Tackling Challenges of Long-Term Electrode Stability in Electrochemical Treatment of 1,4-Dioxane in Groundwater.

Electrochemical advanced oxidation is an appealing point-of-use groundwater treatment option for removing pollutants such as 1,4-dioxane, which is difficult to remove by using conventional separation-based techniques. This study addresses a critical challenge in employing electrochemical cells in practical groundwater treatment─electrode stability over long-term operation. This study aims to simulate realistic environmental scenarios by significantly extending the experimental time scale, testing a flow-through cell in addition to a batch reactor, and employing an electrolyte with a conductivity equivalent to that of groundwater. We first constructed a robust titanium suboxide nanotube mesh electrode that is utilized as both anode and cathode. We then implemented a pulsed electrolysis strategy in which reactive oxygen species are generated during the anodic cycle, and the electrode is regenerated during the cathodic cycle. Under optimized conditions, single-pass treatment through the cell (effective area: 2 cm2) achieved a remarkable 65-70% removal efficiency for 1,4-dioxane in the synthetic groundwater for over 100 h continuous operation at a low current density of 5 mA cm-2 and a water flux of 6 L m-2 h-1. The electrochemical cell and pulse treatment scheme developed in this study presents a critical advancement toward practical groundwater treatment technology.

Peroxymonosulfate-Based Electrochemical Advanced Oxidation: Complication by Oxygen Reduction Reaction.

Peroxymonosulfate (PMS)-based electrochemical advanced oxidation processes (EAOPs) have received widespread attention in recent years, but the precise nature of PMS activation and its impact on the overall process performance remain poorly understood. This study presents the first demonstration of the critical role played by the oxygen reduction reaction in the effective utilization of PMS and the subsequent enhancement of overall pollutant remediation. We observed the concurrent generation of H2O2 via oxygen reduction during the cathodic PMS activation by a model nitrogen-doped carbon nanotube catalyst. A complex interplay between H2O2 generation and PMS activation, as well as a locally increased pH near the electrode due to the oxygen reduction reaction, resulted in a SO4•-/•OH-mixed oxidation environment that facilitated pollutant degradation. The findings of this study highlight a unique dependency between PMS-driven and H2O2-driven EAOPs and a new perspective on a previously unexplored route for further enhancing PMS-based treatment processes.

Pulsed Electrolysis of Boron-Doped Carbon Dramatically Improves Impurity Tolerance and Longevity of H2O2 Production.

Electrocatalytic water treatment has emerged in the limelight of scientific interest, yet its long-term viability remains largely in the dark. Herein, we present for the first time a comprehensive framework on how to optimize pulsed electrolysis to bolster catalyst impurity tolerance and overall longevity. By examining real wastewater constituents and assessing different catalyst designs, we deconvolute the complexities associated with key pulsing parameters to formulate optimal sequences that maximize operational lifetime. We showcase our approach for cathodic H2O2 electrosynthesis, selected for its widespread importance to wastewater treatment. Our results unveil superior performance for a boron-doped carbon catalyst over state-of-the-art oxidized carbon, with high selectivity (>75%) and near complete recoveries in overpotentials even in the presence of highly detrimental Ni2+ and Zn2+ impurities. We then adapt these fine-tuned settings, obtained under a three-electrode arrangement, for practical two-electrode operation using a novel strategy that conserves the desired electrochemical potentials at the catalytic interface. Even under various impurity concentrations, our pulses substantially improve long-term H2O2 production to 287 h and 35 times that attainable via conventional electrolysis. Our findings underscore the versatility of pulsed electrolysis necessary for developing more practical water treatment technologies.

A Protocol for Electrocatalyst Stability Evaluation: H2O2 Electrosynthesis for Industrial Wastewater Treatment.

Electrocatalysis has been proposed as a versatile technology for wastewater treatment and reuse. While enormous attention has been centered on material synthesis and design, the practicality of such catalyst materials remains clouded by a lack of both stability assessment protocols and understanding of deactivation mechanisms. In this study, we develop a protocol to identify the wastewater constituents most detrimental to electrocatalyst performance in a timely manner and elucidate the underlying phenomena behind these losses. Synthesized catalysts are electrochemically investigated in various electrolytes based on real industrial effluent characteristics and methodically subjected to a sequence of chronopotentiometric stability tests, in which each stage presents harsher operating conditions. To showcase, oxidized carbon black is chosen as a model catalyst for the electrosynthesis of H2O2, a precursor for advanced oxidation processes. Results illustrate severe losses in catalyst activity and/or selectivity upon the introduction of metal pollutants, namely magnesium and zinc. The insights garnered from this protocol serve to translate lab-scale electrocatalyst developments into practical technologies for industrial water treatment purposes.

