MRI, FDG-PET/CT and Image-Guidance for Re-Irradiation of Locoregionally Recurrent or Second Primary Head-and-Neck Squamous Cell Carcinoma Patients - Results of a Multicenter Cohort Study

PURPOSE/OBJECTIVE(S)

To investigate patterns of care and prognostic benefits of MRI, FDG-PET/CT and image-guidance in re-irradiation of locoregionally recurrent or second primary head-and-neck squamous cell carcinomas (r/s HNSCCs) within a multicenter cohort study.

MATERIALS/METHODS

Patients receiving re-irradiation for r/s HNSCC between 2009 and 2020 at 16 tertiary cancer centers in Germany were retrospectively analyzed in terms of MRI and FDG-PET/CT usage for treatment planning and regarding image-guidance frequency during re-irradiation. Patterns of use of these modalities over time were analyzed by binary logistic regression analysis, and the association between the usage of these modalities and best locoregional treatment response was analyzed with chi-square tests. Cumulative incidence analyses of locoregional failures with death as competing event were performed.

RESULTS

In the total cohort of 297 patients, 226 (76%) were male, median age was 62 years (IQR, 56-70), and median ECOG was 1 (IQR, 1-2). There were 260 locoregionally recurrent HNSCCs, and 37 second primary HNSCCs; 44 patients (15%) had distant metastases at the time of re-irradiation. MRI and FDG-PET/CT was used for re-irradiation planning in 117 (39%) and 71 patients (24%), respectively. In median, image guidance (IGRT) was performed twice weekly (IQR, 1-5), usually with cone beam CTs or megavolt-CTs, and 85 patients (29%) received daily IGRT during re-irradiation. Usage of MRI (OR = 0.967; 95% CI, 0.892-1.048; p = .416), FDG-PET/CT (OR = 1.053; 95% CI, 0.960-1.156; p = .274), or daily IGRT (OR = 1.057; 95% CI, 0.968-1.115; p = .218) did not increase in frequency over time within the analyzed time span but was significantly dependent on the treatment center (χ2(15), P<.001 for all modalities). Daily IGRT was associated with a higher rate of at least stable disease after re-irradiation as assessed by RECIST criteria (χ2(1) = 4.011, p<.05). There was a trend towards better RECIST-assessed treatment response for MRI (χ2(1) = 3.223, p = .073) and FDG-PET/CT (χ2(1) = 2.792, p = .095) as part of the re-irradiation planning process. Incidence of locoregional failures was not dependent on MRI (SHR = 0.94; 95% CI, 0.67-1.33; p = 0.741, Fine-Gray), FDG-PET/CT (SHR = 0.88; 95% CI, 0.59-1.33; p = 0.552) or daily IGRT (SHR = 0.76; 95% CI, 0.51-1.14, p = 0.182), There was a trend towards lower acute grade 3/4-toxicities in patients receiving daily IGRT (χ2(1) = 3.354, p = 0.067).

CONCLUSION

Our data suggest that daily IGRT may increase disease control and should be regularly applied for re-irradiation of r/s HNSCCs. MRI and FDG-PET/CT usage were not associated with the incidence of locoregional failures after re-irradiation. However, prospective trials with multiparametric MRI and/or FDG-PET/CT for optimal re-irradiation planning are warranted.

Long-term prognostic value of left atrial longitudinal strain in a low-risk community-based cohort

 

Numerous studies established the significant predictive value of left ventricular (LV) global longitudinal strain (GLS) on adverse clinical outcomes in various cardiac diseases. Despite the well-known importance of left atrial (LA) mechanics in diastolic function, data are scarce regarding the prognostic power of LA longitudinal strain and its potential added value in the risk stratification of a low-risk population.

Accordingly, our aim was to determine the long-term prognostic importance of 2D speckle-tracking echocardiography-derived peak atrial longitudinal strain (PALS) in a community-based screening sample comprising of low-risk adult individuals.

Three hundred fourteen volunteers were retrospectively identified from a population-based screening program (mean age 62±11, 58% female) with a median follow-up of 9.5 years. All subjects who participated in the screening program underwent 2D echocardiography to measure LV volumes and ejection fraction (EF), LV GLS and PALS, as well as low-dose cardiac CT to determine the Agatston score. The primary endpoint was all-cause mortality.

Thirty-nine subjects (12.4%) met the primary endpoint. Subjects with adverse outcome had significantly decreased LV GLS (dead vs. alive; −19.2±4.3 vs. −20.6±3.5%, p&lt;0.05) and PALS (32.3±12.0 vs. 41.8±14.2%, p&lt;0.001), whereas LV EF did not show a difference between the two groups (51.1±7.0 vs. 52.1±6.2, %, p=NS). By multivariable Cox regression analysis, PALS (hazard ratio 0.970 [95% CI: 0.943–0.998], p&lt;0.05) and Agatston score were independently associated with all-cause mortality, whereas GLS was not (hazard ratio 1.008 [95% CI, 0.919–1.105], p=NS). Furthermore, we dichotomised the population based on PALS values using a guideline-directed cut-off of 39%. In subjects with lower PALS values, the risk of all-cause mortality was almost 2.5 times higher than in subjects with PALS values above 39% (hazard ratio 2.499 [95% 1.334–4.682], p&lt;0.05) as shown on the Kaplan-Meier curve (Figure 1).

Beyond the assessment of LV EF and LV GLS, PALS offers incremental value in cardiovascular risk stratification in a community-based cohort. PALS was found to be the only significant and independent predictor of long-term mortality among other echocardiographic functional parameters. Our results emphasize the importance of a thorough evaluation of LA mechanics even in a low-risk population.

Funding Acknowledgement

Type of funding sources: None.

There is more than just longitudinal strain: prognostic significance of biventricular circumferential mechanics

 

Global longitudinal strain is a well-established predictive parameter of adverse outcomes in several cardiac diseases, therefore, it is widely used in clinical practice. Despite the significant contribution of circumferential shortening to the global ventricular function, data are scarce concerning the biventricular circumferential strain phenotypes and their prognostic value on long-term mortality.

Accordingly, the aim of our study was to assess both left (LV) and right ventricular (RV) global circumferential strain (GCS) using 3D echocardiography in order to determine the prognostic importance of the deterioration of biventricular circumferential mechanics.

Three hundred and sixty-four patients with various established left-sided heart diseases were retrospectively identified (age: 64.8±15.0 years, 69% males) with a median follow-up of 41 months. All patients underwent clinically indicated transthoracic echocardiography and left (LV) and right ventricular (RV) ejection fractions (EF) were measured by 3D analysis. 3D LV and RV GCS were also quantified by dedicated softwares. In order to determine the prognostic power of the different patterns of biventricular circumferential mechanics, we divided the patient population into four groups using the median values of LV and RV GCS (absolute values of 27.1% and 17.9%, respectively). Group 1 consisted of patients with both LV and RV GCS above median values; Group 2 was defined as patients with LV GCS above the median, while RV GCS below the median, whereas in Group 3 patients had LV GCS values below the median, while RV GCS was above median. Group 4 was defined as patients with both LV and RV GCS below the median. The primary endpoint of our study was all-cause mortality.

Fifty-five patients (15.1%) met the primary endpoint. The overall patient population showed balanced values of LV and RV EF (49.0±15.7 and 48.2±9.4%, respectively). Comparing the population separated into the above-mentioned four groups based on LV and RV GCS values enabled a detailed risk stratification as shown on the Kaplan-Meier curve (Figure 1.) When comparing Group 1 vs. Group 4, patients who had lower LV and RV GCS values the risk of all-cause mortality was more than 5 times higher than in patients with both LV and RV GCS above the median (HR, 5.240 [95% CI, 2.750–9.985], p&lt;0.001). By comparing Group 2 with Group 3, the associated risks for all-cause mortality did not show a difference (HR, 0.461 [95% CI, 0.178 to 1.194], p=NS) as shown on the Kapan-Meier curve (Figure 2).

Based on the different phenotypes of LV and RV GCS, decreased biventricular circumferential shortening was associated with a significantly increased risk of long-term all-cause mortality. Interestingly, decreased RV GCS with maintained LV GCS showed a similar risk of adverse outcomes than decreased LV GCS with maintained RV GCS. Our results emphasize the importance of the assessment of biventricular circumferential mechanics.

Funding Acknowledgement

Type of funding sources: None.

Extension of fitness evaluations with muscle oxygen saturation measurements based on near-infrared spectroscopy analysis during cardiopulmonary exercise testing in elite athletes

Introduction

Many cardiovascular parameters of sport adaptation have become an area of detailed research in recent decades. However, details of local circulatory and metabolic processes ongoing in the working muscles during physical exercise need to be revealed.

