Standardized angiographic projections allow evaluation of coronary artery side branches with quantitative flow ratio (QFR)

Quantitative flow ratio (QFR) is a novel, software-based noninvasive method for the quantitative evaluation of coronary physiology. QFR results correlate with invasive FFR measurements in the three main epicardial coronary arteries. However, QFR data for the evaluation of coronary side branches (SB) are scarce. The evaluation of QFR-performance of SB was retrospective and prospective. Eighty-seven patients with suspected chronic coronary syndrome, who received angiography using routine core lab projections, were retrospectively analyzed. On the second part 37 patients, who received angiography using recommended standardized coronary angiography projections, were prospectively analyzed. Quantitative analysis was performed for SB with a maximum lumen diameter proximal of ≥2 mm based on quantitative coronary angiography (QCA) by two certified experts with the software QAngio XA 3D 3.2. Using routine projections, QFR computation in 55 % of the SB were obtained (123 out of 224). Using standardized projections, 85 % of SB were computed by QFR (64 out of 75; p < 0.001 vs routine projections). The fluoroscopy time for recommended projections was not significantly different as opposed to routine projections (3.75 ± 2.2 vs. 4.58 ± 3.00 min, p = 2.6986). Using the standardized projections was associated with a higher amount of contrast medium (53.44 ± 24.23 vs. 87.95 ± 43.73 ml, p < 0.01), longer overall procedure time (23.23 ± 16.35 vs. 36.14 ± 17.21 min, p < 0.01) and a higher dose area product (1152.28 ± 576.70 vs. 2540.68 ± 1774.07 cGycm2, p < 0.01). Our study shows that the blood flow of the vast majority of coronary SB can be determined non-invasively by QFR in addition to the main epicardial coronary arteries when standardized projections are used.

Evaluation of coronary artery side branches (SB) with Quantitative Flow Ratio (QFR) by comparing the use of recommended angiographic projections with routine angiographic projections as Reference

Background

Contrast-flow quantitative flow ratio (QFR) is a novel, noninvasive method for the quantitative evaluation of coronary physiology using computational fluid dynamics based on 3D vessel reconstruction in angiograms. Computing this 3D-model with analyzing the dynamics of the contrast medium flow with a specialized algorithm, the software computes the virtual FFR. This new technique has shown a high accuracy in determining the functional significance of coronary stenosis of the three main epicardial coronary arteries using the gold standard FFR as reference. However, QFR data for the evaluation of coronary side branches (SB) are scarce. Therefore, the study aimed to determine the feasibility of this novel method to analyze SB and to characterize optimal viewing angles for evaluation using QFR.

Methods

A total of 87 patients, who underwent invasive coronary angiography with routine core lab projections, were enrolled in the study and were analyzed retrospectively by two certified experts with the software QAngio XA 3D 3.2. In addition, 37 patients were enrolled prospectively using coronary angiography projections recommended for the virtual QFR-Analysis. Quantitative Analysis was performed only for SB with a maximum lumen diameter (MLD) of ≥2mm. The following outcome parameters were analyzed: baseline characteristics, anatomical SB parameters such as MLD (mm) and vessel length (VL; mm) of the SB, result of the QFR-computation and procedure parameters, such as use of applicated contrast medium and fluoroscopy time.

Results

187 side branches (obtuse marginal [OM], diagonal branch [DB], intermediate artery [IA], posterolateral branch [PLB] and posterior descending artery [PDA]) were analyzed using QFR. Out of 87 patients undergoing an invasive coronary angiography with routine core lab projections with 244 SB ≥2mm, 123 SB (55%) were computable with the use of QFR. In the prospective cohort of 37 patients with recommended angiographic projections for QFR analysis of main branches, 75 SB ≥2mm were found. 64 of the 75 SB (84%) were computable with the use of QFR. The use of recommended projections led to an overall higher evaluability of SB (85% vs. 55%). The data show that the fluoroscopy time for recommended QFR projections was not significantly different as the time for routine cath lab projections (3.7±2.2 vs. 4.6±3, p=2.69). The study shows a significant increase of the amount of contrast medium used for QFR projections (55.4±24.2 vs. 87.9±43.7, p&lt;0.01).

Conclusion

To our knowledge this is the first study evaluating QFR for SB analysis. QFR is feasible for the routine assessment of side branches (SD) with MLD ≥2mm. The use of recommended projections significantly improved the quality of the QFR SB analysis apart from PDA, without increasing the fluoroscopy time during coronary angiography. Overall QFR could increase the use of physiologically guided coronary interventions, not only for the main epicardial vessels, but also for the SB.