Elucidating the Role of Single-Atom Pd for Electrocatalytic Hydrodechlorination.

In this study, we loaded Pd catalysts onto a reduced graphene oxide (rGO) support in an atomically dispersed fashion [i.e., Pd single-atom catalysts (SACs) on rGO or Pd1/rGO] via a facile and scalable synthesis based on anchor-site and photoreduction techniques. The as-synthesized Pd1/rGO significantly outperformed the Pd nanoparticle (Pdnano) counterparts in the electrocatalytic hydrodechlorination of chlorinated phenols. Downsizing Pdnano to Pd1 leads to a substantially higher Pd atomic efficiency (14 times that of Pdnano), remarkably reducing the cost for practical applications. The unique single-atom architecture of Pd1 additionally affects the desorption energy of the intermediate, suppressing the catalyst poisoning by Cl-, which is a prevalent challenge with Pdnano. Characterization and experimental results demonstrate that the superior performance of Pd1/rGO originates from (1) enhanced interfacial electron transfer through Pd-O bonds due to the electronic metal-support interaction and (2) increased atomic H (H*) utilization efficiency by inhibiting H2 evolution on Pd1. This work presents an important example of how the unique geometric and electronic structure of SACs can tune their catalytic performance toward beneficial use in environmental remediation applications.

Polyarteritis nodosa in childhood: recognition of early dermatologic signs may prevent morbidity.

Systemic polyarteritis nodosa (PAN) is a vasculitis that affects small to medium-size arteries. Onset in childhood is rare and can cause significant morbidity. Often, cutaneous manifestations can provide early clues toward diagnosis. This article describes a case of childhood systemic PAN that presented with fever, a necrotic skin lesion, and oral ulceration. Intestinal perforation complicated this case. Prompt recognition of childhood PAN is important to prevent serious complications.

Underpotential Deposition of 3D Transition Metals: Versatile Electrosynthesis of Single-Atom Catalysts on Oxidized Carbon Supports.

Use of single-atom catalysts (SACs) has become a popular strategy for tuning activity and selectivity toward specific pathways. However, conventional SAC synthesis methods require high temperatures and pressures, complicated procedures, and expensive equipment. Recently, underpotential deposition (UPD) has been investigated as a promising alternative, yielding high-loading SAC electrodes under ambient conditions and within minutes. Yet only few studies have employed UPD to synthesize SACs, and all have been limited to UPD of Cu. In this work, a flexible UPD approach for synthesis of mono- and bi-metallic Cu, Fe, Co, and Ni SACs directly on oxidized, commercially available carbon electrodes is reported. The UPD mechanism is investigated using in situ X-ray absorption spectroscopy and, finally, the catalytic performance of a UPD-synthesized Co SAC is assessed for electrochemical nitrate reduction to ammonia. The findings expand upon the usefulness and versatility of UPD for SAC synthesis, with hopes of enabling future research toward realization of fast, reliable, and fully electrified SAC synthesis processes.

The Impact of Prematurity at Birth on Short-Term Postoperative Outcomes Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

Prematurity is associated with surgical complications. This study sought to determine the risk of prematurity on 30-day complications, reoperations, and readmissions following ≥7-level PSF for AIS which has not been established. Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)-Pediatric dataset, all AIS patients undergoing ≥7-level PSF from 2012-2016 were identified. Cases were 1:1 propensity score-matched to controls by age, sex, and number of spinal levels fused. Prematurity sub-classifications were also evaluated: extremely (<28 weeks), very (28-31 weeks), and moderate-to-late (32-36 weeks) premature. Univariate analysis with post hoc Bonferroni compared demographics, hospital parameters, and 30-day outcomes. Multivariate logistic regression identified independent predictors of adverse 30-day outcomes. 5531 patients (term = 5099; moderate-to-late premature = 250; very premature = 101; extremely premature = 81) were included. Premature patients had higher baseline rates of multiple individual comorbidities, longer mean length of stay, and higher 30-day readmissions and infections than the term cohort. Thirty-day readmissions increased with increasing prematurity. Very premature birth predicted UTIs, superficial SSI/wound dehiscence, and any infection, and moderate-to-late premature birth predicted renal insufficiency, deep space infections, and any infection. Prematurity of AIS patients differentially impacted rates of 30-day adverse outcomes following ≥7-level PSF. These results can guide preoperative optimization and postoperative expectations.