Purpose

Our aim was to extend cardiopulmonary exercise testing with near-infrared spectroscopy measurements to focus on observing local changes in the contracting muscles during running.

Methods

Mixed muscle oxygen saturation values (SmO2) measured in the left vastus lateralis muscle of athletes were analyzed by near-infrared spectroscopy during vita maxima treadmill cardiopulmonary exercise testing with 2-min fingertip lactate measurements. Body composition analysis was carried out with bioimpedance method. One-way repeated measures ANOVA, Tukey post-hoc test, Shapiro–Wilk test and Pearson correlation were used for statistical analysis.

Results

The results of 66 elite athletes (male: 40; age: 17.9±3.6 y; training: 17.7±6.6 h/w; water polo player: 56, wrestler: 8, basketball player: 2) were analyzed. The 10-second averaged values of the measured saturation values were examined at rest (65.8±11.1%), at the anaerobic threshold (40.7±22.8%), at maximum load (30.2±20.5%) and after 5 minutes of cool-down (70.9±12.8%). Significant differences were measured between the four measurement time points in all pairings. A negative correlation was found between the achieved maximal oxygen uptake and the muscle oxygen saturation values measured at the anaerobic threshold and at the maximal load (respectively r=−0.30, p&lt;0.02; r=−0.32, p&lt;0.01). Oxygen uptake at the end of cool-down was also negatively correlated with muscle oxygen saturation values measured at the anaerobic threshold and at the peak of exercise (respectively r=−0.27, p&lt;0.05; r=−0.27, p&lt;0.05). The fat-free mass of the identical limb showed negative correlation with the muscle oxygen saturation values measured at the anaerobic threshold, at the maximal load and at the cool-down (respectively r=−0.43, p&lt;0.01; r=−0.44, p&lt;0.01; r=−0.35, p&lt;0.01), while positive interactions were observed between the body-fat mass of the same limb and the muscle oxygen saturation values (respectively r=0.51, p&lt;0.01; r=0.55, p&lt;0.01; r=0.41, p&lt;0.01). Muscle oxygen saturation values showed no significant correlations with exercise time, lactate levels, or heart rate measurements.

Conclusions

By our results, muscle oxygen saturation measurements can be reliably applied during exercise physiological measurements. During exercise, muscle oxygen saturation values negatively correlated with oxygen uptake. At the cool-down phase, a rebound effect could be observed compared to the resting measurements. On the identical limb, the higher the muscle mass was, the higher muscle desaturation could be measured. This easy-to-perform test provides insight into muscle metabolism processes and can help with training planning and athlete follow-up.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 135076). Supported by the ÚNKP-21-3-I-SE-68 New National Excellence Program of the Ministry for Innovation and Technology from the Source of the National Research, Development and Innovation fund.

Clinical determinants of non-invasive global myocardial work index before and after transcatheter aortic valve implantation: a prospective study

 

The estimation of non-invasive global myocardial work indices is a novel method of the left ventricular (LV) functional assessment, which may overcome the load-sensitvity of the traditional functional measures. The diagnostic and prognostic role of this approach may gain particular importance in pressure overload states, such as in patients with severe aortic stenosis. However, the longitudinal changes of this recently introduced measure are scarcely investigated, and data are also lacking about the main determinants of these measures.

Accordingly, our aim was to investigate the clinical determinants of preoperative and also postoperative GMWI in patients undergoing transcatheter aortic valve replacement (TAVR).

Fifty patients (62% male, age: 78±5 years) were enrolled. Prior to the procedure, subjects underwent echocardiographic investigation and the detailed medical history was also recorded. Speckle-tracking analysis was performed and global longitudinal strain (GLS) was measured. LV pressure curve was estimated by adding the mean aortic valve gradient to the systolic blood pressure. Using these measures, global myocardial work index (GMWI) and global constructive work index (CMWI) was quantified by commercially available software. A 6 months follow-up examination was also performed and at that time point we determined the aforementioned parameters.

At follow-up, GLS has significantly increased (−13.0±4.1 vs. −14.8±3.8%; p&lt;0.001), while GMWI was significantly lower compared to baseline (1789±748 vs. 1506±561 mmHg%, p&lt;0.01). CMWI did not differ between the two time points (2309±782 vs. 2086±609 mmHg%, p=0.11). Using multivariable analysis, age (β=0.30; p&lt;0.05) preoperative New York Heart Association (NYHA) class (β=−0.48; p&lt;0.001) and having a pacemaker (β=−0.44; p&lt;0.01) were found to be independent predictors of the preoperative GMWI (R2=0.39; overall p&lt;0.001). On the other hand, postoperative GMWI was determined (R2=0.48; overall p&lt;0.001) by gender (β=−0.25; p&lt;0.05), the presence of diabetes mellitus (β=−0.37; p&lt;0.01) and also by having a pacemaker (β=−0.38; p&lt;0.01).

TAVR significantly alters LV functional measures. Different clinical factors influence GMWI before and after the procedure: age, NYHA class-based symptom severity and having a pacemaker were found to be independently associated with preoperative GMWI, while gender, the presence of diabetes mellitus and pacemaker device are the most important clinical determinants of the postoperative GMWI value.

Funding Acknowledgement

Type of funding sources: None.

Right ventricular mechanics and its association with symptoms in transcatheter aortic valve replacement candidates: a three-dimensional echocardiography study

 

Aortic valve stenosis is one of the most prevalent valvular disease with significant clinical burden. While it is initially a disorder of the left ventricle (LV), long-term effects of the disease also affect the right ventricle (RV) as well. Nevertheless, data are scarce regarding the changes of RV mechanics and their association with symptomatic status of the patients. 3D echocardiography allows a more detailed assessment of the RV, which may unveil distinct changes of its morphology and function in this clinical setting.

Accordingly, our aim was to examine LV and RV mechanics in TAVR candidate patients with severe aortic stenosis using three-dimensional (3D) echocardiography.

Seventy patients (51% male, age: 80±6 years) were enrolled. Detailed medical history and symptomatic status were obtained. Beyond conventional transthoracic echocardiographic protocol, 3D loops were also acquired. We measured 3D LV and RV end-diastolic volume indexed to body surface area (EDVi), ejection fraction (EF) and global longitudinal (GLS) using dedicated software. Furthermore, we have determined 3D RV global longitudinal (RV GLS) and circumferential strain (RV GCS) using the ReVISION method.

LV EF (r=0.28, p&lt;0.05) and LV GLS (r=−0.26, p&lt;0.05) significantly correlated with age, while RV EF (r=0.21, p=0.11), RV GLS (r=−0.17, p=0.19) and RV GCS (r=−0.07, p=0.61) did not show association with it. 41% (n=29) of the patient population mentioned angina or had syncope. Patients with these symptoms had comparable LV EDVi (73±23 vs. 69±25 mL/m2, p=0.47), LV EF (47±15 vs. 51±10%, p=0.14) and LV GLS (−13.6±4.8 vs. −14.8±2.6%, p=0.25) to those who did not mention these complaints. On the other hand, patients with angina or syncope in their medical history had significantly lower RV EDVi (58±13 vs. 70±23 mL/m2, p&lt;0.05), while having significantly higher RV EF (46±10 vs. 52±7%, p&lt;0.05). Moreover, symptomatic patients had significantly lower RV GCS (−15.7±5.6 vs. −19.6±5.3%, p&lt;0.01), while RV GLS did not differ (−15.8±4.8 vs. −17.4±4.1%, p=0.17).

Patients with severe aortic stenosis have marked changes in not only the LV, but the RV mechanics as well. While the symptomatic status does not seem to be associated with LV morphology and function, patients with angina or syncope had distinct changes in RV size and the contraction pattern of the chamber.

Funding Acknowledgement

Type of funding sources: None.

Evaluation of the interplay between NASH and HFpEF in varied murine age groups

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 Research and Innovation Programme, grant agreement no. 739593

New National Excellence Program of the Ministry of Human Capacities (ÚNKP-21-3-II)

Introduction

Heart failure with preserved ejection fraction (HFpEF) is characterized by diastolic dysfunction, left ventricular hypertrophy, left atrial enlargement and increased serum levels of NT-pro-BNP. HFpEF accounts for 50% of heart failure cases, and typically develops in patients with metabolic comorbidities. Non-alcoholic fatty liver disease and subsequent steatohepatitis (NAFLD, NASH) is the most common chronic liver disease developing due to obesity. Although clinical/epidemiological data exists in humans showing that NASH may lead to cardiac dysfunction per se, experimental data in this regard is lacking.

Purpose

We aimed to evaluate whether NASH is an independent factor of cardiac dysfunction and to investigate the age-dependent effects of NASH on cardiac function.

