4-Year Follow-Up After Transcatheter Tricuspid Valve Replacement Using the EVOQUE System.

Transcatheter tricuspid valve replacement (TTVR) is an increasingly used treatment technique for patients with severe tricuspid regurgitation (TR). Currently, available data from international registries and randomized controlled trials provide outcome data until a maximum follow-up of 2 years after the procedure. This case report presents 4-year follow-up data for an 84-year-old woman who underwent TTVR for torrential TR in 2019. The patient experienced durable TR reduction, symptomatic improvement, right ventricular reverse remodeling, and substantial improvement in liver and kidney function.

Comparison of methods for estimating Young's moduli of mortar specimens.

Precisely estimating material parameters for cement-based materials is crucial for assessing the structural integrity of buildings. Both destructive (e.g., compression test) and non-destructive methods (e.g., ultrasound, computed tomography) are used to estimate Young's modulus. Since ultrasound estimates the dynamic Young's modulus, a formula is required to adapt it to the static modulus. For this formulas from the literature are compared. The investigated specimens are cylindrical mortar specimens with four different sand-to-cement mass fractions of 20%, 35%, 50%, and 65%. The ultrasound signals are analyzed in two distinct ways: manual onset picking and full-waveform inversion. Full-waveform inversion involves comparing the measured signal with a simulated one and iteratively adjusting the ultrasound velocities in a numerical model until the measured signal closely matches the simulated one. Using computed tomography measurements, Young's moduli are semi-analytically determined based on sand distribution in cement images. The reconstructed volume is segmented into sand, cement, and pores. Young's moduli, as determined by compression tests, were better represented by full-waveform inversions (best RMSE = 0.34 GPa) than by manual onset picking (best RMSE = 0.87 GPa). Moreover, material parameters from full-waveform inversion showed less deviation than those manually picked. The maximal standard deviation of a Young's modulus determined with FWI was 0.36, while that determined with manual picking was 1.11. Young's moduli from computed tomography scans match those from compression tests the closest, with an RMSE of 0.13 GPa.

Photoredox catalysis harvesting multiple photon or electrochemical energies.

Photoredox catalysis (PRC) is a cutting-edge frontier for single electron-transfer (SET) reactions, enabling the generation of reactive intermediates for both oxidative and reductive processes via photon activation of a catalyst. Although this represents a significant step towards chemoselective and, more generally, sustainable chemistry, its efficacy is limited by the energy of visible light photons. Nowadays, excellent alternative conditions are available to overcome these limitations, harvesting two different but correlated concepts: the use of multi-photon processes such as consecutive photoinduced electron transfer (conPET) and the combination of photo- and electrochemistry in synthetic photoelectrochemistry (PEC). Herein, we review the most recent contributions to these fields in both oxidative and reductive activations of organic functional groups. New opportunities for organic chemists are captured, such as selective reactions employing super-oxidants and super-reductants to engage unactivated chemical feedstocks, and scalability up to gram scales in continuous flow. This review provides comparisons between the two techniques (multi-photon photoredox catalysis and PEC) to help the reader to fully understand their similarities, differences and potential applications and to therefore choose which method is the most appropriate for a given reaction, scale and purpose of a project.

Electron-Poor Acridones and Acridiniums as Super Photooxidants in Molecular Photoelectrochemistry by Unusual Mechanisms.

Electron-deficient acridones and in situ generated acridinium salts are reported as potent, closed-shell photooxidants that undergo surprising mechanisms. When bridging acyclic triarylamine catalysts with a carbonyl group (acridones), this completely diverts their behavior away from open-shell, radical cationic, 'beyond diffusion' photocatalysis to closed-shell, neutral, diffusion-controlled photocatalysis. Brønsted acid activation of acridones dramatically increases excited state oxidation power (by +0.8 V). Upon reduction of protonated acridones, they transform to electron-deficient acridinium salts as even more potent photooxidants (*E1/2 =+2.56-3.05 V vs SCE). These oxidize even electron-deficient arenes where conventional acridinium salt photooxidants have thusfar been limited to electron-rich arenes. Surprisingly, upon photoexcitation these electron-deficient acridinium salts appear to undergo two electron reductive quenching to form acridinide anions, spectroscopically-detected as their protonated forms. This new behaviour is partly enabled by a catalyst preassembly with the arene, and contrasts to conventional SET reductive quenching of acridinium salts. Critically, this study illustrates how redox active chromophoric molecules initially considered photocatalysts can transform during the reaction to catalytically active species with completely different redox and spectroscopic properties.

