Differences in phenotypes, symptoms, and survival in patients with cardiomyopathy-a prospective observational study from the Sahlgrenska CardioMyoPathy Centre

Introduction

Cardiomyopathy is the fourth most common cause of heart failure. The spectrum of cardiomyopathies may be impacted by changes in environmental factors and the prognosis may be influenced by modern treatment. The aim of this study is to create a prospective clinical cohort, the Sahlgrenska CardioMyoPathy Centre (SCMPC) study, and compare patients with cardiomyopathies in terms of phenotype, symptoms, and survival.

Methods

The SCMPC study was founded in 2018 by including patients with all types of suspected cardiomyopathies. This study included data on patient characteristics, background, family history, symptoms, diagnostic examinations, and treatment including heart transplantation and mechanical circulatory support (MCS). Patients were categorized by the type of cardiomyopathy on the basis of the diagnostic criteria laid down by the European Society of Cardiology (ESC) working group on myocardial and pericardial diseases. The primary outcomes were death, heart transplantation, or MCS, analyzed by Kaplan-Meier and Cox proportional regression, adjusted for age, gender, LVEF and QRS width on ECG in milliseconds.

Results

In all, 461 patients and 73.1% men with a mean age of 53.6 ± 16 years were included in the study. The most common diagnosis was dilated cardiomyopathy (DCM), followed by cardiac sarcoidosis and myocarditis. Dyspnea was the most common initial symptom in patients with DCM and amyloidosis, while patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) presented with ventricular arrythmias. Patients with ARVC, left-ventricular non-compaction cardiomyopathy (LVNC), hypertrophic cardiomyopathy (HCM), and DCM had the longest time from the debut of symptoms until inclusion in the study. Overall, 86% of the patients survived without heart transplantation or MCS after 2.5 years. The primary outcome differed among the cardiomyopathies, where the worst prognosis was reported for ARVC, LVNC, and cardiac amyloidosis. In a Cox regression analysis, it was found that ARVC and LVNC were independently associated with an increased risk of death, heart transplantation, or MCS compared with DCM. Further, female gender, a lower LVEF, and a wider QRS width were associated with an increased risk of the primary outcome.

Conclusions

The SCMPC database offers a unique opportunity to explore the spectrum of cardiomyopathies over time. There is a large difference in characteristics and symptoms at debut and a remarkable difference in outcome, where the worst prognosis was reported for ARVC, LVNC, and cardiac amyloidosis.

A Systematic Review of Animal Models of NAFLD Finds High-Fat, High-Fructose Diets Most Closely Resemble Human NAFLD

BACKGROUND AND AIMS

Animal models of human disease are a key component of translational hepatology research, yet there is no consensus on which model is optimal for NAFLD.

APPROACH AND RESULTS

We generated a database of 3,920 rodent models of NAFLD. Study designs were highly heterogeneous, and therefore, few models had been cited more than once. Analysis of genetic models supported the current evidence for the role of adipose dysfunction and suggested a role for innate immunity in the progression of NAFLD. We identified that high-fat, high-fructose diets most closely recapitulate the human phenotype of NAFLD. There was substantial variability in the nomenclature of animal models: a consensus on terminology of specialist diets is needed. More broadly, this analysis demonstrates the variability in preclinical study design, which has wider implications for the reproducibility of in vivo experiments both in the field of hepatology and beyond.

CONCLUSIONS

This systematic analysis provides a framework for phenotypic assessment of NAFLD models and highlights the need for increased standardization and replication.

240 Aetiology and Outcomes of Head and Neck Free Flaps in Patients Aged ≥ 65 Years: The Cambridge Experience

Introduction

Elderly patients often present to the Head & Neck Plastic Surgery department with complex reconstructive needs, for which free flaps are the gold-standard management. In order to provide appropriate, patient-centred care, it is imperative to understand how increasing age and related factors affect long-term free flap outcomes.

Method

The authors carried out a retrospective review of all patients 65+ years who underwent free flap surgery at Addenbrooke’s Hospital from 2008-2019. Patient, operative, and flap characteristics, and outcomes, were analysed using Excel and RStudio.