Methods

Middle aged (10 months old) and aged (24 months old) C57Bl/6J mice were fed either control diet or Choline Deficient (CDAA) diet over a period of eight weeks. Young (2 months old) mice were used as a control. Before termination, echocardiography was performed. Upon termination, organs were isolated for further analysis.

Results

CDAA diet lead to the development of NASH in both age groups, without inducing weight gain, allowing us to investigate the direct effects of NASH on cardiac function. Left ventricular end-diastolic volume (EDV) was increased in aged animals, compared to young and middle aged animals, suggesting increased ventricular pressure. Aged animals were characterized by increased posterior wall thickness (PWT) during diastole and by increased LV mass, indicating left ventricular hypertrophy. Assessment of ejection fraction showed an age-dependent decline. Pulse wave and tissue Doppler measurements showed no difference in E/e’ ratio between the groups. However, strain analysis showed that diastolic dysfunction developed only in aged mice due to NASH.

Conclusion

We conclude that there were no observed changes in cardiac diastolic function due to NASH when using standard echocardiographic evaluation; however, the more sensitive method of strain analysis with 2D speckle tracking was able to show evidence of diastolic dysfunction due to NASH in aging animals.

Changes of the non-invasive myocardial work in patient undergoing transcatheter aortic valve replacement: the influence of left bundle branch block

Funding Acknowledgements

Type of funding sources: None.

Patients with left bundle branch block (LBBB) are known to have substantially increased afterload sensitivity. It gains particular importance in subjects with aortic stenosis: patients with pre-existing LBBB may benefit more from interventions such as transcatheter aortic valve replacement (TAVR) by an effective and rapid reduction of the left ventricular (LV) pressures.

Accordingly, our aim was to investigate the changes of LV myocardial work indices in patients undergoing TAVR by the presence of preoperative LBBB. Non-invasive myocardial work indices are novel echocardiographic parameters which adjust LV deformation to the instantaneous LV pressure, overcoming the the load-sensitivity of the traditional LV functional measures.

Thirty patients undergoing TAVR were enrolled (37% female; age: 78±6 years; aortic valve area [AVA]: 0.7±0.3 cm2). Fourteen patients (47%; LBBB group) showed LBBB pattern on ECG, by demonstrating native LBBB (n=6; 20%) or having ventricular pacing dependency (n=8; 27%), while 16 patients had narrow QRS (53%; non-LBBB group). Prior to the procedure, subjects underwent a detailed echocardiographic investigation. Speckle-tracking analysis was performed and global longitudinal strain (GLS) was measured. LV pressure curve was estimated by adding the mean aortic valve gradient to the aortic systolic pressure. Using these measures, LV global constructive work index (CMWI) and global work efficiency (GWE). were quantified by commercially available software. A 6 months follow-up examination was also performed and at that time point we determined the aforementioned parameters.

As expected, AVA significantly improved after the procedure in the pooled study group (1.8±0.4 cm2; p&lt;0.001). GLS also significantly increased (-13.2±4.2 vs. -15.2±3.9 %; p&lt;0.01), while CMWI only showed a tendential decrease (2422±788 vs. 2166±640 mmHg%; p=NS) at the follow-up. GLS (-10.6±3.7 vs. -15.5±3.4%; p&lt;0.001), CMWI (1877±679 vs. 2898±529 mmHg%; p&lt;0.001), and also GWE (82±9 vs. 91±4%; p&lt;0.01) was significantly lower in the LBBB-group compared to the non-LBBB patients. At the follow-up, GLS was still significantly lower in the LBBB patients (-13.2±4.6 vs. -16.9±2.1%; p&lt;0.01), however, CMWI was comparable between the two groups (1956±776 vs. 2350±439 mmHg%, p=NS).

Pressure overload of the LV may affect patients with LBBB substantially more than subjects without it. TAVR causes an immediate and significant decrease in the LV afterload, which results in a more pronounced improvement in the LBBB group compared to those with no LBBB.

Unexpectedly low Incidence of COVID-19 among Refugees of War from Ukraine to Slovakia in First Month of Conflict (Original Research)

Several armed conflicts and military troop interventions have been associated with minor pandemics, however, not always, and with the extent varied. e.g. during the most catastrophic loss of lives in the Bosnian Conflict in 1993-95 where 160,000 civilians and soldiers fell into mass graves, only one small epidemic of Hepatitis A was reported to the European branch of WHO.                                                       In contrast, epidemics of cholera in Haiti, not related to war but associated with troop deployment (UN battalion from Nepal) in 2014, led to a devastating epidemic of cholera in the Artibonite River District with 1,000s of deaths. The same was reported during civil war and genocide in Rwanda in 1988-98 where hundreds died, and refugees of war-related exodus from Rwanda to the DRC in Goma. Finally, pipeline and water supply devastation during war in Yemen, led to the largest cholera outbreak in Yemen (1-3). Therefore, fear of epidemics, especially during COVID-19 Omicron wave is of concern mainly when the numbers of positive cases in Austria and other EU countries are increasing.                                                       The aim of this study was to report the results of COVID-19 antigen testing in those escaping from war in Ukraine.

Biventricular mechanical pattern of the athlete"s heart: comprehensive characterization using 3D echocardiography

Funding Acknowledgements

Type of funding sources: None.

Regular, intense exercise results in complex morphological and functional cardiac remodeling, commonly referred to as the athlete"s heart. While left ventricular (LV) adaptation is thoroughly studied, data are scarce concerning the right ventricular (RV) mechanical changes and their continuum with exercise performance.

Accordingly, our aim was to characterize biventricular morphology and function and its relation to sex, age and sport classes in a large cohort of elite athletes using 3D echocardiography.

Four hundred and twenty-two elite, competitive athletes (male/female: 295/127, adult/adolescent: 207/215) from the 4 major sport classes (mixed type n = 293; endurance n = 88; power n = 33; skill n = 8) and healthy, sedentary volunteers (n = 55) were enrolled. 3D transthoracic echocardiographic datasets were acquired to quantify LV and RV end-diastolic volumes (EDVi), and ejection fractions (EF). In order to characterize biventricular mechanical parameters, LV and RV global longitudinal (GLS) and global circumferential strains (GCS) were measured using dedicated softwares. Additionally, all subjects underwent cardiopulmonary exercise testing in order to determine peak oxygen uptake (VO2/kg).

Athletes had significantly higher LV and RV EDVi compared with controls, whereas male athletes had larger volumes than female athletes, and adult athletes had also larger LV EDVi than adolescent athletes (all p &lt; 0.05). However, RV EDVi was similar between the two age groups. Endurance athletes had significantly larger RV EDVi compared with the other sport classes (ANOVA p &lt; 0.05). 

Concerning biventricular functional parameters, athletes had significantly lower resting LV and RV EF (athletes vs. controls; LVEF: 57 ± 4 vs. 61 ± 5%; RVEF: 55 ± 5 vs. 59 ± 5%; p &lt; 0.001) as well as LV GLS (-19.2 ± 2.3 vs. -21.2 ± 2.0%), LV GCS (-27.7 ± 3.0 vs. -31.0 ± 3.5%), and RV GCS (-20.9 ± 4.4 vs. -24.5 ± 4.5%; all p &lt; 0.001) compared with controls. In contrast, RV GLS (-21.8 ± 3.4 vs. -22.2 ± 3.6%) did not differ between athletes and controls. The exercise-induced relative decrease in LV GLS (9.5 ± 10.7%) and LV GCS (10.7 ± 9.8%) was similar, however, the decrement in RV GCS (14.8 ± 17.8%) was disproportionately larger compared with RV GLS (1.7 ± 15.4%, p &lt; 0.01) in the athlete population. By multivariable linear regression analysis among echocardiographic parameters using ordinary least squares, RVEDVi was found to be the strongest and independent predictor of VO2/kg, followed by RV GCS and LV EDVi.

Regular physical exercise results in significant and specific changes in LV and RV geometry and function. Resting LV mechanics of the athlete"s heart is characterized by a balanced decrement in GLS and GCS, however, in the RV the circumferential shortening decreases disproportionately compared with the longitudinal shortening. Moreover, this mechanical pattern is associated with better exercise capacity, which emphasizes the importance of the RV in determining athletic performance.

Differences in mitral and tricuspid annular geometry in elite athletes with versus without functional mitral regurgitation: a 3D echocardiographic study

 

Intense exercise exposes the heart to significant hemodynamic demands, resulting in adaptive changes in cardiac morphology and function. Nevertheless, the athletic adaptation of the atrioventricular valves remains to be elucidated. Our study aimed to characterize the geometry of mitral (MA) and tricuspid (TA) annuli in elite athletes using 3D echocardiography.