Funding Acknowledgement

Type of funding sources: None.

Comparison of one-year survival prediction tools in patients with advanced heart failure

Background

Predicting survival in patients with advanced heart failure (HF) remains difficult and prognostic scores such as the Seattle Heart Failure Model (SHFM) are cumbersome to use. Alternative approaches like the Surprise Question (SC) or the number of HF hospitalisations within the last year (NoH) could simplify prognostication.

Purpose

We assessed the prognostic utility of the SHFM, SC and NoH for predicting one-year survival status in patients with advanced HF.

Methods

A secondary analysis of a multisite, single-blinded cluster-randomized, controlled trial to test whether a structured intervention of educational content and automated reminders increased the likelihood of ICD deactivation conversations and ICD deactivation. The study was performed within the advanced HF practices at six US academic medical centers, between September 2011 to February 2016. Patient eligibility criteria included advanced HF, an implantable cardiac defibrillator and a high risk of death, with complete data on SHFM, SC, NoH and one-year survival status. SHFM survival was calculated from baseline variables; the SC (“Would you be surprised if the patient were to die within one year?”) was answered by cardiologists; and the NoH was extracted from medical records. For prediction of survival status, cut-offs for predicted survival per SHFM and NoH were chosen empirically by means of receiver operating characteristic (ROC) curve analysis maximising Youden's index. The resulting binary prediction models were assessed based on area under the ROC curve (AUC), sensitivity and specificity.

Results

Of the 535 subjects in our sample, 82 (15.3%) had died after one-year of follow-up. For the SHFM and the NoH, optimal cut-offs were found to be a predicted survival &lt;86% and ≥2 hospitalisations, respectively.

Performance metrics of prognostic models are detailed in Table 1. The SHFM yielded an AUC of 0.65 (0.60–0.71 95% confidence interval [CI]), a sensitivity of 0.76 (0.65–0.84 95% CI), and a specificity of 0.55 (0.50–0.60 95% CI). The SC demonstrated a comparable AUC 0.58 (0.54–0.63 95% CI), similar sensitivity 0.84 (0.74–0.91 95% CI), but lower specificity 0.33 (0.28–0.37 95% CI) compared to the SHFM. The NoH demonstrated a comparable AUC 0.56 (0.50–0.62 95% CI), similar sensitivity 0.56 (0.45–0.67 95% CI), and similar specificity 0.56 (0.51–0.61 95% CI) compared to the SHFM. The combination of positive SC and NoH ≥2 showed significantly higher specificity compared to the SHFM (0.68 [0.64–0.73 95% CI]).

Conclusion

The SC and NoH are clinically feasible bedside alternatives to the more complex SHFM model, yet yield similar overall prognostic utility for one-year survival status among advanced HF patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart, Lung, and Blood Institute

Evaluation of Ti/Al alloy coated with biogenic hydroxyapatite as an implant device in dogs' femur bones

The main target of the present research was a full assessment of the toxicity effects and biocompatibility of a Ti/Al-alloy device coated with biogenic hydroxyapatite (bHA) when implanted in dogs in comparison with those of an uncoated Ti/Al-alloy device. The coating of the alloy was carried out using controlled high-velocity suspension flame spray (HVSFS) technique. Both coated and uncoated devices were implanted in dogs' femur bones for different time periods (45 days and 90 days). Bone-formation ability and healing were followed up, and blood analysis was performed, at Time zero (immediately post surgery), and then at 3 days, 45 days, and 90 days post surgery. Bone mineral density checks, radiological scans of the femur bone, and histological analysis were also conducted. The in-vivo study results proved that implantation of a device made from bHA-coated Ti/Al alloy in dogs' femur bones is completely safe. This is due to the high osteoconductivity of the coated alloy, which enables the formation of new bone and a full connection between new and original bone material. At 90 days post surgery, the coated alloy had been completely digested within the original bone; thus, it appeared as a part of the femur bone and not as a foreign body. Both the scanning electron microscopy with energy-dispersive X-ray and histology analysis findings affirmed the results. Furthermore, the blood tests indicated no toxicity effects during the 90 days of implantation.