Results

163 patients were identified (54F, 109M). The majority were ALT (n = 74), radial forearm (n = 35), and fibula flaps (n = 23).

Of pre-operative comorbidities, only neurological comorbidities (n = 16), were significantly associated with long-term flap failure (p = 0.016). There was no significant association between number of comorbidities and flap outcome. There was no association between age group and length of stay.

Flap site complications, and particularly venous complications, were significantly associated with later failure (p = 0.001). No other complications were statistically associated with flap failure.

Conclusions

The high success rate supports the use of free flaps in the 65+ population. This data supports a case-by-case approach to assessing fitness for free flap surgery rather than excluding patients on the basis of age or specific comorbidities.

Weight loss, insulin resistance, and study design confound results in a meta-analysis of animal models of fatty liver

The classical drug development pipeline necessitates studies using animal models of human disease to gauge future efficacy in humans, however there is a low conversion rate from success in animals to humans. Non-alcoholic fatty liver disease (NAFLD) is a complex chronic disease without any established therapies and a major field of animal research. We performed a meta-analysis with meta-regression of 603 interventional rodent studies (10,364 animals) in NAFLD to assess which variables influenced treatment response. Weight loss and alleviation of insulin resistance were consistently associated with improvement in NAFLD. Multiple drug classes that do not affect weight in humans caused weight loss in animals. Other study design variables, such as age of animals and dietary composition, influenced the magnitude of treatment effect. Publication bias may have increased effect estimates by 37-79%. These findings help to explain the challenge of reproducibility and translation within the field of metabolism.

Comparison of the duration of hospital stay after laparoscopic or open distal pancreatectomy: randomized controlled trial

Background

Studies have suggested that laparoscopic distal pancreatectomy (LDP) is advantageous compared with open distal pancreatectomy (ODP) regarding hospital stay, blood loss and recovery. Only one randomized study is available, which showed enhanced functional recovery after LDP compared with ODP.

Methods

Consecutive patients evaluated at a multidisciplinary tumour board and planned for standard distal pancreatectomy were randomized prospectively to LDP or ODP in an unblinded, parallel-group, single-centre superiority trial. The primary outcome was postoperative hospital stay.

Results

Of 105 screened patients, 60 were randomized and 58 (24 women, 41 per cent) were included in the intention-to-treat analysis; there were 29 patients of mean age 68 years in the LDP group and 29 of mean age 63 years in the ODP group. The main indication was cystic pancreatic lesions, followed by neuroendocrine tumours. The median postoperative hospital stay was 5 (i.q.r. 4–5) days in the laparoscopic group versus 6 (5–7) days in the open group (P = 0·002). Functional recovery was attained after a median of 4 (i.q.r. 2–6) versus 6 (4–7) days respectively (P = 0·007), and duration of surgery was 120 min in both groups (P = 0·482). Blood loss was less with laparoscopic surgery: median 50 (i.q.r. 25–150) ml versus 100 (100–300) ml in the open group (P = 0·018). No difference was found in the complication rates (Clavien–Dindo grade III or above: 4 versus 8 patients respectively). The rate of delayed gastric emptying and clinically relevant postoperative pancreatic fistula did not differ between the groups.

Conclusion

LDP is associated with shorter hospital stay than ODP, with shorter time to functional recovery and less bleeding. Registration number: ISRCTN26912858 (www.isrctn.com).

Conceptualising post-stroke fatigue: a cross-sectional survey of UK-based physiotherapists and occupational therapists

With survival after stroke improving, more people are discharged into the community with multiple and persistent deficits. Fatigue is a common unmet need for stroke survivors, but there are no evidence-based guidelines for its assessment and management. This study explored how UK-based therapists conceptualise post-stroke fatigue (PSF) in current practice.

OBJECTIVE

To describe current understanding of PSF among physiotherapists (PT) and occupational therapists (OT).

DESIGN

A cross-sectional online survey using Qualtrics software (a survey creation and analysis programme) was sent to therapists working with stroke survivors in 2019. Responses to the open ended question, 'How would you describe PSF if approached by another healthcare professional?' were analysed thematically by two independent researchers.