Thirty-four athletes presented with functional mitral regurgitation (FMR) were retrospectively identified and compared to 34 athletes without MR, and 34 healthy, sedentary volunteers. 3DE datasets were used to quantify MA and TA geometry and leaflet tenting by dedicated softwares.

MA and TA areas, as well as tenting volumes, were higher in athletes compared to controls. MA area was significantly higher in athletes with MR compared to those without (8.2±1.0 vs. 7.2±1.0 cm2/m2, p&lt;0.05, Figure 1). Interestingly, athletes with MR also presented with a significantly higher TA area (7.2±1.1 vs. 6.5±1.1 cm2/m2, p&lt;0.05, Figure 2). Non-planar angle describing the MA's saddle shape was less obtuse in athletes without MR, whereas the values of athletes with MR were comparable to controls (Figure 1). The exercise-induced relative increases in left ventricular (35±25%) and left atrial (40±29%) volumes were similar; however, the increment in the MA area was disproportionately higher (63±23%, overall p&lt;0.001). The relative increase in TA area (40±23%) was also higher compared to the increment in right ventricular volume (34±25%, p&lt;0.05).

Atrioventricular annuli undergo a disproportionate remodeling in response to regular exercise. Athletic adaptation is characterized by both annular enlargement and increased leaflet tenting of both valves. There are differences in MA geometry in athletes presented with versus without FMR.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Office of Hungary (NKFIA; NVKP_16-1-2016-0017 National Heart Program). The research was partly financed by the Thematic Excellence Programme (Tématerületi Kiválόsági Program, 2020-4.1.1.-TKP2020) of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging programmes of the Semmelweis University. Figure 1Figure 2

Frequent constriction-like echocardiographic findings in elite athletes following mild COVID-19: in the grasp of SARS-CoV-2?

 

The COVID-19 pandemic had a major impact on the sports community as well. Despite the vast majority of athletes experiencing mild symptoms, potential cardiac involvement and complications have to be explored to support a safe return to play. Accordingly, we were aimed at a comprehensive echocardiographic characterization of post-COVID athletes (P-CA) by comparing them to a propensity-matched healthy, non-COVID athlete (N-CA) cohort.

One hundred and seven elite athletes with COVID-19 were prospectively enrolled after an appropriate quarantine period and formed the P-CA group (23±6 years, 23% female). From our retrospective database comprising 425 elite athletes, 107 age-, gender-, body surface area-, and weekly training hours-matched subjects were selected as a reference group using propensity score matching (N-CA group). All athletes underwent a comprehensive clinical investigation protocol comprising 2D and 3D echocardiography. Left (LV) and right ventricular (RV) end-diastolic volumes (EDVi) and ejection fractions (EF) were quantified using dedicated softwares. To characterize LV longitudinal deformation, 2D global longitudinal strain (GLS) and the ratio of free wall versus septal longitudinal strain (FWLS/SLS) were also calculated. In order to describe septal flattening (SF – frequently seen in P-CA), LV eccentricity index (EI) was measured.

P-CA and N-CA athletes had comparable LV and RV EDVi (P-CA vs N-CA; 77±12 vs 78±13mL/m²; 79±16 vs 80±14mL/m², respectively). P-CA group had significantly higher LV EF (58±4 vs 56±4%, p<0.001) and GLS (−18.2±1.8 vs −17.6±2.2%, p<0.05). Eccentricity index was significantly lower in P-CA (0.89±0.10 vs 0.99±0.04, p<0.001), which was attributable to a distinct subgroup of P-CA athletes with a prominent SF (n=34, 32%), further provoked by inspiration. In this subgroup, the eccentricity index was markedly lower compared to the rest of the P-CA group (0.79±0.07 vs 0.95±0.07, p<0.001).

In the SF subgroup, LV EDVi was significantly higher (80±14 vs 75±11 mL/m², p<0.001), while RV EDVi did not differ (82±16 vs 78±15mL/m²). Moreover, the FWLS/SLS ratio was significantly lower in the SF subgroup (0.92±0.09 vs 0.97±0.08, p<0.01). Interestingly, P-CA athletes with SF experienced fatigue (17 vs 34%, p<0.05) or chest pain (0 vs 15%, p=N/A) less frequently during the course of the infection; however, the presence of a mild pericardial effusion was more common (41 vs 12%, p<0.01).

Elite athletes following COVID-19 showed distinct morphological and functional cardiac changes compared to a propensity score-matched control athlete group. These results are mainly driven by a subgroup, which presented with some echocardiographic features characteristic of constrictive pericarditis (septal flattening, lower FWLS/SLS ratio, pericardial effusion). Follow-up of athletes and further, higher case number studies are warranted to determine the clinical significance and potential effects on exercise capacity of these findings.

Funding Acknowledgement

Type of funding sources: None.

Mechanical contraction patterns of the systemic right ventricle: a 3D echocardiography study

Funding Acknowledgements

Type of funding sources: None.

Background. In patients with transposition of great arteries (TGA) post atrial switch operation or with congenitally corrected TGA (ccTGA), the morphologically right ventricle (RV) has to adapt to the chronically increased systemic pressure.

Purpose. To investigate the functional adaptation of the systemic RV in patients with TGA post Mustard repair or ccTGA. 

Methods. RV volumes and EF were measured by 3D echocardiography in 33 patients with the systemic RV (21 TGA and 12 ccTGA; 45 ± 13y, 61% male), and in 33 healthy volunteers (44 ± 13y, 61% male). 

The 3D RV model was postprocessed by the ReVISION software and its contraction was decomposed along the longitudinal, radial and anteroposterior directions (Fig.A, Systemic RV in TGA) providing longitudinal, radial and anteroposterior EF (LEF, REF and AEF). Relative contribution of each component was measured as the ratio between LEF, REF and AEF to the global RVEF (LEFi, REFi and AEFi).

Results. Systemic RV was significantly larger with reduced function compared to controls (Tab). 3D RVEF demonstrated stronger correlation with BNP (Rho -0.76, p &lt; 0.0001) compared to other parameters of RV function (free wall strain 0.55, p = 0.0083; FAC -0.47, p = 0.024; S’ -0.39 and TAPSE 0.06, p &gt; 0.05).

While in healthy volunteers, all 3 components of RV systolic function contributed equally to the global RV EF, in patients with TGA the relative contribution of the anteroposterior component was dominant and differed significantly from longitudinal and radial components (AEFi 0.48 ± 0.06 vs LEFi 0.31 ± 0.07 vs REFi 0.36 ± 0.09, p &lt; 0.0001)(Fig. B,C). In patients with ccTGA the longitudinal component was dominant and provided a relative compensation for the reduced anteroposterior and radial components (LEFi 0.47 ± 0.07 vs AEFi 0.34 ± 0.07, p = 0.0002 and vs REFi 0.36 ± 0.09, p = 0.0023)(Fig. B,C). Relative contribution of the radial contraction was significantly reduced in all systemic RV patients.

Conclusions. Systemic RV contraction patterns change significantly with anteroposterior contraction being dominant in patients with TGA post Mustard repair and longitudinal component being dominant in ccTGA.

3DE should be a part of routine assessment of the systemic RV, especially in TGA since no conventional echo parameters take into account anteroposterior RV contraction.

Parameters of RV systolic function Parameter Control group (N = 33) All SRV patients (N = 33) TGA (N = 21) ccTGA (N = 12) 3D EF, % 60 ± 3.8 36 ± 8.6* 34 ± 7.3* 38 ± 10* FAC, % 41.4 ± 3.7 25.9 ± 9.3* 25.1 ± 9.2* 27.1 ± 9.9* TAPSE, mm 24.6 ± 4.2 11.9 ± 3.9* 11.1 ± 2.9* 13.2 ± 5.1* RV free wall strain, % -32.5 ± 4.2 -14.5 ± 3.5* -14.5 ± 2.9* -15.5 ± 3.5* * p &lt; 0.0001 Abstract Figure.

Assessment of right ventricular segmental volumes and ejection fractions using a 15-segment model: three-dimensional echocardiographic study in healthy volunteers

Funding Acknowledgements

Type of funding sources: None.

On top of global ventricular function, segmental metrics may bear clinically relevant information. Concerning the left ventricle (LV), standardized segmentation is widely performed in different cardiovascular imaging modalities mainly to correlate regional dysfunction with coronary perfusion territories, or to appreciate and quantify distinct patterns in LV myocardial function. The same applies to the right ventricle (RV); as pulmonary hypertension, or arrhythmogenic cardiomyopathy are just two clinical examples among several others, where established regional dysfunction exists. Nevertheless, only a few options are available for the comprehensive and quantitative assessment of the segmental RV function due to its complex three-dimensional (3D) shape.

Therefore, our aim was to develop a 3D echocardiographic software solution for volumetric partitioning of the RV using a 15-segment model and to investigate a large number of healthy volunteers to describe the normal segmental pattern.