[Current situation of allocation of academic medical personnel in ophthalmology departments in Germany]

BACKGROUND

At present minimum nursing staff numbers have been defined and are being implemented. In December 2019 the German Medical Association asked the German professional associations about their general experience with planning of medical personnel in hospital departments. As no structured data were available on this subject, the German Ophthalmological Society (DOG) founded a working group in March 2020 to answer this request.

METHOD

In the course of several consensus meetings, the working group on personnel planning for physicians in hospitals of the DOG prepared a questionnaire on previous experiences in personnel planning of eye hospitals, which was sent to the heads of all university eye hospitals and departments of ophthalmology in Germany. The questionnaire consisted of individual items with fixed choices and free answers regarding the procedure and current situation of staffing as well as the range of tasks and organization of the medical service.

RESULTS

Out of 104 departments 53 (51%) responded, of which 25 were from university departments (64% response), 23 from departments of other public or non-profit ownership (46%) and 5 from departments with private hospital ownership (33%). Of these 49% stated that there was no transparent basis for calculation of the number of medical positions in their hospital. Of the surveyed departments, outpatient tasks, services and revenues were considered in the calculations in only 47%. There was a statistically significant higher ratio of full-time personnel to the numbers of beds in university departments compared to private and publicly owned non-profit institutions (p < 0.001, t‑test). All departments have to cope with multiple additional tasks in addition to clinical patient care, which are taken into account only to a limited extent in the staffing. Approximately 70% of the departments provide a 24 h/7 day (24/7) medical on-call service on site, 91% have a 24/7 surgery on-call service and 34% have a cooperation with emergency services run by the Association of Statutory Health Insurance Physicians.

CONCLUSION

The results show how heterogeneously and nontransparent German departments of ophthalmology are staffed in terms of medical doctors. On average, university departments have higher personnel resources per hospital bed to cope with additional tasks in research and teaching. Outpatient tasks, which contribute significantly to the revenues of an eye department, and multiple other tasks are often not taken into account in the personnel calculation. A transparent and uniform basis for calculation of the medical staff of the departments is desirable in order to achieve a sufficient personnel staffing for a patient and employee-oriented working environment.

P1760Incidence and effects of stroke, MI and bleeding on mortality among patients with ACS undergoing PCI: a comparative analysis from the PROMETHEUS registry

Background

Stroke represents a potentially calamitous complication among patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) even though its rates are relatively low. Data on the distribution of stroke occurrence over time and its overlap with myocardial infarction (MI) and bleeding after PCI is scarce.

Purpose

We sought to compare the occurrence and impacts of stroke, MI and bleeding on subsequent mortality in ACS patients undergoing PCI in contemporary clinical practice.

Methods

A total of 19,914 ACS patients who underwent PCI in the PROMETHEUS multi-center observational study were analyzed. We calculated the cumulative stroke incidence at 30 days and 1 year using Kaplan Meier (KM) method. We also compared the distribution of stroke, myocardial infarction (MI) and bleeding across time and evaluated the overlap between their occurrences. Predictors of 1 year stroke occurrence were identified through multivariable Cox-regression and stroke, MI and bleeding were entered as time-updated covariates to estimate their individual effects on subsequent mortality.

Results

Of the total number of patients, 244 patients (1.5%) had a stroke within 1 year. 48 of these patients also experienced an MI while another 48 patients experienced a bleeding event. Furthermore, 14 of these overlapping patients experienced a stroke, MI and bleeding event, all within the 1-year follow-up. Patients who sustained a stroke were more likely to have a prior history of cerebrovascular disease, peripheral artery disease, MI and heart failure compared to those who did not have a stroke. Mortality risk was significantly higher among those with stroke versus those without stroke (adjusted HR 4.84, p<0.0001). However, the association attenuated over time with a much larger effect in the first 30 days of its occurrence (adjusted HR 17.7, p<0.0001) versus beyond 30 days (adjusted HR 1.22; 95% CI: 0.6–2.46, p=0.58). Although the effects of MI and bleeding on subsequent mortality within 30 days of occurrence were significantly lower than stroke (adjusted HR 6.22, p<0.0001; adjusted HR 7.30, p<0.0001, respectively), their effects were more sustained on mortality beyond 30 days (adjusted HR 2.89, p<0.0001; adjusted HR 3.05, p<0.0001, respectively).

Conclusion

When compared with MI and bleeding, stroke had a substantially stronger impact on mortality that attenuated rapidly over time among ACS patients undergoing PCI. Optimization of modifiable risk factors and medication adherence are essential parts of management of stroke following PCI for ACS.

