The impact and challenges of implementing CTCA according to the 2019 ESC guidelines on chronic coronary syndromes: a survey and projection of CTCA services in the Netherlands.

BACKGROUND: The 2019 ESC-guidelines on chronic coronary syndromes (ESC-CCS) recommend computed tomographic coronary angiography (CTCA) or non-invasive functional imaging instead of exercise ECG as initial test to diagnose obstructive coronary artery disease. Since impact and challenges of these guidelines are unknown, we studied the current utilisation of CTCA-services, status of CTCA-protocols and modeled the expected impact of these guidelines in the Netherlands. METHODS AND RESULTS: A survey on current practice and CTCA utilisation was disseminated to every Dutch hospital organisation providing outpatient cardiology care and modeled the required CTCA capacity for implementation of the ESC guideline, based on these national figures and expert consensus. Survey response rate was 100% (68/68 hospital organisations). In 2019, 63 hospital organisations provided CTCA-services (93%), CTCA was performed on 99 CTCA-capable CT-scanners, and 37,283 CTCA-examinations were performed. Between the hospital organisations, we found substantial variation considering CTCA indications, CTCA equipment and acquisition and reporting standards. To fully implement the new ESC guideline, our model suggests that 70,000 additional CTCA-examinations would have to be performed in the Netherlands. CONCLUSIONS: Despite high national CTCA-services coverage in the Netherlands, a substantial increase in CTCA capacity is expected to be able to implement the 2019 ESC-CCS recommendations on the use of CTCA. Furthermore, the results of this survey highlight the importance to address variations in image acquisition and to standardise the interpretation and reporting of CTCA, as well as to establish interdisciplinary collaboration and organisational alignment.

Conformational transmission in the glyceryl backbone of phospholipid model compounds, induced by a P(4-coordinated) into trigonal bipyramidal P(5-coord) transition.

Triesterified phospholipid model compounds have been synthesized and extensively studied with 300-MHz 1H NMR in the monomer phase in order to get additional support for the effect of conformational transmission induced by a P(4-coord) into a trigonal bipyramidal P(5-coord) transition, as was suggested by Merkelbach and Buck. To elucidate any conformational preferences around the C2-C3 bond, the stereospecifically deuterated precursor 1,2-dihexanoyl-(3R)-sn-[3-2H]glycerol was synthesized. The results reveal that a coordinational change of phosphorus from four to five is transmitted in a significant increase in population of the conformer, in which the vicinally substituted oxygens O-2 and O-3 are trans located. The impact of this transmission seems not to be restricted to conformational changes in the adjacent C2-C3 bond, but is also present in specific rotations around the C1-C2 bond, thereby shifting the C1-C2 conformational equilibrium towards a decreased contribution of the trans arrangement of the acyl chains. As a consequence the interchain distance will be reduced and thus van der Waals interactions will be maximized. The results are interpreted in terms of increased electron density on O-3 when axially located in a P(5-coord) trigonal bipyramidal compound, thereby introducing enhanced electrostatic repulsions within the oxygen pairs O-3, O-2 and O-3, O-1. Relaxation of this energetically unfavourable geometry leads to the observed conformational shifts. Absence of conformational transmission, as found in P(5-coord) trigonal bipyramidal compounds with the 2-ester group substituted for an alkyl moiety, can be considered as additional support for the introduced concept. In the alkyl part of the model phospholipids, however, no conformational changes were observed by means of 13C NMR. Extrapolating this outcome to more condensed phases, a proposition could be made about the mechanism by which conformational changes in the head-group and/or glyceryl backbone will be compensated.

A centrifugal elutriation system of separating small numbers of cells.

One of the major disadvantages of centrifugal elutriation (CE) is the relatively large volume (150 ml) of the various fractions, especially if small numbers of cells have to be separated and the fractions contain few cells. To reduce the volume of the fractions 2 elutriator rotors were coupled in series. Since the rotor speed of the second rotor was always kept 750 rpm higher than that of the first rotor, cells elutriated from rotor 1 were collected in rotor 2. After elutriation of a complete fraction from rotor 1, and collection in rotor 2, the cells were harvested from rotor 2. This was achieved by means of a flow distribution unit (FDU), which made it possible to disconnect the flow of both rotors and simultaneously reverse the flow of the second rotor. It is demonstrated that 40-95 X 10(6) mononuclear leukocytes may be fractionated without loss of resolution in fractions of only 9 ml. The lymphocyte (greater than 99%) and monocyte subpopulations (88-94%) obtained were as pure as with CE carried out with only 1 rotor. In addition, the cells in rotor 2 could be washed and suspended in culture medium prior to harvesting by means of the FDU. In this way loss of cells by additional centrifugation steps was avoided. Erythrocytes (RBC) present in certain lymphocyte fractions were lysed with NH4Cl and after lysis of the RBC and elution of ghosts and debris, the cells were washed and harvested. This procedure did not affect cell viability and the PHA response of the lymphocytes. The versatile system described made it possible to apply CE for the separation of small numbers of cells without loss of resolution, and demonstrated that CE is ideally suitable for concentration and washing of cells, and removal of contaminating RBC, not affecting the recovery, viability and function of the cells.

Isolation of large numbers of highly purified lymphocytes and monocytes with a modified centrifugal elutriation technique.

A modified centrifugal elutriation technique is described for the isolation of large numbers of lymphocytes and monocytes. Elutriation was carried out by lowering the rotor speed at a constant flow rate which was generated by hydrostatic pressure. The flow rate could be kept constant if the separation procedure was performed at high pressure and high systemic resistance. Up to 2.3 X 10(9) mononuclear cells derived from 2000 ml blood were separated in one single experiment in approximately 1 h. The lymphocytes and monocytes were isolated at purities of 98 +/- 1% and 94 +/- 1% respectively. The purity of the lymphocytes was increased to 99.8 +/- 0.1% by a second elutriation run. Additional advantages of the elutriation procedures are that the choice of medium is free, and that relatively large numbers of cells may be separated with high recoveries.