Long-term prognostic value of vasodilator stress cardiac magnetic resonance in patients with atrial fibrillation.

AIMS: Although the prevalence of coronary artery disease (CAD) is high among patients with atrial fibrillation (AF), studies on stress perfusion cardiac magnetic resonance (CMR) imaging frequently exclude patients with AF, and its prognostic and diagnostic value in high-risk patients with suspected or known CAD remains unclear. METHODS AND RESULTS: In this longitudinal cohort study, we included 164 consecutive patients with AF during vasodilator perfusion CMR. Diagnostic value was evaluated regarding invasive coronary angiography in a subset of patients. We targeted a follow-up of >5 years and used CMR results as stratification, and the primary outcome was major adverse cardiac events [MACE, cardiovascular (CV) death and myocardial infarction (MI)]. Secondary outcomes included late coronary revascularization or stroke and the components of the primary outcome. Of the whole cohort (73.8% male, mean age 72.2 years ± 7.8 SD), 99.4% were successfully scanned (163/164 patients). Median CHA2DS2-VASc score was 4 [interquartile range (IQR) 3-5], and median 10-year risk for CV events based on SMART risk score was high (24%, IQR 16-32%). Thirty-two patients (19.6%) presented with ischaemia and 52 patients (31.9%) with late gadolinium enhancement (LGE). A combination of LGE and inducible ischaemia was present in 20 patients (12.3%). Diagnostic accuracy was 86.2% [confidence interval (CI) 68.3-96.1%]. The median follow-up was 6.6 years (IQR 3.6-7.8). Ischaemia in vasodilator perfusion CMR was significantly associated with the occurrence of MACE [P < 0.01; hazard ratio (HR) 2.65, CI 1.39-5.08], as well as LGE (P = 0.03; 1.74, CI 1.07-3.64) and the combination of both (P < 0.01; HR 2.67, CI 1.59-5.62). After adjustment by age, left ventricular ejection fraction, and the presence of diabetes, ischaemia in vasodilator perfusion CMR remained significantly associated with the occurrence of MACE (2.10, CI 1.08-4.10; P = 0.03). In secondary endpoint analysis, there was a significant association of ischaemia in CMR with CV death (P < 0.05; HR 1.93, CI 0.95-3.9) and MI (P < 0.01; HR 13, CI 1.35-125.4), while no significant association was found regarding the occurrence of revascularization (P = 0.45; HR 1.43, CI 0.57-3.58) or stroke (P = 0.99; HR 0.99, CI 0.21-2.59). CONCLUSIONS: Vasodilator stress perfusion CMR demonstrated an excellent diagnostic and significant prognostic value at long-term follow-up in high-risk patients with persistent AF and suspected or known CAD.

Techniques to Relieve Pain Associated With Botulinum Injections for Palmar and Plantar Hyperhidrosis.

BACKGROUND: Palmar and plantar hyperhidrosis (HH) is a common condition characterized by excessive sweating of the palms and soles. Botulinum neurotoxin (BTX) is a very effective and safe treatment. However, the associated intense injection pain is a major limiting factor deterring patients from selecting this treatment. OBJECTIVE: The aim of this study was to review the numerous techniques used to minimize pain accompanying injections for palmoplantar HH. Additionally, the advantages and limitations of each modality will be discussed. MATERIALS AND METHODS: The authors performed a comprehensive literature search in PubMed/MEDLINE, Embase, Cochrane Central, and Google Scholar on randomized controlled trials, cohort studies, and case series on techniques to relieve pain of BTX injections for treatment of palmar and plantar HH. RESULTS: Current available techniques in reducing botulinum injection with merits and drawbacks are nerve blocks, Bier blocks, cryoanalgesia, needle-free anesthesia, topical anesthetics, and vibration anesthesia. CONCLUSION: Topical anesthesia, ice, and vibration are the safest and most convenient noninvasive available methods to relieve pain associated with botulinum injection. Nerve blocks, Bier block, and needle-free anesthesia provide better anesthesia but are limited by the need for training and equipment.

Cardiac Myxomas Show Elevated Native T1, T2 Relaxation Time and ECV on Parametric CMR.