Age and Synchronization of Daphnia magna Affect Sensitivity to Teflubenzuron in Acute Standardized Toxicity Tests.

The standard Daphnia sp. acute toxicity test for assessing the adverse effects of chemicals on aquatic invertebrates stipulates the use of neonates that are ≤24 h old (hours post release [hpr]) at the start of the exposure. However, when one is assessing acute effects of chemicals interfering with endocrine relevant-processes such as molting, both age synchronization and absolute age can influence the test outcome, because the occurrence of molting and associated mortality is highly time specific. Hence, a 24-h age synchronization window may mask the real effects of these compounds. To explore the influence of age synchronization and absolute age in standard acute toxicity tests, we exposed D. magna from different synchronization windows and absolute ages (≤4, 4-8, 8-12, ≤12, and ≤24 hpr at the beginning of the exposure) to 0.5-12 µg/L of the chitin synthesis inhibitor (CSI) teflubenzuron (TEF) using the Organisation for Economic Co-operation and Development test guideline 202 (Daphnia sp. 48 h immobilization test). Our results show significant differences in 48-h median lethal concentrations between animals with a synchronization window of ≤4 hpr (2.9 µg/L) and longer synchronization windows such as ≤12 hpr (5.1 µg/L) and ≤24 hpr (16.8 µg/L). A concurrent decreasing trend in molting median effect concentrations was observed for the same synchronization windows: ≤4 hpr (4.0 µg/L), ≤12 hpr (5.9 µg/L), and ≤24 hpr (30.0 µg/L). Together, our results show that both synchronization and absolute age are determinant factors for the sensitivity of D. magna to TEF. A narrow synchronization window (e.g., ≤4 hpr) may provide a more conservative estimate of TEF toxicity and should be considered when one is performing standardized toxicity tests for molting-disrupting compounds such as TEF. Environ Toxicol Chem 2023;42:1806-1815. © 2023 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Chronic Pleural Effusion in Ventriculoperitoneal Shunt due to Diaphragmatic CSF Fistula: Report of a Case Treated by Endoscopic Choroid Plexus Coagulation and Literature Review.

INTRODUCTION: Chronic pleural cerebrospinal fluid (CSF) effusion is a rare complication after ventriculoperitoneal (VP) shunt insertion and only 18 cases in children and adults have been described so far without catheter dislocation to the intrathoracic cavity. CASE PRESENTATION: We report on a 4-year-old girl with a complex history of underlying neurogenetic disorder, a hypoxic-ischemic encephalopathy after influenza A infection with septic shock and severe acute respiratory distress syndrome, followed by meningitis at the age of 10 months. In consequence, she developed a severe cerebral atrophy and post-meningitic hydrocephalus requiring placement of a VP shunt. At age 4, she was admitted with community-acquired mycoplasma pneumonia and developed increasing pleural effusions leading to severe respiratory distress and requiring continuous chest tube drainage (up to 1,000-1,400 mL/day) that could not be weaned. ß trace protein, in CSF present at concentrations >6 mg/L, was found in the pleural fluid at low concentrations of 2.7 mg/L. An abdomino-thoracic CSF fistula was finally proven by single photon emission computerized tomography combined with low-dose computer tomography. After shunt externalization, the pleural effusion stopped and the chest tube was removed. CSF production rate remains high above 500 mL/24 h. An atrial CSF shunt could not be placed, since a hemodynamically relevant atrial septum defect with frail circulatory balance would not have tolerated the large CSF volumes. Therefore, she underwent a total bilateral endoscopic choroid plexus laser coagulation (CPC) within the lateral ventricles via bi-occipital burr holes. Postoperatively CSF production rate went close to 0 mL and after external ventricular drain removal no signs and symptoms of hydrocephalus developed during a follow-up of now 2.5 years. CONCLUSION: In summary, pleural effusions in patients with VP shunt can rarely be caused by an abdomino-thoracic fistula, with non-elevated ß-trace protein in the pleural fluid. The majority of reported cases in literature were treated by ventriculoatrial shunt. This is the 2nd reported case, which has been successfully treated by radical CPC alone including the temporal horn choroid plexus, making the child shunt independent.

