brain slice cultures and in vivo orthotopic xenografts in mice. Gene knockdown in invasive GBM cell lines was compared with overexpression in non-invasive cells. RNA sequencing of knockdown cells, along with the generation of deletion constructs were applied to uncover the mechanisms regulating invasion.

RESULTS

Through a whole genome shRNA screen, a zinc-finger containing protein was identified as an invasion essential candidate gene. Knockdown of this gene confirmed a strong decrease in invasion capacity in two highly invasive GBM cell lines. In contrast, gene overexpression switched non-invasive GBM cells to an invasive phenotype. Deletion of either one or both zinc-finger motifs led to decreased invasion indicating that the two zinc-finger motifs are essential for regulating invasion. Mutation of the nuclear localisation signal resulted in retention of the protein in the cytoplasm and loss of the invasion phenotype demonstrating that the protein activity is required in the nucleus. Gene expression analyses revealed that invasion-related genes are significantly regulated by the candidate gene once it is localized in the nucleus.

CONCLUSION

We identified a zinc-finger containing protein as a novel driver of GBM invasion, presumably through a transcription factor activity resulting in the induction of an invasive transcriptional program. This protein and its downstream pathway may represent a novel promising target to overcome invasive capacities in GBM.

P11.09 Pan-RTK inhibition of sLRIG1 mediates AXL downregulation in Glioblastoma

INTRODUCTION

Aberrant regulation of receptor tyrosine kinase (RTK) activity is characteristic of Glioblastoma (GBM). However, RTK-based targeted therapies have been largely unsuccessful in GBM patients, partially due to the complexity and redundance of RTK signaling. LRIG1 (Leucine-rich Repeats and ImmunoGlobulindomains protein 1) is known as an endogenous inhibitor of epidermal growth factor receptor (EGFR) during health and disease, however its mechanism of action is poorly understood. We previously showed that the soluble form of LRIG1 potently inhibits of GBM growth in vivo, irrespective of EGFR expression level and status, suggesting the involvement of other RTKs. Here, we aimed to shed light on the molecular mechanisms underlying its anti-cancer activity.

MATERIAL AND METHODS

We generated a recombinant human soluble LRIG1 protein by expressing LRIG1 ectodomain in insect cells via baculovirus infection and subsequent His-tag purification. rh-sLRIG1 was applied in the medium of classical GBM cell lines, patient-derived GBM stem-like cells and patient-derived 3D tumor organoids. Using different cell-based assays, cell proliferation, invasion, cell morphology, as well as protein expression and protein-protein interactions were investigated.

RESULTS

We find that recombinant sLRIG1 efficiently reduces proliferation, invasion and viability of GBM cells and patient-derived organoids, and modulates cytoskeleton proteins and cell shape. In line with previous data, the effect of recombinant sLRIG1 is independent of EGFR expression. Interestingly sLRIG1 regulates several RTKs by direct protein downregulation, including AXL, while EGFR expression is not affected. At the molecular level, we find that sLRIG1 interferes with AXL dimerization, while no protein interaction with EGFR is detected.

CONCLUSION

We identify AXL as a novel LRIG1 target and provide evidence that sLRIG1-mediated RTK downregulation requires direct protein-protein interaction. These data pave the way for a potential therapeutic application of recombinant sLRIG1 in the inhibition of growth factor signaling in GBM.

Priorities for future research into asthma diagnostic tools: A PAN-EU consensus exercise from the European asthma research innovation partnership (EARIP)

The diagnosis of asthma is currently based on clinical history, physical examination and lung function, and to date, there are no accurate objective tests either to confirm the diagnosis or to discriminate between different types of asthma. This consensus exercise reviews the state of the art in asthma diagnosis to identify opportunities for future investment based on the likelihood of their successful development, potential for widespread adoption and their perceived impact on asthma patients. Using a two-stage e-Delphi process and a summarizing workshop, a group of European asthma experts including health professionals, researchers, people with asthma and industry representatives ranked the potential impact of research investment in each technique or tool for asthma diagnosis and monitoring. After a systematic review of the literature, 21 statements were extracted and were subject of the two-stage Delphi process. Eleven statements were scored 3 or more and were further discussed and ranked in a face-to-face workshop. The three most important diagnostic/predictive tools ranked were as follows: "New biological markers of asthma (eg genomics, proteomics and metabolomics) as a tool for diagnosis and/or monitoring," "Prediction of future asthma in preschool children with reasonable accuracy" and "Tools to measure volatile organic compounds (VOCs) in exhaled breath."

[The use of sunglasses during leisure time and work : Lack of prevention of sun-induced eye damage]

OBJECTIVE

This study aimed at collecting representative national data on the use of sunglasses on sunny summer days during leisure time or work as well as identifying population and professional groups with a pronounced lack of preventive measures to avoid sun-induced eye damage.

MATERIAL AND METHODS

Within the representative National Cancer Aid Monitoring, data on the use of sunglasses during leisure time was assessed among 3000 individuals aged 14-45 years in 2015, as well as on the use during outdoor work among 485 workers aged 14-45 years in 2016. Associations between the use of sunglasses and sociodemographic characteristics were assessed with the χ²-test. Additionally, descriptive and bivariate methods were used to assess connections between the use of sunglasses at work and each professional group.

RESULTS

While more than half of the general population normally or often wear sunglasses on a sunny summer day, only one third of outdoor workers do so. While approximately every seventh individual surveyed never wears sunglasses during leisure time, among outdoor workers it is one out of three. The use during leisure time increases with age.

DISCUSSION

Use of sunglasses during work could be supported by targeted information on UV-induced eye damage by ophthalmologists and company physicians with additional support from accident insurances and employers. Concerning preventive measures occupational groups such as landscapers, farmers and bricklayers who are strongly exposed to sunlight but rarely wear sunglasses are important groups.