One hundred and fifty healthy adults with a balanced age range and an equal sex distribution were investigated (15-15 women and men in each age groups: 20-29, 30-39, 40-49, 50-59, 60+). Beyond standard two-dimensional echocardiographic protocol, full volume 3D datasets were acquired. Using commercially available software, we reconstructed the 3D mesh model of the RV and measured end-diastolic (EDV), end-systolic volumes and ejection fraction (EF). The 3D model was post-processed using the ReVISION method to calculate regional and segmental volumes and EFs. Fifteen standard segments were separated and quantified (Figure).

Increasing age resulted in significantly lower RV stroke volume (r=-0.17; p &lt; 0.05) and tended towards lower RV EDV (r=-0.15, p = 0.06). EDVs of inflow tract and outflow tract segments decreased during aging (r=-0.21, p &lt; 0.05 and r=-0.26, p &lt; 0.01, respectively). Between the pre-specified age groups, there was no difference concerning global RVEF (ANOVA p = NS). In the 50-59 age group, regional EF of septal segments and also free wall segments were significantly lower compared to subjects in the 30-39 and 40-49 age categories (both p &lt; 0.05). Global RV EDV was significantly lower in women (women vs. men: 95 ± 20 vs. 125 ± 28 ml; p &lt; 0.05) along with a higher RV EF compared to men (62 ± 4 vs. 59 ± 4; p &lt; 0.05). However, segmental EFs of apical, septal mid anterior, free wall mid posterior, free wall mid lateral, septal basal anterior and inflow tract segments were comparable between genders.

The ReVISION method allows a volumetric partitioning of the RV 3D models to investigate segmental geometry and function in a 15-segment model. We have explored segmental differences between different ages and genders. Further studies are warranted to justify the importance of segmental assessment of the RV in different cardiac diseases.

Abstract Figure. Separation of 15 standard RV segments

Mechanical diversity in the adaptation of left and right ventricular function to long-term exercise: 3D echocardiographic study in a large cohort of competitive athletes

 

Regular physical exercise results in complex remodelling of the left- (LV) and right ventricle (RV), commonly referred as the athlete's heart. Despite the well-known changes in ventricular volumes and mass, data are scarce regarding ventricular mechanics and its connection to exercise performance.

Accordingly, our aim was to characterize biventricular morphological and functional changes and their association with peak exercise capacity in a large cohort of athletes using three-dimensional (3D) echocardiography.

Competitive athletes of various training regimes (n=525, age: 20±6 years, training: 15±7 hours/week, 30% female) were enrolled, while 73 age- and gender-matched sedentary volunteers served as the control group. Full volume 3D echocardiographic datasets focused on the LV or the RV were acquired for further analysis: LV and RV end-diastolic volume (EDVi), LV mass (Mi) indices and ejection fraction (EF) were quantified. To characterize biventricular mechanics, LV and RV global longitudinal strain (GLS) and global circumferential strain (GCS) were also measured using dedicated software. Athletes also underwent cardiopulmonary exercise testing to determine peak oxygen uptake (VO2/kg).

Athletes had significantly higher LV and RV EDVi (81±13 vs. 64±11 mL/m2; 83±14 vs. 63±11 mL/m2; both p&lt;0.001) and also LVMi (87±15 vs. 65±12 g/m2; p&lt;0.001) compared to controls. LV and RV EF were significantly lower in athletes (57±5 vs. 60±6%; 55±5 vs. 58±5%; both p&lt;0.001). LV GLS (−19.5±2.1 vs. −20.6±2.6%; p&lt;0.001) and also LV GCS (−27.9±3.2 vs. −29.8±4.4%; p&lt;0.001) was lower in athletes compared to controls. In opposed to the LV, RV GLS did not differ between the two groups (−29.3±5.8 vs. −29.5±5.3%; p=NS), however, RVGCS was decreased in athletes compared to controls (−24.4±6.1 vs. −28.6±7.3%; p&lt;0.001). In athletes, ventricular morphology measured by LV and RV EDVi correlated with VO2/kg (both r=0.37; p&lt;0.001), while functional measures, such as lower resting LV GLS (r=0.22; p&lt;0.001) and RV GCS (r=0.14; p&lt;0.01) also showed relationship with better exercise performance.

According to our results, regular physical exercise is associated with significant changes of LV and RV geometry and mechanics. Resting biventricular systolic function of the athlete's heart is characterized by a mild reduction, which is attributable to a lower longitudinal and circumferential shortening on the left side of the heart, while on the right side lower circumferential shortening can be seen along with a maintained longitudinal shortening. Moreover, this mechanical pattern also correlates with exercise performance.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): “National Heart Program” NVKP_16-1-2016-0017; NKFIH K_16 K120277 to BM

P947 Left- and right ventricular mechanics in athletes: a true marker of fitness?

Regular physical exercise results in marked changes of ventricular morphology and function, also referred as the athlete’s heart. Despite the marked changes of cardiac morphology and function in athletes, data is scarce regarding the relationship between exercise performance and cardiac adaptation to exercise.

Accordingly, our aim was to examine the relationship between ventricular morphology and function and exercise capacity in a prospective cohort study.

Young elite soccer players (n = 18, age: 16 ± 1 years) were enrolled and examined at baseline and following 1 year. Athletes underwent cardiopulmonary exercise testing to determine peak oxygen uptake (VO2/kg). Following exercise testing, 3D echocardiography was performed and LV and RV focused loops were obtained. By off-line analysis, we measured left- (LV) and right ventricular (RV) end-diastolic volume indices (EDVi) and LV mass index (LVMi) indexed to body surface area and LV and RV ejection fractions (EF). By 3D speckle-tracking analysis of the LV and RV we also determined global longitudinal (GLS) and circumferential (GCS) strains.

We found improved and decreased peak exercise performance as well during the 1 year follow-up with an overrall increased mean exercise capacity (dVO2/kg: 2.6 ± 7.3 ml/min/kg). LV and RV morphology did not change significantly according to LVEDVi and RVEDVi (LVEDVi: 84 ± 14 vs. 80 ± 7 ml/ m², RVEDVi: 82 ± 11 vs. 84 ± 10 ml/m², both p = NS). LVMi significantly increased (82 ± 14 vs. 89 ± 9 g/m², p &lt; 0.001). LV and RV EF did not change during one year follow-up (LVEF: 58 ± 4 vs. 57 ± 5%; RVEF: 57 ± 4 vs. 55 ± 6%, both p = NS), while LVGLS decreased compared to baseline (19.7 ± 1,8 vs. 19.3 ± 2,8%, p &lt; 0.01). The change in VO2/kg showed correlation with decreased LVGLS and also with decreased RVGCS (dLVGLS vs. dVO2/kg: r=-0.56, dRVGCS vs. dVO2/kg: r=-0.50, both p &lt; 0.05)

During 1 year follow-up cardiac morphology and function significantly changed in our athlete cohort, and these changes showed relationship with the changes of peak exercise performance. Detailed assessment of myocardial mechanics may help to monitor training in athletes.

Inflammatory Bowel Disease [IBD] and Physical Activity: A Study on the Impact of Diagnosis on the Level of Exercise Amongst Patients With IBD

BACKGROUND AND AIMS

Inflammatory bowel disease [IBD] can impair patients' functional capacity with significant negative effects on their quality of life. Our aim was to determine the impact of IBD diagnosis on fitness levels and to assess the levels of engagement in physical activity and fatigue in IBD patient before and after diagnosis.

METHODS

A prospective multi-centre cross-sectional study was performed. Patients diagnosed with IBD in the previous 18 months were recruited. Inclusion criteria included clinical remission and/or no treatment changes within the previous 6 months. Physical exercise levels were assessed by the Godin score and fatigue levels was assessed by the functional assessment of chronic illness therapy [FACIT] score.

RESULTS

In total, 158 patients (100 Crohn's disease [CD]) were recruited. Mean age was 35.1 years (95% confidence interval [CI] ± 2.0). Gender distribution was approximately equal [51.3% male]. The Mean Harvey Bradshaw and Simple Clinical Colitis Activity indices were 2.25 [95% CI ± 0.40] and 1.64 [95% CI ± 0.49], respectively. The mean Godin score difference before and after IBD diagnosis was 6.94 [p = 0.002]. Patients with ulcerative colitis [UC] [41.8%] were more likely than patients with CD [23.0%] to reduce their exercise levels [p = 0.04]. FACIT scores were lower in patients who had experienced relapses [p = 0.012] and had severe disease [p = 0.011]. Approximately one-third of patients reduced their activity level following IBD diagnosis.

CONCLUSIONS

Patients were significantly less physically active after a diagnosis of IBD and this was more apparent in UC. Identification of the risk factors associated with loss of fitness levels would help to address the reduced patient quality of life.

