Complement C1q-dependent engulfment of alpha-synuclein induces ENS-resident macrophage exhaustion and accelerates Parkinson's-like gut pathology

Deposition of misfolded α-synuclein (αsyn) in the enteric nervous system (ENS) is found in multiple neurodegenerative diseases. It is hypothesized that ENS synucleinopathy contributes to both the pathogenesis and non-motor morbidity in Parkinson's Disease (PD), but the cellular and molecular mechanisms that shape enteric histopathology and dysfunction are poorly understood. Here, we demonstrate that ENS-resident macrophages, which play a critical role in maintaining ENS homeostasis, initially respond to enteric neuronal αsyn pathology by upregulating machinery for complement-mediated engulfment. Pharmacologic depletion of ENS-macrophages or genetic deletion of C1q enhanced enteric neuropathology. Conversely, C1q deletion ameliorated gut dysfunction, indicating that complement partially mediates αsyn-induced gut dysfunction. Internalization of αsyn led to increased endo-lysosomal stress that resulted in macrophage exhaustion and temporally correlated with the progression of ENS pathology. These novel findings highlight the importance of enteric neuron-macrophage interactions in removing toxic protein aggregates that putatively shape the earliest stages of PD in the periphery.

Prospective Evaluation of the Correlation Between Gated Cardiac Computed Tomography Detected Vascular Fibrosis and Ease of Transvenous Lead Extraction

BACKGROUND

Difficulty of lead extraction does not track well with procedural complications, but several small retrospective studies have lead fibrosis on computed tomography as an important indicator of difficult lead extraction. The purpose of the present study was to apply a standardized gated cardiac computed tomography (CT) protocol to assess fibrosis and study it prospectively to examine the need for powered sheaths and risk outcomes.

METHODS

We performed a prospective, blinded, multicenter, international study at high-volume lead extraction centers and included patients referred for transvenous lead extraction with at least one lead with a dwell time >1 year and ability to receive a cardiac CT. The degree of fibrosis (as measured by amount of lead adherence to vessel wall) was graded on a scale of 1 to 4 by dedicated CT readers in 3 zones (vein entry to superior vena cava, superior vena cava, and right atrium to lead tip). The primary outcome of the study was number of extractions requiring powered sheaths at zone 2 for each fibrosis group.

RESULTS

A total of 200 patients were enrolled in the trial with 196 completing full gated CT and lead extraction analysis. The primary endpoint of powered sheath (laser and mechanical) sheath use was significantly higher in patients with higher fibrosis seen on CT (scores 3+4; 67.8%) at the zone 2 compared to patients with lower fibrosis (scores 1+2; 38.6%; P<0.001). There were 5 major complications with 3 vascular lacerations all occurring in zone 2 in the study.

CONCLUSIONS

Gated, contrasted CT can predict the need for powered sheaths by identification of fibrosis but did not identify an absolute low-risk cohort who would not need powered sheaths.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03772704.

Thymomas With Intravascular and Intracardiac Growth

Thymomas are derived from the epithelial component of the thymus and constitute the most common tumor of the anterior mediastinum. These neoplasms are considered malignant for their potential for invasion and metastases. Several histopathologic subclassification schemes have been proposed over the years, however, correlation of histotypes with prognosis remains controversial. In contrast, studies invariably have shown that staging and resection status correlate with oncologic behavior and disease outcomes. In this regard, several staging systems have been presented, though transcapsular invasion and degree of involvement of adjacent anatomic structures are common denominators of all schemes. Involvement of the great vessels and heart most commonly results from direct invasion, which may lead to unusual clinical presentations such as superior vena cava syndrome. Moreover, intravascular and intracardiac growth with or without direct mural invasion rarely occurs. We provide an overview of thymomas with intravascular and intracardiac involvement.

Sex-based differences in left ventricular remodeling in patients with chronic aortic regurgitation: a multi-modality study

BACKGROUND

Significant aortic regurgitation (AR) leads to left ventricular (LV) remodeling; however, little data exist regarding sex-based differences in LV remodeling in this setting. We sought to compare LV remodeling and AR severity, assessed by echocardiography and cardiovascular magnetic resonance (CMR), to discern sex-based differences.

