Effectiveness and Equity in Community-Based Rehabilitation on Pain, Physical Function, and Quality of Life After Unilateral Lower Limb Amputation: A Systematic Review

OBJECTIVES

To synthesize evidence for (1) the effectiveness of exercise-based rehabilitation interventions in the community and/or at home after transfemoral and transtibial amputation on pain, physical function, and quality of life and (2) the extent of inequities (unfair, avoidable differences in health) in access to identified interventions.

DATA SOURCES

Embase, MEDLINE, PEDro, Cinahl, Global Health, PsycINFO, OpenGrey, and ClinicalTrials.gov were systematically searched from inception to August 12, 2021, for published, unpublished, and registered ongoing randomized controlled trials.

STUDY SELECTION

Three review authors completed screening and quality appraisal in Covidence using the Cochrane Risk of Bias Tool. Included were randomized controlled trials of exercise-based rehabilitation interventions based in the community or at home for adults with transfemoral or transtibial amputation that assessed effectiveness on pain, physical function, or quality of life.

DATA EXTRACTION

Effectiveness data were extracted to templates defined a priori and the PROGRESS-Plus framework was used for equity factors.

DATA SYNTHESIS

Eight completed trials of low to moderate quality, 2 trial protocols, and 3 registered ongoing trials (351 participants across trials) were identified. Interventions included cognitive behavioral therapy, education, and video games, combined with exercise. There was heterogeneity in the mode of exercise as well as outcome measures employed. Intervention effects on pain, physical function, and quality of life were inconsistent. Intervention intensity, time of delivery, and degree of supervision influenced reported effectiveness. Overall, 423 potential participants were inequitably excluded from identified trials (65%), limiting the generalizability of interventions to the underlying population.

CONCLUSIONS

Interventions that were tailored, supervised, of higher intensity, and not in the immediate postacute phase showed greater promise for improving specific physical function outcomes. Future trials should explore these effects further and employ more inclusive eligibility to optimize any future implementation.

CXD101 and nivolumab in patients with metastatic microsatellite-stable colorectal cancer (CAROSELL): a multicentre, open-label, single-arm, phase II trial

BACKGROUND

Patients with microsatellite stable (MSS) colorectal carcinoma (CRC) do not respond to immune checkpoint inhibitors. Preclinical models suggested synergistic anti-tumour activity combining CXD101 and anti-programmed cell death protein 1 treatment; therefore, we assessed the clinical combination of CXD101 and nivolumab in heavily pre-treated patients with MSS metastatic CRC (mCRC).

PATIENTS AND METHODS

This single-arm, open-label study enrolled patients aged 18 years or older with biopsy-confirmed MSS CRC; at least two lines of systemic anticancer therapies (including oxaliplatin and irinotecan); at least one measurable lesion; Eastern Cooperative Oncology Group performance status of 0, 1 or 2; predicted life expectancy above 3 months; and adequate organ and bone marrow function. Nine patients were enrolled in a safety run-in study to define a tolerable combination schedule of CXD101 and nivolumab, followed by 46 patients in the efficacy assessment phase. Patients in the efficacy assessment cohort were treated orally with 20 mg CXD101 twice daily for 5 consecutive days every 3 weeks, and intravenously with 240 mg nivolumab every 2 weeks. The primary endpoint was immune disease control rate (iDCR).

RESULTS

Between 2018 and 2020, 55 patients were treated with CXD101 and nivolumab. The combination therapy was well tolerated with the most frequent grade 3 or 4 adverse events being neutropenia (18%) and anaemia (7%). Immune-related adverse reactions commonly ascribed to checkpoint inhibitors were surprisingly rare although we did see single cases of pneumonitis, hypothyroidism and hypopituitarism. There were no treatment-related deaths. Of 46 patients assessable for efficacy, 4 (9%) achieved partial response and 18 (39%) achieved stable disease, translating to an immune disease control rate of 48%. The median overall survival (OS) was 7.0 months (95% confidence interval 5.13-10.22 months).

CONCLUSIONS

The primary endpoint was met in this phase II study, which showed that the combination of CXD101 and nivolumab, at full individual doses in the treatment of advanced or metastatic MSS CRC, was both well tolerated and efficacious.

Fibrin, Bone Marrow Cells And Macrophages Interactively Modulate Cardiomyoblast Fate: An In Vitro Study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was supported by the Swiss National Science Foundation (SNF 310030_149986) attributed to MNG, the University of Fribourg and the Fonds Scientifique Cardiovasculaire FSC, Fribourg Hospital attributed to SC

The spatiotemporal interaction of macrophages with the cardiac extracellular matrix, cardiomyocytes and non-cardiomyocytes has shown increasing interest in cardiac repair and regeneration. Due to their immunomodulatory capacities, cell-based therapies for myocardial infarction (MI) may influence macrophages fate. In addition, the use of biomaterials combined with cells is nowadays a recommended approach for cell-based therapies to fosters cell retention and survival. Depending on their composition and structure, scaffolds may modulate macrophage phenotypes. We interrogated the influence of fibrin, a biologically active scaffold, on the fate of cells including bone marrow cells (BMC), macrophages and cardiomyoblasts.