PARTICIPANTS

137 survey respondents (71 PT and 66 OT) from a range of clinical settings (25 acute care, 24 sub-acute rehabilitation care, 3 primary care and 85 community care) with 7 months-36 years of experience working with stroke survivors completed the survey.

RESULTS

Respondents stated that PSF should be regarded as an important medical condition because it is common and can be associated with severe symptoms. Symptoms were perceived to be highly variable and the syndrome was difficult to define objectively. It was felt to have both physical and cognitive components. A variety of different opinions were expressed with regard to causation, conceptualisation and best management.

CONCLUSION

Therapists working with stroke survivors conceptualise and manage PSF in different ways. Clinical practice is hampered by a lack of a widely adopted definition, and a small evidence base. Research into causes and management of PSF is a priority.

P3680Baseline hemodynamics and its effect on survival in patients with idiopathic versus CTD-associated pulmonary arterial hypertension: data from the Swedish Pulmonary Arterial Hypertension Register

Background

Patients with CTD-APAH have a worse prognosis than those with IPAH, despite having lower pulmonary vascular resistance at diagnosis.

Purpose

To compare the effect of baseline hemodynamics on one-year survival in incident CTD-APAH patients and IPAH patients.

Methods

Patients with IPAH and CTD-APAH reported to the SPAHR between January 2008 and December 2018 were analyzed. Clinical data, hemodynamic parameters, lung transplantation, and survival were extracted from SPAHR. The relation between baseline hemodynamics and one-year survival was assessed by Cox proportional regression.

Results

There was no difference in age, WHO-FC, and 6MWD. IPAH patients had more often hypertension and diabetes; CTD-APAH patients had worse DLCO. No difference was found regarding kidney function, atrial fibrillation, stroke, and thyroid dysfunction. For details regarding hemodynamics, see Table 1.

One-year survival was similar in IPAH (84%) and CTD-APAH (82%, n.s.). After adjustment for age and gender, the only hemodynamic parameters that independently predicted survival were mRAP (CTD-APAH 1.06; 1.01–1.13, p=0.046 vs. IPAH 1.08; 1.01–1.15, p=0.048) and trans-pulmonary gradient, TPG (CTD-APAH 1.04; 1.01–1.07, p=0.008 vs. IPAH 1.02; 1.01–1.04, p=0.026).

Patient characteristics at diagnosis IPAH (n=311) CTD-APAH (n=204) p-value Age (years) 63±16 65±13 NS Female gender (%) 57 79 <0.001 WHO-FC III (%) 73 67 NS Hypertension (%) 50 38 0.014 Diabetes (%) 27 11 <0.001 6MWD (m) 288 (180–382) 260 (180–393) 0.474 DLCO (%) 45 (31–62) 38 (31–49) 0.002 Hemoglobin (g/L) 147 (134–158) 131 (121–144) <0.001 NTproBNP (ng/L) 1750 (758–4124) 1250 (351–3449) 0.003 mPAP (mmHg) 48 (41–55) 38 (31–45) <0.001 mRAP (mmHg) 8 (5–11) 6 (3–10) <0.001 PVR (WU) 9.4 (7.0–12.3) 6.8 (4.5–10.3) <0.001 CI (L/min/m2) 2.2 (1.8–2.6) 2.5 (2.0–3.0) <0.001 SvO2 (%) 60 (54–66) 64 (57–71) <0.001

Conclusion

Despite having better hemodynamic profile at baseline, CTD-APAH patients had similar one-year survival to IPAH patients; mRAP and TPG were independent predictors of survival in both groups.

P1635A risk score for prediction of TIA/ischemic stroke in patients with heart failure and sinus rhythm

Background

Prediction of ischemic cerebral events in patients with heart failure (HF) in the absence of atrial fibrillation (AF) is challenging.

Purpose

To prospectively test a staged approach to identify patients with HF and sinus rhythm who are at high risk of developing TIA/ischemic stroke (TIA/IS) during the first two years after diagnosis.