METHODS

Patients with ≥ moderate chronic AR by echocardiography who underwent CMR within 90 days between December 2005 and October 2015 were included. Nonlinear regression models were built to assess the effect of AR regurgitant fraction (RF) on LV remodeling. A generalized linear model and Bland Altman analyses were constructed to evaluate differences between CMR and echocardiography. Referral for surgical intervention based on symptoms and LV remodeling was evaluated.

RESULTS

Of the 243 patients (48.3 ± 16.6 years, 58 (24%) female), 119 (49%) underwent surgical intervention with a primary indication of severe AR, 97 (82%) men, 22 (18%) women. Significant sex differences in LV remodeling emerged on CMR. Women demonstrated significantly smaller LV end-diastolic volume index (LVEDVI) (96.8 ml/m2 vs 125.6 ml/m2, p < 0.001), LV end-systolic volume index (LVESVI) (41.1 vs 54.5 ml/m2, p < 0.001), blunted LV dilation in the setting of increasing AR severity (LVEDVI p value < 0.001, LVESVI p value 0.011), and LV length indexed (8.32 vs 9.69 cm, p < 0.001). On Bland Altman analysis, a significant interaction with sex and LV diameters was evident, demonstrating a significant increase in the difference between CMR and echocardiography measurements as the LV enlarged in women: LVEDVI (p = 0.006), LVESVI (p < 0.001), such that echocardiographic measurements increasingly underestimated LV diameters in women as the LV enlarged. LV length was higher for males with a linear effect from RF (p < 0.001), with LV length increasing at a higher rate with increasing RF for males compared to females (two-way interaction with sex p = 0.005). Sphericity volume index was higher for men after adjusting for a relative wall thickness (p = 0.033).

CONCLUSIONS

CMR assessment of chronic AR revealed significant sex differences in LV remodeling and significant echocardiographic underestimation of LV dilation, particularly in women. Defining optimal sex-based CMR thresholds for surgical referral should be further developed.

TRIAL REGISTRATION

NA.

A 51-year-old man with chronic cough and left hilar prominence

A 51-year-old male in good overall health presented with a dry cough of 5 months' duration. He was working as a long-distance truck driver and was a life-long nonsmoker. He had no associated dyspnoea, wheezing, rhinosinusitis, haemoptysis or syncope, nor constitutional symptoms such as weight loss or fevers. Physical examination and vital signs were normal on presentation. Chest radiographs with posterior–anterior and lateral views are shown in figure 1.

What is the diagnosis of this man with a chronic dry cough and left hilar prominence on chest radiography?https://bit.ly/3fL7QMx

Improvement in left ventricular mechanics following medical treatment of constrictive pericarditis

OBJECTIVE

Patients with constrictive pericarditis (CP) with active inflammation may show resolution with anti-inflammatory therapy. We aimed to investigate the impact of anti-inflammatory medications on constrictive pathophysiology using echocardiography in patients with CP.

METHODS

We identified 35 patients with CP who were treated with anti-inflammatory medications (colchicine, prednisone, non-steroidal anti-inflammatory drugs) after diagnosis of CP (mean age 58±13; 80% male). Clinical resolution of CP (transient CP) was defined as improvement in New York Heart Association class during follow-up. We assessed constrictive pathophysiology using regional myocardial mechanics by the ratio of peak early diastolic tissue velocity (e') at the lateral and septal mitral annulus by tissue Doppler imaging (lateral/septal e') or the ratio of the left ventricular lateral and septal wall longitudinal strain (LS_lateral/LS_septal) by two-dimensional speckle-tracking echocardiography. Longitudinal data were analysed using a mixed effects model.