Methods

In vivo, two weeks post-MI induction, animals with an ejection fraction between 35-60% were either sham-operated animals or treated with an epicardial implantation of a BMC and fibrin. In vivo, two weeks post-MI induction, animals with an ejection fraction between 35-60% were either sham-operated animals or treated with an epicardial implantation of a BMC and fibrin. In vitro, non-polarized macrophages were differentiated toward either pro-inflammatory or anti-inflammatory phenotypes and stimulated with the conditioned medium of fibrin-primed BMC (F-BMC). Proteomic, cytokine levels quantification, and qPCR were performed. EdU incorporation and real time cell analysis assessed the effect of F-BMC on macrophages and cardiomyoblasts H9C2 proliferation.

Results

In vivo, epicardial implantation of Fibrin and BMC reduced the loss of cardiac function induced by MI and prevented the fibrotic scar expansion. After 4 and 12 weeks, the infarct content of CD68+ and CD206+ macrophages were similar in control and treated animals. To investigate acute effect, we performed in vitro assays. We showed that fibrin profoundly influenced gene expression and the secreted proteome of BMC, simultaneously upregulating both pro- and anti-inflammatory mediators. Furthermore, the conditioned medium from F-BMC significantly increased the proliferation of anti-inflammatory macrophages and modulated their gene expression and cytokines secretion. For example, F-BMC downregulated the expression of pro-inflammatory genes, in particular Nos2, Il6 and Ccl2/Mcp1. Anti-inflammatory genes such as Arg1, Tgfb and IL10 were significantly upregulated. Interestingly, anti-inflammatory macrophages educated by F-BMC stimulated EdU incorporation in H9C2 cardiomyoblasts.

In conclusion, our study provides evidence that F-BMC secretome promoted the growth of anti-inflammatory macrophages, stimulated macrophage plasticity and altered the balance between the pro and anti-inflammatory macrophage subsets. F-BMC secretome favoured the mitogenic properties of anti-inflammatory macrophages promoting cardiac cell growth. In vivo, F-BMC treatment lowered the infarct extent and increased wall thickness and improved cardiac function.

Outcomes and phenotypic expression of rare variants in hypertrophic cardiomyopathy genes in over 200,000 adults

Background

Hypertrophic cardiomyopathy (HCM) is caused by rare variants in sarcomere-encoding genes, but little is known about the clinical significance of these variants in the general population.

Purpose

To determine the population prevalence of HCM-associated sarcomeric variants, characterise their phenotypic manifestations, estimate penetrance, and identify associations between sarcomeric variants and clinical outcomes, we performed an observational study of 218,813 adults in the UK Biobank (UKBB), of whom 200,584 have whole exome sequencing (WES).

Methods

We carried out an integrated analysis of WES and cardiac magnetic resonance (CMR) imaging in UK Biobank participants stratified by sarcomere-encoding variant status. Computer vision techniques were used to automatically segment the four chambers of the heart (Figure 1). Cardiac motion analysis was used to derive strain and strain rates. Regional analysis of left ventricular wall thickness was performed using three-dimensional modelling of these segmentations.

Results

Median age at recruitment was 58 (IQR 50–63 years), and participants were followed up for a median of 10.8 years (IQR 9.9–11.6 years) with a total of 19,507 primary clinical events reported.

The prevalence of rare variants (allele frequency <0.ehab724.17314) in HCM-associated sarcomere-encoding genes in 200,584 participants was 2.9% (n=5,727; 1 in 35), and the prevalence of pathogenic or likely pathogenic variants (SARC-P/LP) was 0.24% (n=474, 1 in 423).

SARC-P/LP variants were associated with increased risk of death or major adverse cardiac events (MACE) compared to controls (HR 1.68, 95% CI 1.37–2.06, p<0.001), mainly due to heart failure endpoints (Figure 2: cumulative hazard curves with zoomed plots for lifetime risk of A) death and MACE or B) heart failure, stratified by genotype; genotype negative (SARC-NEG), carriers of indeterminate sarcomeric variants (SARC-IND) or SARC-P/LP; C) Forest plot of comparative lifetime risk of clinical endpoints by genotype).

While males had a higher overall risk of adverse outcomes, the incremental genetic risk from SARC-P/LP mutations was greater in females (HR for females: 2.18 CI 1.65–2.89, p<0.001; HR for males: 1.42 CI 1.05–1.9, p=0.02).

In 21,322 participants with CMR, SARC-P/LP were associated with asymmetric increase in left ventricular maximum wall thickness (10.9±2.7 vs 9.4±1.6 mm, p<0.001) but hypertrophy (≥13mm) was only present in 16% (n=7/43, 95% CI 7–31%). Other rare sarcomere-encoding variants had a weak effect on wall thickness (9.5±1.7 vs 9.4±1.6 mm, p=0.002) with no combined excess cardiovascular risk.

Conclusions

In the general population, SARC-P/LP variants have low aggregate penetrance for overt HCM but are associated with increased risk of adverse cardiovascular outcomes and a sub-clinical cardiomyopathic phenotype. Although absolute event rates are low, identification of these variants may enhance risk stratification beyond familial disease.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was supported by the Medical Research Council, UK (MC-A651-53301); National Institute for Health Research (NIHR) Imperial College Biomedical Research Centre; NIHR Royal Brompton Cardiovascular Biomedical Research Unit; British Heart Foundation (NH/17/1/32725, RG/19/6/34387, RE/18/4/34215).

Obesity prevalence and associations with socio-economic and behavioral factors in population-based studies in Russia and Norway, 2015–2017

Background

Obesity is an epidemic of XXI century, as its prevalence doubled during the last forty years. As Russia and Norway are countries with different life expectancy there could be differences in obesity and its correlates.