Methods

The analysis is based on patient data reported in the Swedish Heart Failure Register from January 2003 until December 2013. Patients with AF and those treated with anticoagulants were excluded. The study population was categorized in two groups according to left ventricular ejection fraction: LVEF ≤40% and LVEF >40%. Factors associated with TIA/IS were determined by univariate proportional hazard regression. The risk score included: age (1p for 65–74y; 2p for 75–84y; 3p for ≥85y), previous ischemic heart disease (1p), hypertension (1p), diabetes mellitus (1p), TIA/IS (2p), and kidney dysfunction (1p). Two-year hazard ratios with death as competing risk were computed. The probability of observing the outcome was calculated using the cumulative incidence function.

Results

A total of 16,865 patients (mean age 72.1±13.2y) were included in the study, 39.9% women; 59.7% had LVEF ≤40%. The two-year crude rate of TIA/IS, hemorrhagic stroke, and all-cause mortality were 3.3%, 0.3%, and 26%, respectively.

An incremental absolute risk for TIA/IS was observed for patients with LVEF ≤40% and score 1- ≥6: 1.6, 2.3, 3.6, 2.9, 6.3, and 7.1%, respectively. The corresponding HRs with 95% confidence interval (CI) and the patients with 0 points as reference group were: 2.8 (1.1–7.3), 4.0 (1.6–10.1), 6.6 (2.7–16.2), 5.5 (2.2–13.8), 14.4 (5.8–35.9) for score 1- ≥6, where all p-values were less than 0.05 and Wald χ2 for overall model fit <0.0001. The cumulative incidence per 1000 person-years was: 8.2 (5.4–12.5), 11.8 (8.3–16.7), 19.4 (15.1–24.8), 16.3 (12.6–21.1), 36.6 (29.4–45.4), and 42.1 (33.0–53.8), respectively.

In patients with LVEF >40% and score 1–≥6, the absolute TIA/IS risk was: 1.3, 3.1, 3.1, 3.3, 4.6, and 5.3%, respectively. The corresponding HRs with 95% CI and patients with 1 point as reference group was: 2.4 (1.1–5.2), 2.5 (1.2–5.3), 2.7 (1.3–5.7), 3.9 (1.8–8.2); and 4.6 (2.2–9.8), for score 1- ≥6 (all p<0.05 and Wald χ2 for overall model fit p=0.0002). The cumulative incidence per 1000 person-year was: 6.7 (3.4–13.2), 16.0 (10.8–23.8), 16.7 (12.5–22.2), 18.0 (13.9–23.4), 25.8 (19.4–34.3), and 30.6 (21.7–43.0), for score 1- ≥6, respectively.

Conclusion

In the current study, a risk score compiling age and specific comorbidity was shown to predict increased risk of TIA/IS, regardless of LVEF, during the first two years after diagnosis in patients with incident HF in sinus rhythm.

Prospective study of pain, quality of life and the economic impact of open inguinal hernia repair

BACKGROUND

There are variations in quality of life (QoL) and reported risk of chronic pain after inguinal hernia repair. The aim of this study was to investigate the improvement in pain and QoL after open inguinal hernia repair, and the economic impact.

METHODS

Patients undergoing open mesh repair of a primary unilateral inguinal hernia were stratified depending on preoperative levels of symptoms and pain. Short Form 36 (SF-36®) and EQ-5D™ questionnaires were filled in before, and at 3 and 12 months after surgery. EQ-5D™ data, together with information on the mean value of a quality-adjusted life-year and the societal cost of hernia repair, were used to calculate the monetary value of QoL gained and the mean return on investment.

RESULTS

Of 225 patients who began the study, 184 completed follow-up at 12 months. Some 77·2 per cent reported improvement in pain and 5·4 per cent reported increased pain after surgery. Significant improvement in SF-36® scores, pain scores measured on a visual analogue scale (VAS), and symptoms were found in the majority of patients, even those with mild symptoms before surgery. For the whole group, the bodily pain score increased from 56·4 before surgery to 82·6 at 12 months after hernia repair (P < 0·050), and the VAS score decreased from a median of 4 to 0 (P < 0·050). The return on investment was positive for all groups of patients, including those with mild symptoms.

CONCLUSION

QoL improves after open inguinal hernia repair, with a good return on investment independent of symptom severity.