Crohn's disease in total knee arthroplasty patients correlates with increased rates of 90-day and overall postoperative complications and readmissions.

BACKGROUND: Joint involvement is a common extraintestinal manifestation of Crohn's Disease (CD) that may require total knee arthroplasty (TKA). There is a paucity of evidence regarding the relationship between CD and postoperative outcomes after TKA surgery. This study seeks to evaluate the impact of CD on 90-day and ≥2-year follow-up postoperative outcomes of TKA patients. METHODS: We retrospectively analyzed the Statewide Planning and Research Cooperative System database (2009-2013) and isolated ICD-9 codes for TKA patients (8154), while excluding those with any revision of knee replacements (0080-0084) and split into 2 groups with or without CD (5550-5559). Patient demographics and postoperative outcomes were compared. Logistic regression analyses with covariates (sex, race, Deyo score, age, and insurance) were utilized to evaluate the association of CD with 90-day and overall postoperative outcomes. RESULTS: A total of 89,134 TKA patients were identified, 244 of whom had CD. Significant differences in age, race distribution, insurance, and Deyo score (all, p < 0.05) were found. Multivariable analysis demonstrated CD was an independent risk factor for 90-day and overall medical complications, surgical complications, and readmission. Univariate and multivariable analyses report CD had significant increased rates and was a predictor, respectively, of overall blood transfusions (OR 1.5 [95% CI 1.1-2.0] p < 0.01), acute renal failure (OR 1.7 [95% CI 1.1-2.6] p = 0.03), and pulmonary embolism (OR 2.5 [95% CI 1.3-4.6] p = 0.01). CONCLUSION: Patients with CD undergoing TKA have increased risk both 90-day and overall surgical and medication complications, as well as readmissions compared to patients without CD.

The 5-factor modified frailty index (mFI-5) is predictive of 30-day postoperative complications and readmission in patients with adult spinal deformity (ASD).

BACKGROUND: There is limited research regarding the association between the mFI-5 and postoperative complications among adult spinal deformity (ASD) patients. METHODS: Using the National Surgical Quality Improvement Project (NSQIP) database, patients with Current Procedural Terminology (CPT) codes for > 7-level fusion or < 7-level fusion with International Classification of Diseases, Ninth Revision (ICD-9) codes for ASD were identified between 2008 and 2016. Univariate analyses with post-hoc Bonferroni correction for demographics and preoperative factors were performed. Logistic regression assessed associations between mFI-5 scores and 30-day post-operative outcomes. RESULTS: 2,120 patients met criteria. Patients with an mFI-5 score of 4 or 5 were excluded, given there were<20 patients with those scores. Patients with mFI-5 scores of 1 and 2 had increased 30-day rates of pneumonia (3.5 % and 4.3 % vs 1.6 %), unplanned postoperative ventilation for > 48 h (3.1 % and 4.3 % vs 0.9 %), and UTIs (4.4 % and 7.4 % vs 2.0 %) than patients with a score of 0 (all, p < 0.05). Logistic regression revealed that compared to an mFI-5 of 0, a score of 1 was an independent predictor of 30-day reoperations (OR = 1.4; 95 % CI 1.1-18). A score of 2 was an independent predictor of overall (OR = 2.4; 95 % CI 1.4-4.1) and related (OR = 2.2; 95 % CI 1.2-4.1) 30-day readmissions. A score of 3 was not predictive of any adverse outcome. CONCLUSION: The mFI-5 score predicted complications and postoperative events in the ASD population. The mFI-5 may effectively predict 30-day readmissions. Further research is needed to identify the benefits and predictive value of mFI-5 as a risk assessment tool.