Purpose

To investigate and compare prevalence and socio-economic and behavioral factors associated with obesity in Russia and Norway with data from population-based studies.

Methods

We used multivariable logistic regression to examine associations of obesity (body mass index>30 kg/m2) with socio-economic factors (age, education, marital status, and poor financial situation defined as difficulty to afford clothes) and behavioral characteristics (smoking, alcohol use) in participants aged 40–69 years from the Know Your Heart study (Russia, 2015–2017, N=4 106) and the seventh Study (Norway, 2015–16, N=17 604). All results for covariates are mutually adjusted. Between-study comparisons of the associations of obesity with the same covariates were performed through investigation of their interactions with the “study” variable.

Results

The age-standardized prevalence of obesity was higher in Russia among women (36.8 vs 22.0%, p<0.001) and did not differ among men (26.7 vs 25.7%, p=0.224). In Russian women, obesity was positively associated with age of 50–69 years relative to 40–49 years (OR=2.5, 95% CI 2.0–3.1), no university education (OR=1.5, 95% CI 1.2–1.8), and poor financial situation (OR=1.5, 95% CI 1.2–1.9). In Norwegian women, obesity was negatively associated with the age of 50–69 years (OR=0.8, 95% CI 0.8–1.0), current smoking (OR=0.8, 95% CI 0.7–1.0) and drinking alcohol ≥2 times per week (OR=0.6, 95% CI 0.5–0.6), and positively associated with no university education (OR=1.5, 95% CI 1.3–1.7), previous smoking (OR=1.3, 95% CI 1.1–1.4), and drinking ≥5 alcohol drinks per occasion (OR=1.7, 95% CI 1.3–2.2). In Russian men, obesity was positively associated with living with spouse/partner (OR=1.5, 95% CI 1.1–2.2), drinking alcohol ≥2 times per week (OR=1.4, 95% CI 1.1–1.8), and negatively associated with current smoking (OR=0.6, 95% CI 0.4–0.8). In Norwegian men, obesity was positively associated with no university education (OR=1.4, 95% CI 1.2–1.6), previous smoking (OR=1.3, 95% CI 1.2–1.5), and drinking ≥5 alcohol drinks per occasion (OR=1.7, 95% CI 1.5–1.9), and negatively associated with current smoking (OR=0.8, 95% CI 0.7–1.0) and drinking alcohol ≥2 times per week (OR=0.7, 95% CI 0.6–0.7). Interactions with the “study” variable in women were significant for age, financial situation, frequency of alcohol use; in men - for living with spouse/partner, frequency of alcohol use, number of alcohol drinks taken per occasion.

Conclusion

The prevalence of obesity was higher in Russian compared to Norwegian women, but there was no difference between Russian and Norwegian men. There were different between-country patterns of the associations of obesity with the socio-economic and behavioral characteristics.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The Know Your Heart study was a component of International Project on Cardiovascular Disease in Russia and funded by Wellcome Trust Strategic Award [100217], UiT The Arctic University of Norway, Norwegian Institute of Public Health, and Norwegian Ministry of Health and Care Services. The Tromsø Study was funded by UiT The Arctic University of Norway, Northern Norway Regional Health Authority, Norwegian Ministry of Health and Care Services, Norwegian Research Council, and various public and charity research funds in Norway. PhD scholarship and operational funds of the first author were provided by Northern State Medical University, Arkhangelsk, Russia and by UiT The Arctic University of Norway

Small artificial waterbodies are widespread and persistent emitters of methane and carbon dioxide

Inland waters play an active role in the global carbon cycle and emit large volumes of the greenhouse gases (GHGs), methane (CH₄ ) and carbon dioxide (CO₂ ). A considerable body of research has improved emissions estimates from lakes, reservoirs and rivers but recent attention has been drawn to the importance of small, artificial waterbodies as poorly quantified but potentially important emission hotspots. Of particular interest are emissions from drainage ditches and constructed ponds. These waterbody types are prevalent in many landscapes and their cumulative surface areas can be substantial. Furthermore, GHG emissions from constructed waterbodies are anthropogenic in origin and form part of national emissions reporting, whereas emissions from natural waterbodies do not (according to Intergovernmental Panel on Climate Change guidelines). Here, we present GHG data from two complementary studies covering a range of land uses. In the first, we measured emissions from nine ponds and seven ditches over a full year. Annual emissions varied considerably: 0.1-44.3 g CH₄  m^-2  year^-1 and -36-4421 g CO₂  m^-2  year^-1 . In the second, we measured GHG concentrations in 96 ponds and 64 ditches across seven countries, covering subtropical, temperate and sub-arctic biomes. When CH₄ emissions were converted to CO₂  equivalents, 93% of waterbodies were GHG sources. In both studies, GHGs were positively related to nutrient status (C, N, P), and pond GHG concentrations were highest in smallest waterbodies. Ditch and pond emissions were larger per unit area when compared to equivalent natural systems (streams, natural ponds). We show that GHG emissions from natural systems should not be used as proxies for those from artificial waterbodies, and that artificial waterbodies have the potential to make a substantial but largely unquantified contribution to emissions from the Agriculture, Forestry and Other Land Use sector, and the global carbon cycle.

Successful management of aspiration pneumopathy without antimicrobial agents: 14 dogs (2014-2021)

OBJECTIVES

To describe clinical cases of aspiration pneumonitis and pneumonia in dogs, which were successfully managed without antimicrobials.