Protease activation, pancreatic leakage, and inflammation in acute pancreatitis: differences between mild and severe cases and changes over the first three days

BACKGROUND/AIMS

The pathophysiology of acute pancreatitis (AP) may be studied using markers of protease activation (active carboxypeptidase B (aCAP), the activation peptide of carboxypeptidase B (CAPAP)), leakage of pancreatic enzymes (trypsinogen-2, procarboxypeptidase B (proCAP), amylase), and inflammation (monocyte chemoattractant protein-1 (MCP-1), CRP).

METHODS

This prospective study included 140 cases of AP. Mild (n = 124) and severe (n = 16) cases were compared with respect to serum levels of trypsinogen-2, proCAP, amylase, aCAP, CAPAP (serum/urine), MCP-1 (serum/urine) and CRP on days 1, 2 and 3 from onset of symptoms. All patients with information on all 3 days were included in a time-course analysis (n = 44-55, except amylase: n = 27).

RESULTS

High levels in severe versus mild cases were seen for trypsinogen-2, CAPAP in serum and urine, and MCP-1 in serum on days 1-3. No differences were seen for proCAP, amylase and aCAP. MCP-1 in urine was significantly elevated on day 1-2, and CRP on day 2-3. CAPAP and MCP-1 levels peaked early and stayed elevated for 48 h in serum.

CONCLUSION

Protease activation and inflammation are early events in AP, with high levels of these markers within 24 h. Protease activation declines after 48 h, whereas inflammation is present for a longer time.

Monocyte chemoattractant protein 1, active carboxypeptidase B and CAPAP at hospital admission are predictive markers for severe acute pancreatitis

BACKGROUND

CAPAP, the activation peptide of procarboxypeptidase B, is a predictor of severe acute pancreatitis (AP). Active carboxypeptidase (aCAP) may be a better predictor, as its turnover is slower. Monocyte chemotactic protein-1 (MCP-1) is an early inflammatory marker and increases before complications in severe AP. We conducted a cohort study to evaluate these markers as predictors for severe AP.

METHOD

140 patients with AP were included, retrospectively grouped as severe or mild by the Atlanta classification. CAPAP, MCP-1 and aCAP were analyzed in admission samples. Receiver operating characteristic curves determined high vs. low levels.

RESULTS

The levels of all markers were significantly higher in patients with severe disease. High levels of serum MCP-1 was associated with a high risk of developing severe AP (OR 40.8; 95% CI 8.5-195). High ORs were also seen for urine MCP-1 (OR 7.3; 95% CI 2.2-24.3), serum CAPAP (OR 5.4; 95% CI 1.6-17.7), urine CAPAP (OR 4.8; 95% CI 1.6-14.2), and serum aCAP (OR 3.7; 95% CI 1.2-11.3).

CONCLUSION

Serum MCP-1 at admission was strongly associated with development of severe AP. MCP-1 in urine, CAPAP in serum and urine and aCAP may also be useful for predicting severe AP. and IAP.

Puromycin aminonucleoside damages the glomerular size barrier with minimal effects on charge density

Puromycin aminonucleoside (PAN) has been suggested to reduce glomerular charge density, to create large glomerular "leaks," or not to affect the glomerular barrier. Therefore, we analyzed glomerular charge and size selectivity in vivo and in isolated kidneys perfused at 8 degrees C (cIPK) in control and PAN-treated rats. The fractional clearances (theta) for albumin and Ficoll of similar hydrodynamic size were 0.0017 +/- 0.0004 and 0.15 +/- 0.02, respectively, in control cIPKs. Two-pore analysis gave similar results in vivo and in vitro, with small- and large-pore radii of 47-52 and 85-105 A, respectively, in controls. Puromycin increased the number of large pores 40-50 times, the total pore area over diffusion distance decreased by a factor of 25-30, and the small-pore radius increased by 33% (P < 0.001 for all comparisons of size selectivity and theta). The effect of PAN was less dramatic on the estimated wall charge density, which was 73% of that of controls. We conclude that puromycin effectively destroys the glomerular size barrier with minimal effects on charge density.