RESULTS

During a median follow-up of 323 days, 20 patients had transient CP, whereas 15 patients had persistent CP. Transient CP had higher baseline erythrocyte sedimentation rates (ESR) (p=0.003) compared with persistent CP. There were no significant differences in LS_lateral/LS_septal and lateral/septal e'. During follow-up, only transient CP showed improvement in lateral/septal e' (p<0.001) and LS_lateral/LS_septal (p=0.003), and recovery of inflammatory markers was similar between the two groups. In the logistic model, higher baseline ESR and greater improvement in lateral/septal e' and LS_lateral/LS_septal were associated with clinical resolution of CP using anti-inflammatory therapy.

CONCLUSIONS

Improvement of constrictive physiology detected by lateral/septal e' and LS_lateral/LS_septal was associated with resolution of clinical symptoms after anti-inflammatory treatment. Serial monitoring of these markers could be used to identify transient CP.

Role of Computed Tomography Angiography in Setting of Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome, predominantly affecting young women. Catheter-based coronary angiography is the gold standard diagnostic test, especially when coupled with intracoronary imaging. Conservative management in stable patients is the preferred approach given the increased risk of complications associated with percutaneous interventions. Noninvasive coronary computed tomography angiography (CTA) has a potential role in the diagnosis and follow-up of SCAD. CTA also plays a role in screening for extracoronary vascular abnormalities frequently associated with SCAD. The goal of this article is to review the potential role of CTA in evaluating SCAD.

Magnetic resonance imaging of the papillary muscles of the left ventricle: normal anatomy, variants, and abnormalities

Left ventricular papillary muscles are small myocardial structures that play an important role in the functioning of mitral valve and left ventricle. Typically, there are two groups of papillary muscles, namely the anterolateral and the posteromedial groups. Cardiovascular magnetic resonance (CMR) is a valuable imaging modality in the evaluation of papillary muscles, providing both morphological and functional information. There is a remarkably wide variation in the morphology of papillary muscles. These variations can be asymptomatic or associated with symptoms related to LV outflow tract obstruction, often associated with hypertrophic cardiomyopathy. Abnormalities of the papillary muscles range from congenital disorders to neoplasms. Parachute mitral valve is the most common congenital abnormality of papillary muscles, in which all the chordae insert into a single papillary muscle. Papillary muscles can become dysfunctional, most commonly due to ischemia. Papillary muscle rupture is a major complication of acute myocardial infarction that results in mitral regurgitation and associated with high mortality rates. The most common papillary neoplasm is metastasis, but primary benign and malignant neoplasms can also be seen. In this article, we discuss the role of CMR in the evaluation of papillary muscle anatomy, function, and abnormalities.

Radiologic review of acquired pulmonary vein stenosis in adults

Acquired pulmonary vein stenosis (PVS) is an uncommon occurrence in adults, but one that carries significant morbidity/mortality. PVS can be secondary to neoplastic infiltration/extrinsic compression, non-neoplastic infiltration/extrinsic compression, or iatrogenic intervention. This article: (I) reviews the common causes of acquired PVS; (II) illustrates direct and indirect cross-sectional imaging findings in acquired PVS (in order to avoid misinterpretation of these imaging findings); and (III) details the role of imaging before and after the treatment of acquired PVS.

A 39-Year-Old Postpartum Woman With Foot Drop and Shortness of Breath

A 39-year-old white woman with a history of adult-onset asthma, chronic sinusitis, and nasal polyposis presented to the ED with dyspnea and left lower extremity weakness and pain. Three months prior to her presentation she had an uncomplicated delivery of her second child, but during her pregnancy she experienced increasing asthma symptoms and nasal congestion. These symptoms progressed after delivery despite treatment with albuterol inhalers and antibiotics.