MATERIALS AND METHODS

Retrospective case review of dogs presenting to a referral teaching hospital between February 2014 and February 2021. Cases were included when a clinical diagnosis of aspiration pneumopathy was made (requiring one or more of the following: radiographic evidence of an aspiration pneumopathy, endotracheal airway sampling consistent with aspiration and/or a positive endotracheal airway sample culture) which was not treated with antimicrobial therapy.

RESULTS

Fourteen cases were identified of which nine had respiratory signs including increased respiratory rate or effort (n=8), arterial hypoxaemia (n=2), or a clinician-determined requirement for oxygen therapy (n=4). Where haematology was performed, five of nine displayed a normal neutrophil count with toxic changes, three displayed neutrophilia and one displayed neutropenia with toxic changes. Endotracheal airway sample cytology in four cases revealed neutrophilic inflammation with bacteria, plant material, yeasts and unidentified foreign material. Where respiratory signs were present, these resolved within 12 to 36 hours.

CLINICAL SIGNIFICANCE

In this case series, immunocompetent dogs sustaining aspiration events, even with classical evidence of pneumonitis or pneumonia, have been managed successfully without antimicrobials. Radiography alone cannot be used to determine the requirement for antimicrobials. Better characterisation of the pathogenesis and clinical trajectory of aspiration pneumopathy is required, which may enable a reduction in inappropriate antimicrobial prescriptions.

A 5-year retrospective review of skin adnexal tumours received at a tertiary dermatopathology service: Implications for linked genetic diagnoses

BACKGROUND

Skin adnexal tumours (SATs) comprise a diverse range of neoplasms, which are difficult to diagnose clinically. They present in paediatric and adult populations, and may be indicative of an underlying genetic syndrome. There is a lack of recent data on the presentation of these tumours in clinical practice in European populations.

OBJECTIVE

To characterise the clinical and pathological features of SATs received at a single tertiary centre over a 5-year period.

METHODS

A retrospective health record audit of SATs received at the Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, during the period November 2012 to October 2017.

RESULTS

107144 skin cases were received during the audit period. 1615 cases of SATs from 1359 patients were included; 1570 (97.2%) were benign and 45 (2.8%) were malignant. Overall, the average age at presentation was 55 years (range 11 months - 97 years) and the male to female ratio was 0.77:1. Sweat gland and hair follicle SATs were most frequently excised; in adults the most frequent tumour was hidrocystoma, and in children, pilomatrixoma. Pre-biopsy diagnosis was correct 28% of the time. Benign SATs are often markers of an associated genetic condition, warranting improved discrimination of sporadic from genetically related SATs.

CONCLUSIONS

 SATs are difficult to diagnose clinically, and clinicopathological correlation may help enhance selection of genetically related SATs from sporadic cases. These data have implications for clinical and dermatopathological training provision, the development of reporting standards, and genetic assessment of selected patients.

Treatment target achievement after myocardial infarction: cardiovascular risk factors, medication use and lifestyle in Norwegian women and men

Funding Acknowledgements

Type of funding sources: None.

Background

Although the use of guidelines in clinical practice is emphasised, large multi-center studies of patients with cardiovascular disease have shown secondary prevention to be suboptimal, which increase the risk of recurrent events.

Purpose

To examine ESC guideline treatment target achievement after myocardial infarction for cardiovascular risk factors, medication use and a broad range of lifestyle factors in women and men from a Norwegian general population.

Methods

In a population-based study conducted 2015-2016 (65% attendance), 637 participants 40-95 years (23% women, 70% ≥65 years) had validated myocardial infarction. Cross-sectionally, we investigated target achievement for blood pressure (<140/90 mmHg, <130/80 mmHg if diabetes), LDL cholesterol (<1.8 mmol/L), HbA1c (<7.0% if diabetes), weight (body mass index (BMI) <25 kg/m2, waist circumference (women <80 cm, men <94 cm)), smoking (non-smoking), physical activity (self-reported >sedentary, accelerometer-measured moderate-to-vigorous ≥150 min/week), diet (intake of fruits ≥200 g/day, vegetables ≥200 g/day, fish ≥200 g/week, saturated fat <10E%, fiber ≥30g/day,  and alcohol (women ≤10 g/day, men ≤20 g/day)), and medication use (antihypertensives, lipid-lowering drugs, antithrombotics, antidiabetics) using regression models.

Results

Proportion of target achievement was for blood pressure 55.8%, LDL cholesterol 9.3%, HbA1c 42.7%, BMI 19.5%, waist circumference 15.6%, non-smoking 86.2%, self-reported physical activity 79.5%, objectively measured physical activity 9.1%, intake of fruits 66.7%, vegetables 38.4%, fish 96.8%, saturated fat 25.4%, fiber 29.5%, and alcohol 78.5%, use of antidiabetics 84.3%, lipid-lowering drugs 86.8%, antihypertensives 78.5% and antithrombotics 77.9%. In total, 0.8% achieved all cardiovascular risk factor targets (blood pressure, LDL cholesterol, BMI and waist circumference combined). Compared to men, a lower proportion of women achieved the target for waist circumference (6.9% vs 18.1%, p = 0.002). Compared to participants 65 years or older, a higher proportion of those 40-64 years achieved the target for blood pressure (71.2% vs 49.0%, p < 0.001), and a lower proportion achieved the target for BMI (15.3 vs 21.4, p = 0.007).