Missed opportunities: Do states require screening of children for health conditions that interfere with learning?

METHODS

Investigators reviewed websites of state departments of health and education, and legislation for all 50 states and DC. For states with mandated screenings and a required form, investigators applied structured analysis to assess HBL inclusion.

RESULTS

No state mandated that schools require screening for all 7 HBLs. Less than half (49%) required comprehensive school health examinations and only 12 states plus DC required a specific form. Of these, 12 of the forms required documentation of vision screening, 11 of hearing screening, and 12 of dental screening. Ten forms asked about asthma and 9 required documentation of lead testing. Seven asked about general well-being, emotional problems, or mental health. None addressed hunger. When including states without comprehensive school health examination requirements, the most commonly required HBL screenings were for vision (80% of states; includes DC), hearing (75% of states; includes DC) and dental (24% of state; includes DC).

CONCLUSION

The lack of state mandated requirements for regular student health screening represents a missed opportunity to identify children with HBLs. Without state mandates, accompanying comprehensive forms, and protocols, children continue to be at risk of untreated health conditions that can undermine their success in school.

Virus and Antibody Diagnostics for Swine Samples of the Dominican Republic Collected in Regions Near the Border to Haiti

The Dominican Republic (DR) and Haiti share the island of Hispaniola, and reportable transboundary animal diseases have been introduced between the two countries historically. Outbreaks of severe teschovirus encephalomyelitis in pigs began occurring in Haiti in February 2009, and a field and laboratort study in April 2010 indicated that the teschovirus disease is prevalent in many regions in Haiti including areas near the border with DR and that other viral disease agents, including CSF virus (CSFV), porcine circovirus type 2 (PCV-2), porcine reproductive and respiratory syndrome virus (PRRSV), and swine influenza virus (SIV), are present in the swine population in these regions. The purpose of this study was to evaluate the introduction of teschovirus encephalomyelitis from Haiti to DR and to identify the other viral disease agents present in the swine population in regions of DR near the border with Haiti. Six of 7 brains and 6 of 7 spinal cords collected from pigs with central nervous system (CNS) signs were positive in reverse transcription-polymerase chain reaction for PTV. Genome sequencing on the Dominican PTV and phylogenetic analysis on the polyprotein of PTV strains indicate that the sequence of the Dominican PTV is 99.1% identical to the Haitian isolate and closely related to other PTV-1 strains in the world. Among 109 serum samples tested, 65 (59.6%) were positive for antibodies to PCV-2, and 51 (46.8%) were positive for antibodies to CSFV. Fifty-four of the 109 serum samples were tested for antibodies to other agents. Among the 54 samples, 20 (37.0%) were seropositive to PTV-1, 17 (31.5%) tested seropositive to SIV H3N2, 12 (22.2%) were seropositive to SIV H1N1, and 1 (1.9%) was seropositive to PRRSV.

Epidemiological analysis, serological prevalence and genotypic analysis of foot-and-mouth disease in Nigeria 2008-2009

The epidemiological situation of foot-and-mouth disease virus (FMDV) is uncertain in Nigeria, where the disease is endemic, and the majority of outbreaks are unreported. Control measures for FMD in Nigeria are not being implemented due to the absence of locally produced vaccines and an official ban on vaccine importation. This study summarizes the findings of a 3-year study aimed at quantifying the seroprevalence of FMD, its distribution in susceptible species and the genetic diversity of FMDV isolated from the Plateau State of Nigeria. A 29% FMD prevalence was estimated using 3ABC enzyme-linked immunosorbent assay (3ABC ELISA). Farms with suspected FMD nearby, with contact with wildlife, that used drugs or FMD vaccines or with >100 animals, and animals of large ruminant species and in pastures other than nomadic grazing were significantly (P < 0.05) associated with FMD. Antibodies against five FMDV serotypes, (A, O, SAT1, SAT2 and SAT3) were detected by the virus neutralization test (VNT) at various titres (<100->800) from all tested sera from most parts of the region. This is probably the first report of the presence of FMDV SAT3 in Nigeria. Further studies to investigate the potential probable presence and prevalence of SAT 3 virus in Nigeria are required. Tissue samples collected from clinical animals were positive for FMDV. Virus isolates were sequenced and confirmed as serotype A. All of the isolates showed marked genetic homogeneity with >99% genetic identity in the VP1 region and were most closely related to a previously described virus collected from Cameroon in 2000. This study provides knowledge on the epidemiological situation of FMD in Plateau State, Nigeria, and will probably help to develop effective control and preventive strategies for the disease in Nigeria and other countries in the West African subregion.

On the role of TRPC1 in control of Ca2+ influx, cell volume, and cell cycle

Ca(+) signaling plays a crucial role in control of cell cycle progression, but the understanding of the dynamics of Ca(2+) influx and release of Ca(2+) from intracellular stores during the cell cycle is far from complete. The aim of the present study was to investigate the role of the free extracellular Ca(2+) concentration ([Ca(2+)](o)) in cell proliferation, the pattern of changes in the free intracellular Ca(2+) concentration ([Ca(2+)](i)) during cell cycle progression, and the role of the transient receptor potential (TRP)C1 in these changes as well as in cell cycle progression and cell volume regulation. In Ehrlich Lettré Ascites (ELA) cells, [Ca(2+)](i) decreased significantly, and the thapsigargin-releasable Ca(2+) pool in the intracellular stores increased in G(1) as compared with G(0). Store-depletion-operated Ca(2+) entry (SOCE) and TRPC1 protein expression level were both higher in G(1) than in G(0) and S phase, in parallel with a more effective volume regulation after swelling [regulatory volume decrease (RVD)] in G(1) as compared with S phase. Furthermore, reduction of [Ca(2+)](o), as well as two unspecific SOCE inhibitors, 2-APB (2-aminoethyldiphenyl borinate) and SKF96365 (1-(β-[3-(4-methoxy-phenyl)propoxyl-4-methoxyphenethyl)1H-imidazole-hydrochloride), inhibited ELA cell proliferation. Finally, Madin-Darby canine kidney cells in which TRPC1 was stably silenced [TRPC1 knockdown (TRPC1-KD) MDCK] exhibited reduced SOCE, slower RVD, and reduced cell proliferation compared with mock controls. In conclusion, in ELA cells, SOCE and TRPC1 both seem to be upregulated in G(1) as compared with S phase, concomitant with an increased rate of RVD. Furthermore, TRPC1-KD MDCK cells exhibit decreased SOCE, decreased RVD, and decreased proliferation, suggesting that, at least in certain cell types, TRPC1 is regulated during cell cycle progression and is involved in SOCE, RVD, and cell proliferation.

Pain, postdural puncture headache, nausea, and pruritus after cesarean delivery: a survey of prophylaxis and treatment

BACKGROUND

The need for a cesarean delivery may interfere negatively with the overall experience of childbirth. Several factors related to anesthesiological management such as postoperative pain and discomfort, nausea and pruritus, and postdural puncture headache (PDPH), may lead to dissatisfaction and have a negative impact on early mobilization and a new mother's ability to care for her newborn baby. Optimal prophylaxis and treatment decrease these complications, increase satisfaction, and prevent chronic pain. This survey determined how prophylaxis and treatment of pain, PDPH, nausea, and pruritus after cesarean section (CS) is managed.

METHODS

A questionnaire was sent to 709 departments of anesthesiology serving an obstetric unit in Germany. The questionnaire asked about different aspects of pain management, the management of accidental dural puncture (ADP), and treatment of PDPH. Further we asked about therapy and prophylaxis of nausea and pruritus in the peripartal setting.

RESULTS

In all, 360 questionnaires (50.8%) were returned; 346 were complete and analyzed (accounting for 330000 births per year). Paracetamol (77.5%) and piritramide (85.6%) are the most common analgesics used. If epidural catheters were used for anesthesia for CS, 47.7% were used for postoperative pain therapy. However, 92.7% of the departments removed catheters in less than 24 hours after delivery. In case of an ADP most departments (69.9%) repeated puncture, 2.6% placed catheters intrathecally. Median blood volume for an epidural blood patch was 10ml.

CONCLUSION

Apart from conservative treatment of PDPH, prophylaxis and treatment of pain after cesarean delivery, PDPH, nausea, and pruritus varied widely, indicating the need for the qualitative evaluation of overall management.

Survey on the use of oxytocin for cesarean section

BACKGROUND

The administration of oxytocin at high doses during cesarean section may cause severe cardiovascular complications. However, a dosage as low as 1 IU has been proven to suffice. Bolus administration is not superior to infusion and causes more severe side effects. The purpose of this survey was therefore to determine dosages and routes of administration of oxytocin during cesarean section in Germany.