P2701Comparison of myocardial ischemia assessed by contrast-flow quantitative flow ratio (cQFR) and by stress MRI in patients with stable coronary artery disease

Background

Contrast-flow quantitative flow ratio (cQFR) is a new technology for evaluation of coronary stenosis. cQFR allows to derive the fractional flow reserve (FFR) from coronary angiograms. Based on a three dimensional coronary model, FFR is calculated from computational fluid dynamics. Head to head comparisons with FFR showed an overall diagnostic accuracy of 85%. cQFR does not require coronary wires or hyperemia. However, the ability of cQFR to detect myocardial ischemia is unknown. Therefore, the aim of this study was to evaluate the relationship between cQFR and myocardial ischemia assessed by stress magnetic resonance imaging (stress MRI).

Methods

cQFR analysis was performed in patients selected from the hospital database who received stress MRI and coronary angiography. A relevant ischemia on stressMRI was defined as a perfusion deficit in ≥2 of 16 segments. The cQFR was based on 3-dimensional quantitative coronary angiography (3D-QCA) using the QAngio XA 3D 1.1, Medis Medical Imaging System, Leiden, The Netherlands. Two blinded investigators analysed all 3 main coronary vessels of each patient measuring diameter stenosis (DS), area stenosis (AS) and cQFR. A cQFR of ≤0.8 was considered abnormal. The primary endpoint was sensitivity and specificity of cQFR using stress MRI as a reference standard.

Results

125 vessels of 53 patients could be fully analysed by cQFR (78.6%). The sensitivity of cQFR in detecting significant epicardial stenoses of coronary vessels with documented ischemia in stress MRI was 75%, the specificity was 87%. The 3D-QCA-derived diameter stenoses and area stenoses in vessels with positive stress MRI were significantly higher than in vessels without ischemia (see Table 1).

Table 1. Means of diameter stenosis (DS) und area stenosis (AS) with interquartile range (IQR) Total (n=125) Ischemia (n=32) No Ischemia (n=93) p-value DS [%] 42.3 (28.3–53.1) 57.1 (47–68.5) 37.7 (27.6–45.1) <0.0001 AS [%] 51.8 (32.4–69.7) 68.9 (56.8–85.9) 46.5 (29.7–62.7) <0.0001

Conclusion

The analysis reveals a high correlation between relevant coronary stenosis measured by cQFR and ischemic areas detected by stress MRI. Differences between the two methods are plausible because stress MRI detects ischemia due to other reasons than epicardial stenosis. Further randomized studies are mandatory to verify the prognostic significance of the cQFR measurements.

Local electronic structure of the peptide bond probed by resonant inelastic soft X-ray scattering

Soft X-ray emission spectroscopy and RIXS are used to determine the local electronic structure of the peptide bond.

Synthesis, spectroscopic characterisation and transmetalation of lithium and potassium diaminophosphanide-boranes

A secondary diaminophosphane-borane (Et₂N)₂PH(BH₃) was prepared from a chlorophosphane precursor and LiBH₄ and metalated by reaction with anion bases (n-BuLi, KN(SiMe₃)₂) to yield the corresponding metal diaminophosphanide-boranes [(Et₂N)₂P(BH₃)]M (M = Li, K). Multinuclear NMR studies permitted the first spectroscopic characterisation of the metalation products and revealed the presence of monomeric (for M = Li) contact ion pairs in solution. NMR spectroscopic evidence that the ions in each pair interact via LiP- rather than LiH₃B-interactions as had been inferred for a Ph-substituted analogue was confirmed by DFT studies, which revealed also that the borane coordination plays a decisive role in boosting the PH-acidity of the original secondary diaminophosphane precursor. Transmetalation of the potassium and lithium diaminophosphanide-boranes with Cu(i) and Zn(ii) chlorides afforded the first functional transition metal complexes of a P-heteroatom-functionalised phosphanide-borane ligand. Both products were fully characterised. Thermolysis of the Cu-complex induced a reaction which involved transfer of an NHC ligand from the metal to the phosphorus atom and yielded a phosphaalkene NHC[double bond, length as m-dash]PH (NHC = N-heterocyclic carbene) as the major phosphorus-containing product.

Myogenic Response Reduction by High Blood Glucose Levels in Human Retinal Arterioles

PURPOSE

The effect of elevated blood glucose level on the myogenic response of human retinal arterioles to acute increases in blood pressure is investigated.