Conclusion

Secondary prevention after myocardial infarction was suboptimal in both women and men. A negligible proportion achieved the treatment target for all risk factors. Improvement in follow-up care after myocardial infarction is needed.

Homelessness, sex and a tale of two sexually transmitted infections

The Young People's Health Service (YPHS) is a free, nurse-led Primary Health Care Clinic, in Melbourne, for young people aged 12-24 who are experiencing homelessness. Sexually transmitted infection (STI) screening is routinely offered as part of comprehensive psychosocial assessments. We wanted to determine the number of people positive for Chlamydia trachomatis (Ct) and Mycoplasma genitalium (Mg), amongst this asymptomatic high-risk population. We also wanted to review our screening practice. All asymptomatic sexually active clients seen by YPHS between 2014 and 2016 were offered a first pass urine polymerase chain reaction-based test for Ct and Mg. Urine samples were taken for men and women. Positivity for Ct and Mg out of those tested was determined and association with gender examined. Between 2014-2016, 272 males and 278 females (n = 550) were screened for Ct, and 72 infections were detected (13.1%. Chlamydia positivity did not differ between males (n = 35; 12.9%, 95% confidence interval [CI]: 8.8-16.8) and females (n = 37; 13.3%, 95%CI: 9.3-17.3). Over the same period 273 males and 284 females were screened for Mg (n = 557) and 55 infections were detected (9.9%). A higher proportion of females (n = 35; 12.3%, 95%CI: 8.5-16.1) tested positive compared to males (n = 20; 7.3%, 95%CI: 4.2-10.4), p = 0.048. Our study demonstrates both Ct and Mg are prevalent in the population, Mg being more common in young women than young men. Referral for specialist care for macrolide-resistant Mg increased and the updated Australian STI management guidelines led to a review of practice.

The genetic architecture of left ventricular non-compaction reveals both substantial overlap with other cardiomyopathies and a distinct aetiology in a subset of cases

Background

Left ventricular non-compaction (LVNC) is a condition characterised by trabeculations in the myocardial wall and is the subject of considerable conjecture as to whether it represents a distinct pathology or a secondary phenotype associated with other cardiac diseases, particularly cardiomyopathies.

Purpose

To investigate the genetic architecture of LVNC by identifying genes and variant classes robustly associated with disease and comparing these to other genetically characterised cardiomyopathies.

Methods

We performed rare variant association analysis using six different LVNC cohorts comprising 840 cases together with 125,748 gnomAD population controls and compared results to similar analyses with dilated cardiomyopathy (DCM) and hypertrophic cardiomyopathy (HCM) cases.

Results

We observed substantial overlap in genes and variant classes enriched in LVNC and DCM/HCM, indicating that in many cases LVNC belongs to a spectrum of more established cardiomyopathies, with non-compaction representing a phenotypic variation in patients with DCM- or HCM-causing variants. In contrast, five variant classes were uniquely enriched in LVNC cases, of which truncating variants in MYH7, ACTN2 and PRDM16 may represent a distinct LVNC aetiology. MYH7 truncating variants are generally considered as non-pathogenic but were detected in 2% of LVNC cases compared to 0.1% of controls, including a cluster of variants around a single splice region. Additionally, structural variants (exon deletions) in RYR2 and missense variants in the transmembrane region of HCN4 were enriched in LVNC cases, confirming prior reports regarding the association of these variant classes with combined LVNC and arrhythmia phenotypes.

Conclusions

We demonstrated that genetic association analysis can clarify the relationship between LVNC and established cardiomyopathies, highlighted substantial overlap with DCM/HCM but also identified variant classes associated with distinct LVNC and with joint LVNC/arrhythmia phenotypes. These results underline the complex genetic landscape of LVNC and inform how genetic testing in LVNC cases should be pursued and interpreted.

Cardiomyopathy rare variant frequencies

Funding Acknowledgement

Type of funding source: None

5-year outcomes in patients with acute coronary syndrome treated with biodegradable polymer sirolimus-eluting stents versus durable polymer everolimus-eluting stents

Background

Newest generation drug-eluting stents (DES) combining ultrathin cobalt chromium platforms with biodegradable polymers may reduce target lesion failure (TLF) as compared to second generation DES among patients with acute coronary syndrome (ACS). While previous studies indicated a potential benefit within the first two years after percutaneous coronary intervention (PCI), it remains uncertain whether the clinical benefit persists after complete degradation of the polymer coating.

Purpose

To compare the long-term effects of ultrathin-strut biodegradable polymer sirolimus-eluting stents (BP-SES) versus thin-strut durable polymer everolimus-eluting stents (DP-EES) for PCI in patients with ACS.

Methods

We performed a subgroup analysis of ACS patients included into the BIOSCIENCE trial (NCT01443104), a randomized trial comparing BP-SES with DP-EES. The primary endpoint of the present post-hoc analysis was TLF, a composite of cardiac death, target vessel myocardial infarction (MI) and clinically indicated target lesion revascularization (TLR), at 5 years.