Incremental value of PET and MRI in the evaluation of cardiovascular abnormalities

Abstract

The cardiovascular system is affected by a wide range of pathological processes, including neoplastic, inflammatory, ischemic, and congenital aetiology. Magnetic resonance imaging (MRI) and positron emission tomography (PET) are state-of-the-art imaging modalities used in the evaluation of these cardiovascular disorders. MRI has good spatial and temporal resolutions, tissue characterization and multi-planar imaging/reconstruction capabilities, which makes it useful in the evaluation of cardiac morphology, ventricular and valvar function, disease characterization, and evaluation of myocardial viability. FDG-PET provides valuable information on the metabolic activity of the cardiovascular diseases, including ischemia, inflammation, and neoplasm. MRI and FDG-PET can provide complementary information on the evaluation of several cardiovascular disorders. For example, in cardiac masses, FDG-PET provides the metabolic information for indeterminate cardiac masses. MRI can be used for localizing and characterizing abnormal hypermetabolic foci identified incidentally on PET scan and also for local staging. A recent advance in imaging technology has been the development of integrated PET/MRI systems that utilize the advantages of PET and MRI in a single examination. The goal of this manuscript is to provide a comprehensive review on the incremental value of PET and MRI in the evaluation of cardiovascular diseases.

Main Messages

• MRI has good spatial and temporal resolutions, tissue characterization, and multi-planar reconstruction

• FDG-PET provides valuable information on the metabolic activity of cardiovascular disorders

• PET and MRI provide complementary information on the evaluation of cardiovascular disorders

Electronic supplementary material

The online version of this article (doi:10.1007/s13244-016-0494-5) contains supplementary material, which is available to authorized users.

POPULATION DYNAMICS OF DROSOPHILA SUZUKII (DIPTERA: DROSOPHILIDAE) IN BELGIUM IN 2013

The vinegar fly Drosophila suzukii (Matsumura) (Diptera Drosophilidae), spotted wing drosophila, is a new invasive fruit pest that recently became established in Europe. Unlike other fruit flies that typically only infest overripe and rotten fruit, D. suzukii females oviposit in ripe fruit leading to considerable economic losses of fruit during production. In 2011 and 2012 D. suzukii was detected at several places in Belgium. In 2013, a large-scale monitoring in frame of the project "FLY ALERT" (FOD) was executed using traps with liquid attractant (apple cider vinegar) at more than 100 locations across Belgium during the whole fruit growing season. At 16 locations we also compared the efficacy of a 'bottle type' trap with a 'cup type' trap. The results show that D. suzukii has expanded its distribution in Belgium. Remarkably, in 2013 as well as in 2012 the first detections were made only in the second part of the growing season (August) and the populations reached their peak only at the very end of the season (November). In the bottle type trap the first flies were caught 2-3 weeks earlier than in the cup type trap. In addition, also the population peaks were on average 1 week earlier when monitored with the bottle trap compared to when monitored with the cup trap. In 2014, after an exceptional mild winter adult D. suzukii flies were continuously detected throughout the winter and early spring. The implications of these findings for the phenology of D. suzukii in the Northwest climate region of Europe are discussed.

PINOT NOIR: pulmonic insufficiency improvement with nitric oxide inhalational response

BACKGROUND

Tetralogy of Fallot (TOF) repair and pulmonary valvotomy for pulmonary stenosis (PS) lead to progressive pulmonary insufficiency (PI), right ventricular enlargement and dysfunction. This study assessed whether pulmonary regurgitant fraction measured by cardiovascular magnetic resonance (CMR) could be reduced with inhaled nitric oxide (iNO).

METHODS

Patients with at least moderate PI by echocardiography undergoing clinically indicated CMR were prospectively enrolled. Patients with residual hemodynamic lesions were excluded. Ventricular volume and blood flow sequences were obtained at baseline and during administration of 40 ppm iNO.

RESULTS

Sixteen patients (11 with repaired TOF and 5 with repaired PS) completed the protocol with adequate data for analysis. The median age [range] was 35 [19-46] years, BMI was 26 ± 5 kg/m(2) (mean ± SD), 50% were women and 75% were in NYHA class I. Right ventricular end diastolic volume index for the cohort was 157 ± 33 mL/m(2), end systolic volume index was 93 ± 20 mL/m(2) and right ventricular ejection fraction was 40 ± 6%. Baseline pulmonary regurgitant volume was 45 ± 25 mL/beat and regurgitant fraction was 35 ± 16%. During administration of iNO, regurgitant volume was reduced by an average of 6 ± 9% (p=0.01) and regurgitant fraction was reduced by an average of 5 ± 8% (p=0.02). No significant changes were observed in ventricular indices for either the left or right ventricle.