METHODS

A questionnaire was sent to 709 departments of anesthesiology. The questionnaire asked about the standard dosage of oxytocin and route of administration (bolus and/or slow infusion) used for cesarean section.

RESULTS

A total of 360 questionnaires (50.8%) were returned; 346 of these were filled out and therefore analyzed (accounting for approximately 329,000 births). It was found that 295 (85.3%) departments administer oxytocin as a bolus, and 48 (13.9%) give it only as a slow infusion. A bolus of 1-3 IU is administered at 176 departments (51.8%), 5-9 IU at 71 (20.9%), 10 IU at 39 (11.6%), and 12-40 IU at 6 (1.8%). Additionally, 3-9 IU were slowly infused at 56 departments (16.7%), 10 IU at 174 (50.3%), 12-20 IU at 51 (14.7%), and 23-40 IU at 22 (6.4%). The median cumulative oxytocin dose is 13 IU, ranging from 1 to 80 IU.

CONCLUSION

Most of the responding departments give oxytocin as a bolus at a relatively low dose. However, despite the potentially fatal side effects, one out of eight departments administers 10 IU or more as a bolus.

TRPC1 channels regulate directionality of migrating cells

Cell migration depends on the generation of structural asymmetry and on different steps: protrusion and adhesion at the front and traction and detachment at the rear part of the cell. The activity of Ca(2+) channels coordinate these steps by arranging intracellular Ca(2+) signals along the axis of movement. Here, we investigated the role of the putative mechanosensitive canonical transient receptor potential channel 1 (TRPC1) in cell migration. We analyzed its function in transformed renal epithelial (Madin-Darby canine kidney-focus) cells with variation of TRPC1 expression. As shown by time lapse video microscopy, TRPC1 knockdown cells have partially lost their polarity and the ability to persistently migrate into a given direction. This failure is linked to the suppression of a local Ca(2+) gradient at the front of migrating TRPC1 knockdown cells, whereas TRPC1 overexpression leads to steeper Ca(2+) gradients. We propose that the Ca(2+) signaling events regulated by TRPC1 within the lamellipodium determine polarity and directed cell migration.

A novel function of capsaicin-sensitive TRPV1 channels: Involvement in cell migration

Cell migration relies on a tight temporal and spatial regulation of the intracellular Ca2+ concentration ([Ca2+]i). [Ca2+]i in turn depends on Ca2+ influx via channels in the plasma membrane whose molecular nature is still largely unknown for migrating cells. A mechanosensitive component of the Ca2+ influx pathway was suggested. We show here that the capsaicin-sensitive transient receptor potential channel TRPV1, that plays an important role in pain transduction, is one of the Ca2+ influx channels involved in cell migration. Activating TRPV1 channels with capsaicin leads to an acceleration of human hepatoblastoma (HepG2) cells pretreated with hepatocyte growth factor (HGF). The speed rises by up to 50% and the displacement is doubled. Patch clamp experiments revealed the presence of capsaicin and resiniferatoxin (RTX)-sensitive currents. In contrast, HepG2 cells kept in the absence of HGF are not accelerated by capsaicin and express no capsaicin- or RTX-sensitive current. The TRPV1 antagonist capsazepine prevents the stimulation of migration and inhibits capsaicin-sensitive currents. Finally, we compared the contribution of capsaicin-sensitive TRPV1 channels to cell migration with that of mechanosensitive TRPV4 channels that are also expressed in HepG2 cells. A specific TRPV4 agonist, 4alpha-phorbol 12,13-didecanoate, does not increase the displacement. In summary, we assigned a novel role to capsaicin-sensitive TRPV1 channels. They are important Ca2+ influx channels required for cell migration.

Guillain-Barre syndrome in patient with Burkitt's lymphoma and type 2 diabetes mellitus

Although peripheral neuropathies are commonly observed in patients with non-Hodgkin's malignant lymphomas (NHML), Guillain-Barre syndrome (GBS) belongs to the occasional complications of lymphoproliferative disorders. It appears in less than 0.3 per cent of NHML. It is worthy of note that in the reported case there occurred three independent risk factors of peripheral neuropathy: Burkitt's lymphoma, chemotherapy and type 2 diabetes mellitus. Based on clinical course, EMG finding and neuropathological examination, in spite of normal cerebrospinal fluid protein content, GBS as a paraneoplastic disorder was diagnosed. It was assumed that chemotherapy and diabetes mellitus conduced to severe neuropathy.

[Neurological deficits in patients with primary and secondary anticardiolipin syndrome]

27 patients (22 women, 5 men); age 17 to 56 yr. (mean age 37 yr.) were included in this study, 4 had primary antiphospholipid syndrome and 18 secondary antiphospholipid syndrome in the course of systemic connective tissue disease and in 5 cases increased levels of anticardiolipid antibodies were found which did not meet the criteria necessary for diagnosis of secondary antiphospholipid syndrome. The mean duration of the disease was 8 yrs. Among primary antiphospholipid syndrome patients two had ischaemic stroke, one migraine-like headache and seizures. 18 patients had lupus erythematosus, two mixed connective tissue disease, one rheumatoid arthritis, one Sjögren syndrome, one Behçet disease. In 55% of patients migraine-like headache, polyneuropathies, encephalophaties, stroke, seizures and vision disturbances were present. In 18.5% of patients EEG exam revealed focal lesions with tendency for generalisation. On brain stem auditory evoked potentials examination, in 11.1% of patients conductivity lesions in mesencephalon and pons were found, visual evoked potentials, in 11.1% of patients in visual tracts. In 37% of patients, neuropathy was found on EMG exam. Neurological symptoms are one of the most frequent disorders in systemic connective tissue disease associated with the presence of anicardiolipin antibodies.

[Psychosocial factors and depressive disorders: pathogenesis model and intervention strategies]

This article gives an overview of the impact of psychosocial factors on the manifestation and course of depressive disorders. It focusses primarily on the large body of work done by G.W. Brown and his co-workers since the 1970s on the pathogenesis of depression. A systematic approach to the treatment of depression should contain not only specific psychotherapy as well as antidepressant drug treatment, but should also include interventions of a psychosocial nature. There are so far hardly any controlled studies in this area. So-called "befriending" projects and psychosocial support schemes for at-risk groups, e.g. single mothers, promise to be interesting approaches. Befriending in this context means a specific kind of relationship that differs structurally from the relationship between a therapist and his client. Interventions of this type on the basis of the prevalence of depressive disorders could have a substantial impact on public health.

[Evaluation of nervous system disorders during the course of gastric carcinoma on the basis of clinical electrophysiologic analysis]

The complex of neurological symptoms, which occur in the course of neoplasms of the internal organs and caused by the distant effect of the neoplasm on the nervous system, excluding other factors which could be responsible for changes in the nervous system, is called the paraneoplastic syndrome (PS). Pathogenesis of PS has not been clearly explained so far. Besides toxic, metabolic and infectious causes, the autoimmunologic one is taken into consideration. Paraneoplastic syndrome is mostly evoked by the oat cell carcinoma, subsequently by the breast, ovary and rarely by gastric carcinoma. The aim of the work was to determine: 1) the changes in the electroneurographic as well as visual and auditory evoked potentials examinations in the course of gastric carcinomas, 2) the influence of the treatment applied in gastric carcinomas on changes in visual and auditory evoked potentials and electroneurographic examinations. The examined group included 33 patients with diagnosed gastric carcinoma and having no clinical symptoms of lesion of the central and peripheral nervous systems. The results were compared to the control group, which consisted of healthy volunteers and patients after ventricular resection because of the chronic peptic ulcer disease. Clinical, neurographic as well as visual and auditory evoked potentials examinations were carried out three times. I.--just after the diagnosis of the neoplastic disease, II.--after end of treatment, III.--after 18 months (on average) since the end of the therapy. All patients had operative treatment. A part of them had supplementary chemotherapy--EEP cycle (Etoposide, Epirubicin, Cisplatin) or 5-fluorouracil. On the basis of the performed examinations of patients with gastric carcinoma, without clinical symptoms of lesions of the nervous system, primary axonal sensory-motoric neuropathic changes were observed in 36%. Changes in visual and auditory evoked potentials were found only in patients over 65 years old in over 50%. In patients after chemotherapy they were observed in visual and auditory evoked potentials and electroneurographic examinations, which could be caused by neurotoxic side-effect of the cytostatics applied.