METHODS

The vascular response to raised blood pressure (Bayliss effect) was measured in 12 healthy volunteers by use of the retinal vessel analyzer (RVA). For a 9-minute period an on-line measurement of the diameter of a retinal branch arteriole was performed. After the first 3 minutes (baseline measurement) a second phase with 3 minutes of isometric exercise caused an acute rise in blood pressure, followed by 3 minutes of recovery (phase III). After the first session 100 g glucose were administered per os. After 30 minutes blood glucose was measured again and an identical second session was performed with higher blood glucose levels. The Wilcoxon test was used for statistical analysis.

RESULTS

During the first session a rise in mean arterial pressure of 22.8 (+/-8.4) mmHg was followed by an arterial vasoconstriction of -6.6 (+/-1.7) %. The administration of 100 g glucose resulted in a significant rise in blood glucose levels within 30 minutes between the two sessions (4.35 mmol/L vs 7.46 mmol/L) (p=0.002). The blood pressure rise of 25.7 (+/-7.3) mm Hg in the second session was associated with a significant loss in arterial vasoconstriction of -2.3 (+/-1.4) % (session I vs session II p=0.002).

CONCLUSIONS

The myogenic response of the arterial wall in human retinal arterioles was significantly reduced during acute rise of blood glucose levels.

Site-specific electronic structure of imidazole and imidazolium in aqueous solutions

The electronic structures of aqueous imidazole and imidazolium solutions are studied in an atom- and site-specific fashion using soft X-ray spectroscopy.

[Refractive lenticule extraction - The ReLEx/SMILE technique : Video article]

Refractive lenticule extraction (ReLEx/SMILE) is a refractive surgical method developed by the authors in stages primarily for correction of myopia and myopic astigmatism, in which a femtosecond laser is exclusively used. In the (ReLEx/SMILE) method a refractive lenticule is generated by the femtosecond laser, which is subsequently extracted through a small incision. Opening of the corneal surface with a flap and use of an excimer laser is no longer necessary. In 2013 the method was newly assessed and classified by the Joint Commisssion for Refractive Surgery (KRC) of the Professional Association of Ophthalmologists (BVA) and the German Ophthalmological Society (DOG). This article presents the individual stages of the technique in a video and possible errors and their avoidance are explained.

[Flexible Guidance of Ultra-Short Laser Pulses in Ophthalmic Therapy Systems]

In the last 20 years, the role of ultrashort pulsed lasers in ophthalmology has become increasingly important. However, it is still impossible to guide ultra-short laser pulses with standard glass fibres. The highly energetic femtosecond pulses would destroy the fibre material, and non-linear dispersion effects would significantly change beam parameters. In contrast, photonic crystal fibres mainly guide the laser pulses in air, so that absorption and dispersive pulse broadening have essentially no effect. This article compares classical beam guidance with mirrors, lenses and prisms with photonic crystal fibres and describes the underlying concepts and the current state of technology. A classical mirror arm possesses more variable optical properties, while the HCF (Hollow-Core Photonic Crystal Fibre) must be matched in terms of the laser energy and the laser spectrum. In contrast, the HCF has more advantages in respect of handling, system integration and costs. For applications based on photodisruptive laser-tissue interaction, the relatively low damage threshold of photonic crystal fibres compared to classic beam guiding systems is unacceptable. If, however, pulsed laser radiation has a sufficiently low peak intensity, e.g. as used for plasma-induced ablation, photonic crystal fibres can definitely be considered as an alternative solution to classic beam guidance.

[Historical Overview of the Clinical Development of the Small Incision Lenticule Extraction Surgery (SMILE)]

The clinical use of femtosecond lasers has led to significant progress in the quality of refractive surgery. SMILE femtosecond laser surgery (SMILE: Small Incision Lenticule Extraction) permits the first one step intrastromal laser procedure without a flap. This article describes the gradual development of this surgery during the last ten years.