Results

Among 2,119 patients enrolled between March 2012 and May 2013, 1,131 (53%) presented with ACS (ST-segment elevation myocardial infarction, 36%). Compared to patients with stable CAD, ACS patients were younger, had a lower baseline cardiac risk profile, including a lower prevalence of hypertension, hypercholesterolaemia, diabetes mellitus, and peripheral artery disease, and had a greater incidence of previous revascularization procedures. At 5 years, TLF occurred similarly in 89 patients (cumulative incidence, 16.9%) treated with BP-SES and 85 patients (16.0%) treated with DP-EES (RR 1.04; 95% CI 0.78–1.41; p=0.78) in patients with ACS, and in 109 patients (24.1%) treated with BP-SES and 104 patients (21.8%) treated with DP-EES (RR 1.11; 95% CI 0.85–1.45; p=0.46) in stable CAD patients (p for interaction=0.77) (Figure 1, Panel A). Cumulative incidences of cardiac death (8% vs. 7%; p=0.66), target vessel MI (5.2% vs. 5.8%; p=0.66), clinically indicated TLR (8.9% vs. 8.3%; p=0.63) (Figure 1, Panel B-D), and definite thrombosis (1.4% vs. 1.0%; p=0.57) at 5 years were similar among ACS patients treated with ultrathin-strut BP-SES or thin-strut DP-EES. Overall, there was no interaction between clinical presentation and treatment effect of BP-SES versus DP-EES.

Conclusion

In a subgroup analysis of the BIOSCIENCE trial, we found no difference in long-term clinical outcomes between ACS patients treated with ultrathin-strut BP-SES or thin-strut DP-EES at five years.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Unrestricted research grant to the institution from Biotronik AG, Switzerland

As a biopatch, fibrin and bone marrow-derived cells modulate macrophage polarization and cardiomyobasts proliferation

Introduction

Repair of the cardiac structure and function is the holy grail for curative treatment of myocardial infarction (MI). Clinical trials for cardiac cell-based therapies have revealed numerous challenges and led to a shift in the initial paradigms. The current concept is that cell/matrix-based therapy modifies the local immune response, releases factors involved in tissue repair, mitigates the progression of ventricular remodelling, and rescues the cardiac function. Macrophages are critical players in cardiac remodelling post-MI with a complex role yet not fully elucidated in cell-based therapy.

Purpose

We, first, investigated in an MI animal model, the myocardial macrophage content following an epicardial application of a biopatch composed of bone marrow-derived cells (BMDCs) and fibrin-based matrix. Second, we analyzed in vitro the cell interactions between the biopath, macrophages and cardiomyoblasts.

Methods

Two weeks post-infarct, performed on female rats, a Cell and Matrix BioPatch (CMBP) composed of fibrin and BMDCs was administered. Heart function and infarct were evaluated by high-resolution echocardiography and histology. Macrophages present 4 weeks post-MI were quantified by immunostaining for CD86 and CD206. In vitro, macrophages (undifferentiated (M0), triggered by IL4 (M2) or LPS/IFN-d (M1)), or cardiomyoblasts (H9C2) were cultured with conditioned media from CMBP. Their proliferation and plasticity were assessed by EDU incorporation and real-time cell analyzer and RT-PCR.

Results

Our data showed a significant improvement in ejection fraction after treatment and a reduced infarct expansion index (IEI MI/untreated= 0.08±0.05 vs. IEI MI/CMBP_treated =0.22±0.09, p=0.002). The ratio of CD86+/CD206+ cells was also significantly reduced in treated compared to untreated groups (ratioMI/untreated=0.96±0.82 vs ratioMI/fibrin_treated=0.51±0.12 and ratioMI/CMBP_treated=0.17±0.13, p<0.05) suggesting an alteration of the macrophage polarization. In vitro assays with CMBP-conditioned medium revealed a significant increase in the proliferation of M0 and M2. Also, M0 were polarized towards an M2 profile. A switch of M1 toward M2 was revealed by Gene expression profiles with a reduction of pro-inflammatory markers (CD86, MCP-1, IL-1beta, CD80, RANTES and iNOS) and an increase in the anti-inflammatory ones (Arginase 1, CD163, CD106). The secretion profile of the macrophages was also modified with a lower secretion of IL-6 and TNF-alpha and increased IL-10. Interestingly, when cardiomyoblasts are cultured with the medium conditioned of the macrophages triggered by CMBP, their proliferation was significantly increased by 16%±1 with M0 or M2 and 18%±1 with M1.

Conclusion

Our data point to a new paracrine communication from a biopatch that triggered macrophages and indirectly cardiac cells. Cell cross-talks promoted an anti-inflammatory response that promoted cardiac cells proliferation.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): University of Fribourg

Age-related clinical and hemodynamic outcome following transcatheter aortic valve replacement: a swiss TAVI registry analysis

Background

Transcatheter aortic valve implantation (TA) is the preferred treatment modality for patients with severe aortic valve disease at high surgical risk and is expanding into lower risk populations. Therefore age range of treated patients is increasing.

Purpose

The aim of this study is to analyze age-related clinical and hemodynamic outcome of patients following TAVI in a nationwide, prospective, multicentre cohort (Swiss TAVI registry).

Methods

We retrospectively analyzed prospectively collected data from all patients included in the Swiss TAVI registry between February 2011 and December 2018. In an adjusted analysis, in-hospital, 30-days and 1-year outcome between four age groups were compared.