Introduction: While cardiac tumors are rare, their identification and differentiation has wide clinical implications. Recent cardiac magnetic resonance (CMR) parametric mapping techniques allow for quantitative tissue characterization. Our aim was to examine the range of values encountered in cardiac myxomas in correlation to histological measurements. Methods and Results: Nine patients with histologically proven cardiac myxomas were included. CMR (1.5 Tesla, Philips) including parametric mapping was performed in all patients pre-operatively. All data are reported as mean ± standard deviation. Compared to myocardium, cardiac myxomas demonstrated higher native T1 relaxation times (1,554 ± 192 ms vs. 1,017 ± 58 ms, p < 0.001), ECV (46.9 ± 13.0% vs. 27.1 ± 2.6%, p = 0.001), and T2 relaxation times (209 ± 120 ms vs. 52 ± 3 ms, p = 0.008). Areas with LGE showed higher ECV than areas without (54.3 ± 17.8% vs. 32.7 ± 18.6%, p = 0.042), with differences in native T1 relaxation times (1,644 ± 217 ms vs. 1,482 ± 351 ms, p = 0.291) and T2 relaxation times (356 ± 236 ms vs. 129 ± 68 ms, p = 0.155) not reaching statistical significance. Conclusions: Parametric CMR showed elevated native T1 and T2 relaxation times and ECV values in cardiac myxomas compared to normal myocardium, reflecting an increased interstitial space and fluid content. This might help in the differentiation of cardiac myxomas from other tumor entities.

Storage of Micellar Casein Powders with and without Lactose: Consequences on Color, Solubility, and Chemical Modifications.

During storage, a series of changes occur for dairy powders, such as protein lactosylation and the formation of Maillard reaction products (MRPs), leading to powder browning and an increase of insoluble matter. The kinetics of protein lactosylation and MRP formation are influenced by the lactose content of the dairy powder. However, the influence of lactose in the formation of insoluble matter and its role in the underlying mechanisms is still a subject of speculation. In this study, we aim to investigate the role of lactose in the formation of insoluble matter in a more comprehensive way than the existing literature. For that, two casein powders with radically different lactose contents, standard micellar casein (MC) powder (MC1) and a lactose-free (less than 10 ppm) MC powder (MC2), were prepared and stored under controlled conditions for different periods of time. Powder browning index measurements and solubility tests on reconstituted powders were performed to study the evolution of the functional properties of MC powders during aging. Proteomic approaches [one-dimensional electrophoresis and liquid chromatography-mass spectrometry (LC-MS)] and innovative label-free quantification methods were used to track and quantify the chemical modifications occurring during the storage of the powders. Reducing the amount of lactose limited the browning of MC powders but had no effect on the loss of solubility of proteins after storage, suggesting that the action of lactose, leading to the production of MRC, does not promotes the formation of insoluble matter. Electrophoresis analysis did not reveal any links between the formation of covalent bonds between caseins and loss in solubility, regardless of the lactose content. However, LC-MS analyses have shown that different levels of chemical modifications occur during the MC powder storage, depending upon the presence of lactose. An increase of protein lactosylation and acetylation was observed for the powder with a higher lactose content, while an increase of protein deamidation and dephosphorylation was observed for that containing lower lactose. The decrease of pH in the presence of lactose as a result of Maillard reaction (MR) may explain the difference in the chemical modifications of the two powders. In view of the present results, it is clear that lactose is not a key factor promoting insolubility and for the formation of cross-links between caseins during storage. This suggests that lactosylation is not the core reaction giving rise to loss in solubility.

Investigation of secondary structure evolution of micellar casein powder upon aging by FTIR and SRCD: consequences on solubility.

BACKGROUND: Synchrotron radiation circular dichroism (SRCD) and Fourier transform infrared (FTIR) spectroscopy were used to examine the conformation evolution of micellar casein (MC) powder during storage and to determine whether the spectral changes could be related to their solubility evolution. RESULTS: A loss in intensity of SRCD spectra as a function of storage time has been observed. Quantification of secondary structures revealed losses of α-helix content during storage. Moreover, a redshift of the amide I band in the FTIR spectrum was demonstrated during the storage and was interpreted as a rearrangement of the secondary structure of the protein, which is in line with the SRCD results. The qualitative results obtained by FTIR clearly support the quantitative evolution of the secondary structure obtained by the analysis of SRCD spectra. Principal component analysis (PCA) of FTIR spectra permits a good separation of samples according to the storage time. PCA shows that the evolution of secondary structures and solubility loss are closely linked. CONCLUSION: With the quantitative data provided by SRCD spectra, it was established that, whatever the storage conditions, a unique curve exists between loss of α-helix content and loss in solubility, showing that loss of α-helix content is a marker of solubility loss for the MC powders studied. © 2017 Society of Chemical Industry.