Investigation of the Ionic Hydration in Aqueous Salt Solutions by Soft X-ray Emission Spectroscopy

Understanding the molecular structure of the hydration shells and their impact on the hydrogen bond (HB) network of water in aqueous salt solutions is a fundamentally important and technically relevant question. In the present work, such hydration effects were studied for a series of representative salt solutions (NaCl, KCl, CaCl2, MgCl2, and KBr) by soft X-ray emission spectroscopy (XES) and resonant inelastic soft X-ray scattering (RIXS). The oxygen K-edge XES spectra could be described with three components, attributed to initial state HB configurations in pure water, water molecules that have undergone an ultrafast dissociation initiated by the X-ray excitation, and water molecules in contact with salt ions. The behavior of the individual components, as well as the spectral shape of the latter component, has been analyzed in detail. In view of the role of ions in such effects as protein denaturation (i.e., the Hofmeister series), we discuss the ion-specific nature of the hydration shells and find that the results point to a predominant role of anions as compared to cations. Furthermore, we observe a concentration-dependent suppression of ultrafast dissociation in all salt solutions, associated with a significant distortion of intact HB configurations of water molecules facilitating such a dissociation.

On the energetics of P–P bond dissociation of sterically strained tetraamino-diphosphanes

Thermochemical data for the homolytic P–P bond fission in tetraaminodiphosphanes (R₂N)₂P–P(NR₂)₂ were determined experimentally and computationally. The results confirm that radical formation is favoured by entropic and structural relaxation effects, and disfavoured by dispersion forces. Unlike aminophosphenium cations, the radicals display no strong preference for a planar (R₂N)₂P unit.

[Investigation of color vision in acute unilateral optic neuritis using a web-based color vision test]

BACKGROUND

In acute unilateral optic neuritis (ON) color vision defects combined with a decrease in visual acuity and contrast sensitivity frequently occur. This study investigated whether a web-based color vision test is a reliable detector of acquired color vision defects in ON and, if so, which charts are particularly suitable.

METHODS

In 12 patients with acute unilateral ON, a web-based color vision test ( www.farbsehtest.de ) with 25 color plates (16 Velhagen/Broschmann and 9 Ishihara color plates) was performed. For each patient the affected eye was tested first and then the unaffected eye.

RESULTS

The mean best-corrected distance visual acuity (BCDVA) in the ON eye was 0.36 ± 0.20 and 1.0 ± 0.1 in the contralateral eye. The number of incorrectly read plates correlated with the visual acuity. For the ON eye a total of 134 plates were correctly identified and 166 plates were incorrectly identified, while for the disease-free fellow eye, 276 plates were correctly identified and 24 plates were incorrectly identified. Both of the blue/yellow plates were identified correctly 14 times and incorrectly 10 times using the ON eye and exclusively correctly (24 times) using the fellow eye. The Velhagen/Broschmann plates were incorrectly identified significantly more frequently in comparison with the Ishihara plates. In 4 out of 16 Velhagen/Broschmann plates and 5 out of 9 Ishihara plates, no statistically significant differences between the ON eye and the fellow eye could be detected.

CONCLUSION

The number of incorrectly identified plates correlated with a decrease in visual acuity. Red/green and blue/yellow plates were incorrectly identified significantly more frequently with the ON eye, while the Velhagen/Broschmann color plates were incorrectly identified significantly more frequently than the Ishihara color plates. Thus, under defined test conditions the web-based color vision test can also be used to detect acquired color vision defects, such as those caused by ON. Optimization of the test by altering the combination of plates may be a useful next step.

Probing hydrogen bonding orbitals: resonant inelastic soft X-ray scattering of aqueous NH3

Resonant inelastic soft X-ray scattering was used to probe the hydrogen bonding orbitals in aqueous ammonia.

[One-year results of small incision lenticule extraction (SMILE) in myopia]

BACKGROUND

This clinical trial is focused on the 12-month results of a new method for refractive correction in myopia, called "small incision lenticule extraction" (SMILE).

PATIENTS AND METHODS

In a prospective study 91 eyes were treated with the new refractive procedure and the results were published after 6 months. A lenticule of intrastromal corneal tissue is cut utilising the Carl Zeiss Meditec AG (Jena, Germany) VisuMax femtosecond laser system. Thereafter, this lenticule is manually removed without lifting a flap. 55 eyes of 33 patients volunteered for a 12-month follow-up. UCVA and BSCVA after 12 months, objective and manifest refraction as well as slit-lamp examination and late side effects were documented.

RESULTS

55 eyes of 33 patients were re-examined in this study 12 months after surgery. The spherical equivalent before surgery was - 4.66 (± 1.75) D; after 12 months - 0.11 (± 0.42) D was manifest. No significant change was observed compared to the 6-month control. Starting with UCVA of 0.1 (± 0.06) before surgery. UCVA was 1.02 (± 0.3) after 12 months. One eye lost more than two lines. All other patients did not have any late side effects.