Results

Overall, 7097 patients underwent TAVI (<70 years: n=324, 70–79 years: n=1913, 80–89 years: n=4353, 90–100 years n=507). Median STS risk score for mortality was 5.23±4.13% and differed significantly between age groups (3.46±4.10%, 3.97±3.73%, 5.57±3.97%, 8.22±4.74%; p=0.001). Valve predilatation was more often performed in older patients (54.3% vs. 54.3% vs. 60.7% vs. 69.6%; p≤0.001). Difference in hospital stay was statistically sigificant between age groups, numerically however not relevant (10.01±7.56 days vs. 9.25±6.38 days vs. 9.55±5.70 days vs 10.03±5.77 days; p=0.02). Post-procedural acute kidney injury stage 3 was highest in the youngest age group (3.4% vs. 1.6% vs. 1.1% vs. 1.0%; RR [95% CI] 0.65 (0.48–0.87); p=0,004) and rate of new pacemakers for conduction abnormalities increased significantly with age (10.2% vs. 13.7% vs. 17.1% vs. 18.7%; RR [95% CI] 1.22 (1.12–1.32); p<0.001). There was no significant difference in life threatening/major bleeding (p=0.288/0.197) or major vascular complications (p=0.083).

All-cause mortality and cardiovascular mortality in hospital, at 30 days and at 1 year were highest in nonagenarians and higher in the patients <70 years compared to patients of 70–79 years: in hospital all-cause mortality 2.2% vs. 1.6% vs. 2.9% vs. 5.5% (RR [95% CI] 1.64 (1.28–2.10), p<0.001); 30 day all-cause mortality 3.1% vs. 2.0% vs. 3.7% vs. 6.7%; (HR [95% CI] 1.59 (1.30–1.96); p<0.0001); 1-year all-cause mortality 10.9% vs. 10.4% vs. 12% vs. 19.5% (HR [95% CI] 1.27 (1.14–1.41); p<0.001); in hospital cardiovascular mortality 1.5% vs. 1.5% vs. 2.6% vs. 5.1% (RR [95% CI] 1.70 (1.31–2.20), p<0.001); 30 day cardiovascular mortality 2.2% vs. 1.9% vs. 3.3% vs. 6.3%; (HR [95% CI] 1.68 (1.35–2.09); p<0.001); 1-year cardiovascular mortality 7.2% vs. 6.9% vs. 8.3% vs. 15.3% (HR [95% CI] 1.36 (1.19–1.55); p<0.001). This held true, when hazard ratio was corrected for STS PROM score, femoral access vs other access and year of procedure.

Conclusion

In-hospital, 30-day and 1-year clinical outcome of nonagenarians undergoing TAVI are less favorable compared to lower age groups. Interestingly, clinical outcome of the patients group 70–79 years was the most favorable.

Mortality at 30 according to age

Funding Acknowledgement

Type of funding source: None

Current fluid and blood product availability in veterinary setting: a survey of UK small animal practices

OBJECTIVES

To investigate and discuss current fluid and blood products stocked in small animal practices in the UK.

METHODS

An online survey was circulated to small animal veterinary practices across the UK. The survey included questions regarding the level of hospital care provided, the type of fluid and blood component products stocked, the most frequently restocked products, and the available options in the event that blood products were required but not stocked.

RESULTS

There were 423 responses including 27 duplicates. The remaining 396 respondents represented a spectrum of practices including 19 referral practices. Crystalloids were stocked in all practices. Lactated Ringer's solution was the most frequently re-stocked product in 355 of 396 (90%) of practices. Where synthetic colloids were stocked, gelatin-based colloids (155/178 [87%]) were stocked in preference to hydroxyethyl starches (23/178 [13%]). Blood products were stocked by 81 of 396 (20%) of practices. If a blood product was required but not stocked, 31% of practices would use a pet blood banking service, 28% would use their own blood donors, and 21% would refer.

CLINICAL SIGNIFICANCE

This study provides an insight into the fluid and blood products stocked and used by a selection of veterinary practices within the UK and serves as a baseline for ongoing research and decision-making in both veterinary practice and industry.

Evolutionary Persistence of DNA Methylation for Millions of Years after Ancient Loss of a De Novo Methyltransferase

Cytosine methylation of DNA is a widespread modification of DNA that plays numerous critical roles. In the yeast Cryptococcus neoformans, CG methylation occurs in transposon-rich repeats and requires the DNA methyltransferase Dnmt5. We show that Dnmt5 displays exquisite maintenance-type specificity in vitro and in vivo and utilizes similar in vivo cofactors as the metazoan maintenance methylase Dnmt1. Remarkably, phylogenetic and functional analysis revealed that the ancestral species lost the gene for a de novo methylase, DnmtX, between 50-150 mya. We examined how methylation has persisted since the ancient loss of DnmtX. Experimental and comparative studies reveal efficient replication of methylation patterns in C. neoformans, rare stochastic methylation loss and gain events, and the action of natural selection. We propose that an epigenome has been propagated for >50 million years through a process analogous to Darwinian evolution of the genome.

P962 The Remodeling Index risk stratifies patients with hypertensive left ventricular hypertrophy

Funding Acknowledgements

National Medical Research Council

BACKGROUND

Hypertensive left ventricular hypertrophy (LVH) is associated with increased cardiovascular events. The authors previously developed the Remodeling Index (RI) that incorporated LV volume and wall-thickness in a single measure of advanced hypertrophy in hypertensive patients.

PURPOSE

This study examined the mechanisms and prognostic potential of the RI in reference with current LVH classifications.

METHODS

Cardiovascular magnetic resonance (CMR) was performed in 400 asymptomatic hypertensive patients. The newly derived RI ([(EDV)^1/3]/t; where EDV is LV end-diastolic volume and t is the maximal wall thickness across 16 myocardial segments) stratified hypertensive patients into 3 groups: without LVH, LVH with normal RI (LVH_Normal-RI) and LVH with low RI (LVH_Low-RI). The primary outcome was a composite of all-cause mortality, acute coronary syndromes, strokes and decompensated heart failure.