The effects of antiepileptic drugs on bone health: A systematic review.

PURPOSE: Epilepsy may be treated with antiepileptic drugs (AEDs), which have been reported to decrease bone mineral density (BMD). Current data is conflicting and variable, and little is known with regard to how duration of AED use or specific AEDs, such as CYP-450 enzyme-inducing (EIAEDs) versus non-enzyme inducing (NEIAEDs) drugs affect BMD. We sought to systematically review BMD changes due to AED use to identify trends in reporting. METHODS: A literature search via Medline (PubMed), EMBASE, and Cochrane databases was performed. Peer-reviewed articles were identified that reported on BMD measurements in conjunction with AEDs. RESULTS: Twenty-six studies met inclusion criteria. Long-term therapy was shown across multiple, well-controlled studies to have the most significant BMD loss. Carbamazepine had the most frequent reporting of unfavorable effects on bone health and Lamotrigine seemed to show the most bone-protective qualities. Serum biochemical markers of bone turnover did not significantly correlate with measured BMD changes. CONCLUSION: The present study provides evidence that long-term AED therapy is the most significant risk factor for BMD loss. Furthermore, there was little compelling evidence to support that EIAEDs, as a class, were more harmful to bone than NEIAEDs, which has been previously suggested in multiple studies. Early clinical concern for significant loss of BMD may not be warranted as lower BMD was less likely to be observed during the initial years of AED therapy. Furthermore, serum markers of bone turnover are not clinically reliable in assessing BMD changes in patients taking AEDs.

CT IVC venogram: normalized quantitative criteria for patency and thrombosis.

PURPOSE: Establish normal attenuation ratios for vein to artery on CT IVC venogram and determine a vascular attenuation ratio diagnostic of thrombus. METHODS: This retrospective, HIPAA-compliant study included 56 CT IVC venograms. Images were reviewed for the presence of femoral vein or IVC thrombus. Attenuation ratios for each vein and its corresponding artery were calculated by two observers and averaged in four venous stations (right and left femoral veins, and IVC at the confluence of the iliac veins and at the left renal vein). The reference standard for the absence of thrombus was clinical follow-up and for the presence of thrombus it was thrombectomy or catheter venogram. Receiver operating characteristic (ROC) analysis was performed using ratios from one venous station and threshold for thrombus was determined using the Youden's index. RESULTS: 36 of 56 CTs demonstrated no thrombus. 20 CTs demonstrated thrombus, confirmed in eight patients. For CTs with no thrombus, median ratios among the venous stations ranged from 0.89 (IQR 0.83-0.93) to 0.91 (IQR 0.86-0.94). ROC analysis of ratios from a single representative station (left femoral vein, n = 4 confirmed clots) demonstrated an area under the curve (AUC) of 0.994 (p = 0.001) and a threshold of 0.67 for diagnosing thrombus [sensitivity 100% (95% CI 39.76-100%), specificity 97.5% (86.84-99.94%)]. CONCLUSION: The normal attenuation ratio of vein to artery in the absence of venous thrombus on a 3-min delay CT IVC venogram is approximately 0.91. A ratio less than 0.67 is highly suggestive of thrombus.

Analysis of weight changes after left gastric artery embolization in a cancer-naive population.

PURPOSE: We aimed to evaluate weight changes after left gastric artery (LGA) embolization in a retrospective cancer-naive cohort. METHODS: A retrospective study was conducted to identify patients who underwent LGA embolization for gastrointestinal bleeding (GI). Patients with known cancer diagnoses at the time of LGA embolization were excluded. Pre- and postprocedure weights were assessed. Statistical analysis was performed using paired t-test and Wilcoxon signed-rank test. RESULTS: A total of 39 patients were identified. In 21 patients who had documented pre- and postprocedural weights, a median of 16.3 kg weight loss (P = 0.045) was observed over a median time of 12 months (range, 2-72). In patients who had pre- and postprocedure endoscopies (n=6), 2 had worsening ulcers following LGA embolization and 4 had stable or no abnormal findings. CONCLUSION: Our preliminary observation suggests that LGA embolization is well tolerated and results in unintended weight loss. Larger studies are needed to confirm these preliminary findings.

Endovascular Management of SVC Syndrome due to Fibrosing Mediastinitis-A Feasibility and Safety Analysis.