CONCLUSION

iNO was successfully administered during CMR acquisition and appears to reduce regurgitant fraction in patients with at least moderate PI suggesting a potential role for selective pulmonary vasodilator therapy in these patients.

TRIALS REGISTRATION

ClinicalTrials.gov, NCT00543933.

Development of a consensus document to improve multireader concordance and accuracy of aortic regurgitation severity grading by echocardiography versus cardiac magnetic resonance imaging

Current guidelines recommend a multiparametric echocardiographic assessment of aortic regurgitation (AR). However, the absence of a hierarchical weighting of discordant parameters could cause interobserver variability. In the present study, we sought to define and improve the interobserver variability of AR assessment. Seventeen level 3 readers graded 20 randomly selected patients with AR. The readers also provided a usefulness score for each parameter, depending on its influence on their decision of the AR severity grade. A consensus strategy was subsequently formulated and validated against cardiac magnetic resonance imaging in a separate group of 80 patients. The readers were updated with the consensus document and recalibrated using the same cases. Agreement was statistically assessed using Randolph's free-marginal multirater kappa. At baseline, no uniform approach was used to combine the individual parameters, contributing to the interobserver variability (overall kappa 0.5). A consensus strategy to categorize AR severity was developed in which the left ventricular volume took precedence over the other parameters and was used to differentiate chronic severe AR from less severe categories. Recalibration of the readers using this consensus strategy improved concordance (kappa increased to 0.7). The new strategy also improved the accuracy relative to cardiac magnetic resonance imaging, as evidenced by full agreement on severe AR between the consensus document-based grading and AR severity defined by cardiac magnetic resonance imaging in the separate validation group of 80 patients. In conclusion, grading of chronic AR using a multiparametric approach has suboptimal consistency between readers and a left ventricular volume-based consensus document improved concordance and accuracy.

Radiation dose and image quality of prospective triggering with dual-source cardiac computed tomography

Prospectively triggered (PT) cardiac computed tomography (CT), whereby radiation is administered only at a predefined phase of the cardiac cycle, has been shown to substantially decrease radiation dose. The aim of our study was to assess the use of this technique in a clinical population using dual-source cardiac CT. Of 312 consecutive patients referred for a dual-source cardiac computed tomographic examination, PT was used in 42 patients for whom, based on physician judgment, it was decided to minimize radiation, whereas retrospective gating was used for 188 patients (coronary artery bypass grafting and pulmonary vein studies were excluded). Kilovolt and milliampere per second were chosen for each patient based on assessment of body habitus and effective radiation dose was calculated. Analysis of nonevaluable vessels was based on clinical readings. For each study, image quality (IQ) was rated on a subjective IQ score and contrast-to-noise and signal-to-noise ratios were calculated. Of the 42 PT examinations (mean age 44.3 years, body mass index 27.8 kg/m(2), 62% men), 28 were referred for coronary evaluation, 11 for aortic disease with/without coronaries, and 3 for other reasons (i.e., suspected mass and congenital disease). Average heart rate was 64.5 beats/min. Average radiation dose of all 42 PT scans was 3.2 +/- 1.6 vs 13.4 +/- 7.8 mSv for the 188 non-PT scans. There was no significant difference in IQ score and contrast-to-noise and signal-to-noise ratios between the 2 groups. Furthermore, the incidence of limited right coronary artery evaluation and of limitations related to right coronary artery motion did not differ between PT and non-PT scans. In conclusion, in selected patients, prospective triggering with dual-source cardiac CT is feasible and results in a dramatic decrease of radiation dose without compromising IQ. Future advances in cardiac CT may further improve this technique, thus allowing for wider use.