CONCLUSION

The one-year results of this new procedure are encouraging. Especially stability of the correction of myopia and myopic astigmatism with the SMILE procedure is very good.

[Morphological analysis of corneal refractive lenticules--is there a correlation with refractive results?]

BACKGROUND

ReLEx®flex is a corneal refractive procedure performed by removing corneal lenticules with a femtosecond (fs) laser system. Using electron microscopy, tissue parameters of extracted lenticules were analysed for potential correlations to the refractive results. Furthermore, the effect of previous contact lens (CL) wear on refractive stability (regression) was tested.

PATIENTS AND METHODS

19 lenticules from 11 patients (age 24-56 years, 8 f, 3 m) were prepared for EM. The central areas of the samples were photographed and the distance between the collagen fibres and their diameters were digitally measured. ANOVA analysis was used to correlate postoperative refractional stability with time of preoperative CL use, fibre diameter and the coefficient of variation (CV) of fibre distance.

RESULTS

14 of 19 lenticules were from patients who had worn CL preoperatively. The cumulative duration of CL wear averaged around 31.2 ± 35.5 thousand hours. Preoperative CL use significantly influenced the postoperative regression: the longer time patients had worn CL, the greater was the regression towards myopia (p = 0.01). Additionally, the morphological parameters collagen fibre diameter (p = 0.09) and CV of fibre distance (p = 0.07) had an impact on regression.

CONCLUSIONS

Prolonged CL use and alterations in ultrastructural patterns affected the refractive stability after ReLExflex. Although the pathophysiological relationships between CL use, corneal morphological parameters, and refractive stability are still poorly understood, these findings could potentially be used as prognostic markers for postoperative refraction after ReLExflex.

Antifouling and Fungicidal Resorcylic Acid Lactones from the Sea Anemone-Derived Fungus Cochliobolus lunatus

Three new 14-membered resorcylic acid lactones, cochliomycins D-F, 1-3, and eight known analogues, 4-11, were isolated from the sea anemone-derived fungus Cochliobolus lunatus. Compounds 1-4 are diastereomers differing from each other by the absolute configurations of the 4',5'-diol chiral centers. The absolute configurations of 1-4 were established by the CD exciton chirality method and TDDFT ECD calculations. In antifouling assays, 1, 3-6, and 6a exhibited potent antifouling activities against the larval settlement of the barnacle Balanus amphitrite at nontoxic concentrations, with EC₅₀ values ranging from 1.82 to 22.5 μg/mL. Noticeably, fungicide whole-plant assays indicated that 6 showed excellent activity on the Plasmopara viticola preventative test at 6 ppm and concentration-dependent activity on the Phytophthora infestans preventative application at 200, 60, and 20 ppm. Preliminary structure-activity relationships are also discussed.

Setup for in situ investigation of gases and gas/solid interfaces by soft x-ray emission and absorption spectroscopy

We present a novel gas cell designed to study the electronic structure of gases and gas/solid interfaces using soft x-ray emission and absorption spectroscopies. In this cell, the sample gas is separated from the vacuum of the analysis chamber by a thin window membrane, allowing in situ measurements under atmospheric pressure. The temperature of the gas can be regulated from room temperature up to approximately 600 °C. To avoid beam damage, a constant mass flow can be maintained to continuously refresh the gaseous sample. Furthermore, the gas cell provides space for solid-state samples, allowing to study the gas/solid interface for surface catalytic reactions at elevated temperatures. To demonstrate the capabilities of the cell, we have investigated a TiO2 sample behind a mixture of N2 and He gas at atmospheric pressure.

Provision of long-acting reversible contraception in HIV-prevalent countries: results from nationally representative surveys in southern Africa

OBJECTIVE

To analyse the current provision of long-acting reversible contraception (LARC) and clinician training needs in HIV-prevalent settings.

DESIGN

Nationally representative survey of clinicians.

SETTING

HIV-prevalent settings in South Africa and Zimbabwe.

POPULATION

Clinicians in South Africa and Zimbabwe.

METHODS

Nationally representative surveys of clinicians were conducted in South Africa and Zimbabwe (n = 1444) to assess current clinical practice in the provision of LARC in HIV-prevalent settings. Multivariable logistic regression was used to analyse contraceptive provision and clinician training needs.

MAIN OUTCOME MEASURE

Multivariable logistic regression of contraceptive provision and clinician training needs.