PURPOSE: To assess the outcomes of endovascular management for superior vena cava (SVC) syndrome secondary to fibrosing mediastinitis (FM). METHODS: Between January 2004 and December 2016, 10 consecutive patients with endovascularly managed SVC syndrome secondary to FM were identified in an institutional database. Venograms were performed to assess the severity and location of the lesion and allow measurement for stent selection. Standard stenting and angioplasty techniques were utilized to establish luminal patency. The safety, feasibility, clinical success, and the primary and secondary patency were evaluated. Kaplan-Meier survival analysis was used to determine median duration of stent patency. A log-rank test was used to test differences in prior stent use. RESULTS: Our cohort was predominantly female (7/10) with an average age of 42.2 years. Of the 10 patients, 3 had undergone endovascular stenting at an outside institution prior to referral to our institution due to new, recurrent, or worsening symptoms. All patients underwent venography demonstrating stenosis (8/10) or occlusion (2/10) at initial presentation. Stenting or angioplasty was technically successful in 9 (90.0%) patients. Eight of 10 patients had primary stenting, while 1 achieved vascular patency and symptom resolution with angioplasty alone. Median duration of primary patency was 31.3 months (95% confidence interval: 5.9-103). Six (54.5%) patients required secondary revision procedures. Median duration of secondary patency was 6.1 months, with 25% of revisions occurring by 4 months and 75% occurring by 20.9 months. All treated patients (9/9) reported symptomatic relief at 1-month follow-up, establishing a clinical success rate of 100%. There were no 30-day adverse effects related to the procedure. CONCLUSION: This study demonstrates that endovascular therapy is a safe and feasible approach for managing FM-related SVC syndrome.

Modified Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) Techniques for the Treatment of Gastric Varices: Vascular Plug-Assisted Retrograde Transvenous Obliteration (PARTO)/Coil-Assisted Retrograde Transvenous Obliteration (CARTO)/Balloon-Occluded Antegrade Transvenous Obliteration (BATO).

Gastric varices in the setting of portal hypertension occur less frequently than esophageal varices but occur at lower portal pressures and are associated with more massive bleeding events and higher mortality rate. Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices has been well documented as an effective therapy for portal hypertensive gastric varices. However, BRTO requires lengthy, higher-level post-procedural monitoring and can have complications related to balloon rupture and adverse effects of sclerosing agents. Several modified BRTO techniques have been developed including vascular plug-assisted retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration, and balloon-occluded antegrade transvenous obliteration. This article provides an overview of various modified BRTO techniques.

Ultrasound-guided Radiofrequency Lesioning of the Articular Branches of the Femoral Nerve for the Treatment of Chronic Post-arthroplasty Hip Pain.

BACKGROUND: Total hip arthroplasty (THA) is a common surgical treatment for several conditions of the hip. While the majority of patients obtain satisfactory results, many develop chronic post-arthroplasty hip pain that can be difficult to treat. OBJECTIVE: We evaluate the effectiveness of cooled (60°C) radiofrequency lesioning of the articular branches of the femoral nerve (ABFN) as a minimally invasive treatment for patients suffering from chronic post-arthroplasty hip pain. This treatment has never been described previously in this population. STUDY DESIGN: Case report. SETTING: Center for Pain Medicine, Massachusetts General Hospital, Harvard Medical School. METHOD: A 59-year-old woman with long-standing osteoarthritis of the right hip who underwent primary total hip arthroplasty and presented with chronic post-arthroplasty hip pain Intervention: Cooled (60°C) radiofrequency lesioning of the ABFN under ultrasound guidance Outcome Measure: Functional ability and numeric rating scale (NRS) scores at rest and with activity. RESULTS: Prior to intervention, the patient reported severe disruption in daily activities, sleep, and relationships; NRS scores at rest and with activity were 4/10 and 10/10, respectively. At 4 weeks following intervention, the patient reported significant improvement in functional ability and NRS scores decreased to 1/10 and 2/10, respectively. At 6 months, the patient's NRS scores at rest and with activity were 0/10 and 1/10, respectively. At 24-month follow-up, the patient continued to endorse significant pain relief with NRS scores at rest and with activity of 0 - 1/10 and 1 - 2/10, respectively. There were no side effects or complications including motor weakness, sensory loss, and neuralgias. LIMITATIONS: Although the patient obtained good results from the intervention, the description of the study is from a single case report. Further study is necessary to investigate the widespread use of this technique and its outcomes. CONCLUSIONS: Cooled (60°C) radiofrequency lesioning of the ABFN under ultrasound guidance is both an effective and minimally invasive intervention for chronic post-arthroplasty hip pain. Key words: Radiofrequency lesioning, articular branches, femoral nerve, post-arthoplasty, total hip arthoplasty, hip pain, chronic pain.