RESULTS

LVH_Low-RI was associated with increased LV mass index, fibrosis burden, impaired myocardial function and elevated biochemical markers of myocardial injury and wall stress. Over 18.3 ± 7.0 months (601.3 patient-years), patients with LVH_Low-RI had more than a 5-fold increase in adverse events compared to those with LVH_Normal-RI (11.6 events/100patient-years versus 2.0 events/100 patient-years, respectively; log-rank P < 0.001; Figure A). The RI provided incremental prognostic value over and above a model consisting of clinical variables and LVH (P = 0.02). Conversely concentric and eccentric LVH were associated with adverse prognosis (4.5 events/100patient-years versus 6.0 events/100patient-years, respectively; log-rank P = 0.62) that was similar as the natural history of hypertensive LVH (5.1 events/100patient-years).

CONCLUSIONS

The RI provides mechanistic insights and prognostic value that improves risk-stratification of hypertensive LVH.

Abstract P962 Figure.

A critical discussion of theoretical foundations and measurement methods of gender roles

Background

Public health researchers have frequently investigated associations of individual gender role norms or attitudes with a variety of health outcomes. It has been suggested that the construct of gender roles is multidimensional, including norms about gender inequality and gender-related division of labour. Implications of multidimensionality and limitations of applied measurement methods, however, have rarely been discussed critically in published studies.

Methods

I will summarise theoretical considerations about the multidimensionality of the construct of gender roles. Examples of recently applied approaches to operationalise gender role attitudes in mental health research will be presented. The talk will conclude with a discussion of advantages and limitations of these approaches regarding consistency with theory, applicability, and reduction of measurement error.

Results

Gender role norms include assumptions about inequality and division of labour in the public and private sphere. Items about gender role attitudes are regularly included in questionnaires of large social surveys and are suitable to explore associations with disease occurrence or quality of healthcare. Data reduction methods such as factor analysis might be applied to differentiate dimensions and to reduce measurement error.

Conclusions

Shortcomings in considering theoretical foundations and inconsistencies in operationalisation might have contributed to the limited recognition of findings about possible impacts of gender roles on health. We need to advance measurement methods to increase the quality of public health research on gender. Finally, aspects of gender on the contextual level should complement investigations of individual gender roles.

P1968Five-year outcomes in patients with diabetes mellitus treated with biodegradable polymer sirolimus-eluting stents versus durable polymer everolimus-eluting stents

Background

Patients with diabetes mellitus (DM) remain at higher risk for adverse events after percutaneous coronary intervention (PCI) compared with non-diabetic individuals. Among available drug-eluting stents (DES), thin-strut durable polymer everolimus-eluting stents (DP-EES) were shown to provide the best safety and efficacy profile in diabetics. Whether biodegradable polymer DES provide additional long-term clinical benefit compared with DP-EES among diabetic patients remains uncertain.

Purpose

To compare the long-term performance of ultrathin-strut biodegradable polymer sirolimus-eluting stents (BP-SES) versus DP-EES for PCI in patients with insulin-requiring and non-insulin-requiring DM.

Methods

We performed a prespecified subgroup analysis of the randomized, multicenter, non-inferiority BIOSCIENCE trial (NCT01443104). Patients with stable coronary artery disease or acute coronary syndrome were randomly assigned to treatment with ultrathin-strut BP-SES or thin-strut DP-EES. Patients were further divided according to diabetic status. The primary endpoint was target lesion failure (TLF), a composite of cardiac death, target-vessel myocardial infarction (MI) and clinically-indicated target lesion revascularization (TLR), within 12 months.

Results

Among 2'119 patients enrolled between March 2012 and May 2013, 486 (22.9%) presented with DM (insulin-requiring, 33.1%). Compared with non-diabetics, patients with DM were older and had a greater baseline cardiac risk profile, including higher prevalence of hypertension, hypercholesterolaemia, peripheral artery disease, chronic renal failure and prior PCI, coronary artery bypass graft surgery, or stroke. At 5 years, TLF occurred similarly in 74 patients (cumulative incidence, 31.0%) treated with BP-SES and 57 patients (25.8%) treated with DP-EES (RR 1.23; 95% CI 0.87–1.73; p=0.24) in diabetics, and in 124 patients (16.8%) treated with BP-SES and 132 patients (16.8%) treated with DP-EES (RR 0.98; 95% CI 0.77–1.26; p=0.90) in non-diabetics (p for interaction=0.31). Cumulative incidences of cardiac death (14.9% vs. 9.5%; p=0.10), target-vessel MI (11.4% vs. 11.0%; p=0.81), clinically-indicated TLR (16.9% vs. 15.8%; p=0.68), and definite thrombosis (3.0% vs. 2.5%; p=0.63) at 5 years were similar among diabetic patients treated with ultrathin-strut BP-SES or thin-strut DP-EES. Overall, there was no interaction between diabetic status and treatment effect of BP-SES versus DP-EES.

Conclusion

In a prespecified subgroup analysis of the BIOSCIENCE trial, we found no difference in clinical outcomes throughout five years between diabetic patients treated with ultrathin-strut BP-SES or thin-strut DP-EES.

Acknowledgement/Funding

BIOSCIENCE was an investigator-initiated trial supported by a dedicated research grant from Biotronik, Bülach, Switzerland

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.