Vascular factors are critical in selective neuronal loss in an animal model of impaired oxidative metabolism

Thiamine deficiency (TD) models the cellular and molecular mechanisms by which chronic oxidative deficits lead to death of select neurons in brain. Region- and cell-specific oxidative stress and vascular changes accompany the TD-induced neurodegeneration. The current studies analyzed the role of oxidative stress in initiating these events by testing the role of intercellular adhesion molecule-1 (ICAM-1) and endothelial nitric oxide synthase (eNOS) in the selective neuronal loss that begins in the submedial thalamic nucleus of mice. Oxidative stress to microvessels is known to induce eNOS and ICAM-1. TD increased ICAM-1 immunoreactivity in microvessels within the submedial nucleus and adjacent regions 1 day prior to the onset of neuronal loss. On subsequent days, the pattern of ICAM-1 induction overlapped that of neuronal loss, and of induction of the oxidative stress marker heme oxygenase-1 (HO-1). The intensity and extent of ICAM-1 and HO-1 induction progressively spread in parallel with the neuronal death in the thalamus. Targeted disruption of ICAM-1 or eNOS gene, but not the neuronal NOS gene, attenuated the TD-induced neurodegeneration and HO-1 induction. TD induced ICAM-1 in eNOS knockout mice, but did not induce eNOS in mice lacking ICAM-1. These results demonstrate that in TD, an ICAM-1-dependent pathway of eNOS induction leads to oxidative stress-mediated death of metabolically compromised neurons. Thus, TD provides a useful model to help elucidate the role of ICAM-1 and eNOS in the selective neuronal death in diseases in which oxidative stress is implicated.

[Breast tuberculosis--a case report]

The authors report a case of breast tuberculosis in a 58-year-old patient in which the diagnosis was made with difficulty, initially the case being interpreted as a neoplastic process. This diagnosis should be considered in such cases. In our area, in the present tuberculosis endemic, the cases of tuberculosis with extrapulmonary localisation are more and more frequent.

[Clinical course and epidemiological analysis of amyotrophic lateral sclerosis in Szczecin in 1986-1995]

49 patients diagnosed as amyotrophic lateral sclerosis (ALS), hospitalized between 1986-1995, inhabitants of Szczecin-City were included in this study. ALS was diagnosed according to WFN criteria. The control group consisted of 60 people. Men:women ratio was 1.57:1. The mean age at ALS onset was 53.2 years. The disease was most often present between 51 and 60 years. Only one ALS patient was observed in the group of patients aged 21-30 and in the group of individuals older than 70 years. ALS incidence was 0.9 per 100,000 inhabitants and its prevalence in 1995 was 2.7 per 100,000 inhabitants. The mean duration was 30.8 months and was slightly higher in women. The shortest duration was observed in the bulbar form of ALS--21 months. Patients with ALS had been exposed to head trauma and contact with animals more often than the average population. There is no difference between Szczecin and previously analysed Polish cities in the considered epidemiological parameters. No discrepancies of clinical picture and course of the disease were found in comparison with other reported by other authors.

Subacute cerebellar degeneration as a remote effect of breast cancer

Clinical investigations on the case of a 61-year-old woman with a few year history of neurological symptoms, who underwent mastectomy caused by ductal carcinoma, 12 years prior to the appearance of the clinical syndrome did not reveal the cause of the disease. On the post-mortem examination solitary metastasis of adenocarcinoma to the retroperitoneal lymph node was present. Histologically, in the cerebellum the degeneration of the Purkinje cells with extensive Bergmann glia reaction was diagnosed. The authors discuss the connection between lesions of CNS and neoplastic disease.

Impaired EDRF production by endothelial cells exposed to fibrin monomer and FDP

Fibrin and fibrinogen and their proteolytic degradation products, found within the atheroma, may contribute to vascular dysfunction. We monitored the production of endothelium-derived relaxing factor (EDRF) by bovine aortic endothelial cells (BAEC) after exposure to fibrinogen, fibrin monomer (FM), and fibrin and fibrinogen degradation products (FDP). Cells incubated with FM and FDP, compared with cells incubated with fibrinogen, were less able to inhibit platelet aggregation, and this effect correlated with a concentration-dependent decrease in EDRF production: BAEC incubated with FM or FDP, but not fibrinogen, produced significantly less nitric oxide (NO), as determined using a photolysis-chemiluminescence system. Northern analysis of BAEC incubated with fibrinogen, FM, or FDP and probed for constitutive bovine endothelial NO synthase mRNA demonstrated decreased expression in cells exposed to FDP or FM. These data show that FM and FDP reduce EDRF produced by BAEC and attenuate constitutive NO synthase expression. These effects may represent a mechanism by which thrombotic determinants adversely affect endothelial function and thereby potentially impair vasomotor responses and contribute to atherothrombogenesis.

Pitfalls in computed tomography of the cervical and lumbar spine

In 10 patients, evaluated by computed tomography studies of the spine, radiological findings alone may have led to misinterpretation of the clinical condition. Five patients demonstrated CT findings of cervical disc herniation or protrusion, while clinical examination resulted in the diagnosis of neuralgic amyotrophy. In contrast, 3 patients with clinical signs of compression of lumbar nerve roots had negative findings in CT studies of the lumbar discs. Additional slices at the level of the vertebral body, however, demonstrated free sequestration of disc substance. Two patients with signs of compression of cervical roots had normal CT findings, but extensive disc herniation was present at surgery.

[Diagnostic difficulties in tumours of foramen occipitale magnum]

The reported case was diagnosed formerly as multiple sclerosis. On autopsy it was found that disseminated neurological symptoms were caused by a neurofibroma of the foramen magnum. The diagnostic difficulties in cases of tumours in this location are discussed.

[Course of conservatively treated acute lumbar root compression syndrome. A computer tomography controlled study]

Of 129 patients with an acute lumbar root compression syndrome due to disc herniation 21, who were symptom-free, were examined by computed tomography (CT) on average 276 days after a three-step regimen of conservative treatment. In no instance had there been a deterioration of the original findings. In 14 patients the CT picture continued to demonstrate disc herniation, although the patients were without symptoms. In two patients a moderate, in five a marked regression of herniation was demonstrated by CT. Clinical improvement without change in the CT picture points to the compression syndrome not being explainable solely in mechanical terms. As a matter of fact, a possible cause may be a disturbance of radicular blood supply resulting in oedematous root swelling which is usually masked in the CT by prolapsed disc tissue. There is as yet no easy explanation for regression in case of prolapsed, perhaps even sequestered, disc tissue. It is possible that there have been reparative processes, such as have been described histopathologically in form of ingrown vessels. More plausibly would be a separation of the herniated and/or sequestered disc tissue in form of an asymptomatic sliding into the terminal caudal region.

Central antiarrhythmic effects of imidazole in anesthetized rats

In urethane anesthetized rats, the intracerebroventricular (icv.) microinjection of sodium glutamate or KCl induced cardiac arrhythmias. These cardiac rhythm disorders could be prevented by the icv. administration of imidazole. The i.v. injection of the same doses of imidazole elicited cardiac arrhythmias. The antiarrhythmic activity of imidazole is probably due to its ability to stimulate phosphodiesterase activity, which leads to a decrease in cGMP and/or cAMP cerebral levels.

Central antiarrhythmic activity of adenosine in anesthetized rats

In urethane-anesthetized rats the intracerebroventricular (icv.) administration of sodium glutamate or desipramine induced cardiac arrhythmias. These cardiac rhythm disturbances could be prevented by icv. administration of adenosine. The i.v. injection of adenosine had an arrhythmogenic action. The antiarrhythmic effect of adenosine could be reversed by icv. aminophylline. It is suggested that the antiarrhythmic activity of adenosine is due to the central inhibition of release of acetylcholine, and/or noradrenalin, produced by the decreased availability of calcium for the excitation-secretion coupling.

[Changes in the length of sleep cycles during administration of flurazepam and lopirazepam]

The influence of narcotics on the duration of the ultradian NREM/REM cycle can be clearly recognized only when the first, particularly instable cycle is also included in the evaluation. A study with Lopirazepame and Flurazepame showed that compared to placebo Lopirazepame prolonged the first cycle particularly. In contrast with Flurazepame the first, but mainly the second cycle was shortened, and not until the third NREM/REM cycle the duration was compatible with that of placebo and Lopirazepame. The result is, that in nights of the same length Flurazepame shows a half or one cycle more compared to Lopirazepame.

The influence of oxytocin on the fibrillation thresholds in rabbits

The intravenous infusion of oxytocin in urethane anaesthetized rabbits induced marked increases of both atrial and ventricular fibrillation threshold. The heart rate and the arterial blood pressure (BP) diminished. Since there was no parallelism between the fibrillation threshold changes and those of heart rate and BP, it might be concluded that the changes of the fibrillation thresholds were very likely primary, i.e. they were due to the modifications of the electrophysiological properties of the heart. The intravenous infusion of 0.5% chlorbutol , a preservant widely used in many commercial preparations induced only minor changes of the investigated parameters.