Impact of gender on patient preferences for technology-based behavioral interventions.

INTRODUCTION: Technology-based interventions offer an opportunity to address high-risk behaviors in the emergency department (ED). Prior studies suggest behavioral health strategies are more effective when gender differences are considered. However, the role of gender in ED patient preferences for technology-based interventions has not been examined. The objective was to assess whether patient preferences for technology-based interventions varies by gender. METHODS: This was a secondary analysis of data from a systematic survey of adult (≥18 years of age), English-speaking patients in a large urban academic ED. Subjects were randomly selected during a purposive sample of shifts. The iPad survey included questions on access to technology, preferences for receiving health information, and demographics. We defined "technology-based" as web, text message, e-mail, social networking, or DVD; "non-technology-based" was defined as in-person, written materials, or landline. We calculated descriptive statistics and used univariate tests to compare men and women. Gender-stratified multivariable logistic regression models were used to examine associations between other demographic factors (age, race, ethnicity, income) and technology-based preferences for information on specific risky behaviors. RESULTS: Of 417 participants, 45.1% were male. There were no significant demographic differences between men and women. Women were more likely to use computers (90.8% versus 81.9%; p=0.03), Internet (66.8% versus 59.0%; p=0.03), and social networks (53.3% versus 42.6%; p=0.01). 89% of men and 90% of women preferred technology-based formats for at least type of health information; interest in technology-based for individual health topics did not vary by gender. Concern about confidentiality was the most common barrier to technology-based use for both genders. Multivariate analysis showed that for smoking, depression, drug/alcohol use, and injury prevention, gender modified the relationship between other demographic factors and preference for technology-based health information; e.g., older age decreases interest in technology-based information for smoking cessation in women but not in men (aOR 0.96, 95% CI 0.93-0.99 versus aOR 1.00, 95% CI 0.97-1.03). CONCLUSION: Our findings suggest ED patients' gender may affect technology preferences. Receptivity to technology-based interventions may be a complex interaction between gender and other demographic factors. Considering gender may help target ED patient populations most likely to be receptive to technology-based interventions.

Mechanism for reduced pericardial adhesion formation in hypercholesterolemic swine supplemented with alcohol.

OBJECTIVE: Previous experiments in Yorkshire swine demonstrated significantly fewer pericardial adhesions and intramyocardial collagen deposition at reoperative sternotomy in animals supplemented with vodka but not with red wine. The purpose of this experiment was to determine a mechanism for adhesion reduction. METHODS: Twenty-seven male Yorkshire swine were fed a high-cholesterol diet to simulate conditions of coronary artery disease followed by the surgical placement of an ameroid constrictor to the left circumflex coronary artery to induce chronic ischaemia. Postoperatively, control pigs continued their high-fat/cholesterol diet alone, whereas the two experimental groups had diets supplemented with either red wine or vodka for 7 weeks followed by reoperative sternotomy and cardiac harvest. RESULTS: The expression of related adhesion focal tyrosine kinase (RAFTK) and caspase 3 in the sodium dodecyl sulphate (SDS)-soluble myocardial fraction was significantly higher only in the vodka-supplemented group. In the more soluble fraction, the expression of caspase 3, cleaved caspase 3 and caspase 9 was lower in both the vodka and red wine treatment groups. CONCLUSIONS: In the SDS-soluble lysate fraction, likely representing the transmembrane/cell-extracellular matrix (ECM), a significant increase in RAFTK and caspase 3 expression was seen only in the vodka-treated animals, which may explain why this group demonstrated significantly fewer pericardial adhesions. Caspase expression/signalling was not increased in the more soluble myocardial lysate, suggesting that the increased apoptotic signalling was specific to the epicardial-ECM.