RESULTS

Provision of the most effective reversible contraceptives is limited: only 14% of clinicians provide copper intrauterine devices (IUDs), 4% levonorgestrel-releasing IUDs and 16% contraceptive implants. Clinicians' perceptions of patient eligibility for IUD use were overly restrictive, especially related to HIV risks. Less than 5% reported that IUDs were appropriate for women at high risk of HIV or for HIV-positive women, contrary to evidence-based guidelines. Only 15% viewed implants as appropriate for women at risk of HIV. Most clinicians (82%), however, felt that IUDs were underused by patients, and over half desired additional training on LARC methods. Logistic regression analysis showed that LARC provision was largely restricted to physicians, hospital settings and urban areas. Results also showed that clinicians in rural areas and clinics, including nurses, were especially interested in training.

CONCLUSIONS

Clinician competency in LARC provision is important in southern Africa, given the low use of methods and high rates of unintended pregnancy among HIV-positive and at-risk women. Despite low provision, clinician interest is high, suggesting the need for increased evidence-based training in LARC to reduce unintended pregnancy and associated morbidities.

Novel signalling mechanisms and targets in renal ischaemia and reperfusion injury

Acute kidney injury (AKI) induced by ischaemia and reperfusion (I/R) injury is a common and severe clinical problem. Vascular dysfunction, immune system activation and tubular epithelial cell injury contribute to functional and structural deterioration. The search for novel therapeutic interventions for I/R-induced AKI is a dynamic area of experimental research. Pharmacological targeting of injury mediators and corresponding intracellular signalling in endothelial cells, inflammatory cells and the injured tubular epithelium could provide new opportunities yet may also pose great translational challenge. Here, we focus on signalling mediators, their receptors and intracellular signalling pathways which bear potential to abrogate cellular processes involved in the pathogenesis of I/R-induced AKI. Sphingosine 1 phosphate (S1P) and its respective receptors, cytochrome P450 (CYP450)-dependent vasoactive eicosanoids, NF-κB- and protein kinase-C (PKC)-related pathways are representatives of such 'druggable' pleiotropic targets. For example, pharmacological agents targeting S1P and PKC isoforms are already in clinical use for treatment for autoimmune diseases and were previously subject of clinical trials in kidney transplantation where I/R-induced AKI occurs as a common complication. We summarize recent in vitro and in vivo experimental studies using pharmacological and genomic targeting and highlight some of the challenges to clinical application of these advances.

Unsafe abortion after legalisation in Nepal: a cross-sectional study of women presenting to hospitals

OBJECTIVE

To investigate abortion practices of Nepali women requiring postabortion care.

DESIGN

Cross-sectional study.

SETTING

Four tertiary-care hospitals in urban and rural Nepal.

SAMPLE

A total of 527 women presenting with complications from induced abortion in 2010.

METHODS

Women completed questionnaires on their awareness of the legal status of abortion and their abortion-seeking experiences. The method of induction and whether the abortion was obtained from an uncertified source was documented. Multivariable logistic regression was used to identify associated factors.

MAIN OUTCOME MEASURES

Induction method; uncertified abortion source.

RESULTS

In all, 234 (44%) women were aware that abortion was legal in Nepal. Medically induced abortion was used by 359 (68%) women and, of these, 343 (89%) took unsafe, ineffective or unknown substances. Compared with women undergoing surgical abortion, women who had medical abortion were more likely to have obtained information from pharmacists (161/359, 45% versus 11/168, 7%, adjusted odds ratio [aOR] 8.1, 95% confidence interval 4.1-16.0) and to have informed no one about the abortion (28/359, 8% versus 3/168, 2%, aOR 5.5, 95% CI 1.1-26.9). Overall, 291 (81%) medical abortions and 50 (30%) surgical abortions were obtained from uncertified sources; these women were less likely to know that abortion was legal (122/341, 36% versus 112/186, 60%, aOR 0.4, 95% CI 0.2-0.7) and more likely to choose a method because it was available nearby (209/341, 61% versus 62/186, 33%, aOR 2.5, 95% CI 1.5-4.3), compared with women accessing certified sources.

CONCLUSIONS

Among women presenting to hospitals in Nepal with complications following induced abortion of pregnancy, the majority had undergone medically induced abortions using unknown substances acquired from uncertified sources. Women using medications and those accessing uncertified providers were less aware that abortion is now legal in Nepal. These findings highlight the need for continued improvements in the provision and awareness of abortion services in Nepal.