Identifying the optimal blood pressure for cerebral autoregulation in infants after cardiac surgery by monitoring cerebrovascular reactivity-A pilot study.

BACKGROUND: Advances in the treatment of pediatric congenital heart disease have increased survival rates. Despite efforts to prevent neurological injury, many patients suffer from impaired neurodevelopmental outcomes. Compromised cerebral autoregulation can increase the risk of brain injury following pediatric cardiac surgery with cardiopulmonary bypass. Monitoring autoregulation and maintaining adequate cerebral blood flow can help prevent neurological injury. AIMS: Our objective was to evaluate autoregulation parameters and to define the optimal blood pressure as well as the lower and upper blood pressure limits of autoregulation. METHODS: Autoregulation was monitored prospectively in 36 infants after cardiopulmonary bypass surgery for congenital heart defects between January and December 2019. Autoregulation indices were calculated by correlating invasive arterial blood pressure, cortical oxygen saturation, and relative tissue hemoglobin levels with near-infrared spectroscopy parameters. RESULTS: The mean patient age was 4.1 ± 2.8 months, and the mean patient weight was 5.2 ± 1.8 kg. Optimal mean arterial pressure could be identified in 88.9% of patients via the hemoglobin volume index and in 91.7% of patients via the cerebral oxygenation index, and a lower limit of autoregulation could be found in 66.7% and 63.9% of patients, respectively. No significant changes in autoregulation indices at the beginning or end of the monitoring period were observed. In 76.5% ± 11.1% and 83.8% ± 9.9% of the 8 and 16 h monitoring times, respectively, the mean blood pressure was inside the range of intact autoregulation (below in 21.5% ± 25.4% and 11.3% ± 16.5% and above in 8.7% ± 10.4% and 6.0% ± 11.0%, respectively). The mean optimal blood pressure was 57.4 ± 8.7 mmHg and 58.2 ± 7.9 mmHg and the mean lower limit of autoregulation was 48.8 ± 8.3 mmHg and 45.5 ± 6.7 mmHg when generated via the hemoglobin volume index and cerebral oxygenation index, respectively. CONCLUSIONS: Postoperative noninvasive autoregulation monitoring after cardiac surgery in children can be reliably and safely performed using the hemoglobin volume index and cerebral oxygenation index and provides robust data. This monitoring can be used to identify individual hemodynamic targets to optimize autoregulation, which differs from those recommended in the literature. Further evaluation of this subject is needed.

AOP Report: Inhibition of Chitin Synthase 1 Leading to Increased Mortality in Arthropods.

Arthropods (including insects, crustaceans, and arachnids) rely on the synthesis of chitin to complete their life cycles (Merzendorfer 2011). The highly conserved chitin synthetic process and the absence of this process in vertebrates make it an exploitable target for pest management and veterinary medicines (Merzendorfer 2013; Junquera et al. 2019). Susceptible, nontarget organisms, such as insects and aquatic invertebrates, exposed to chitin synthesis inhibitors may suffer population declines, which may have a negative impact on ecosystems and associated services. Hence, it is important to properly identify, prioritize, and regulate relevant chemicals posing potential hazards to nontarget arthropods. The need for a more cost-efficient and mechanistic approach in risk assessment has been clearly evident and triggered the development of the adverse outcome pathway (AOP) framework (Ankley et al. 2010). An AOP links a molecular initiating event (MIE) through key events (KEs) to an adverse outcome. The mechanistic understanding of the underlying toxicological processes leading to a regulation-relevant adverse outcome is necessary for the utilization of new approach methodologies (NAMs) and efficient coverage of wider chemical and taxonomic domains. In the last decade, the AOP framework has gained traction and expanded within the (eco)toxicological research community. However, there exists a lack of mature invertebrate AOPs describing molting defect-associated mortality triggered by direct inhibition of relevant enzymes in the chitin biosynthetic pathway (chitin synthesis inhibitors) or interference with associated endocrine systems by environmental chemicals (endocrine disruptors). Arthropods undergo molting to grow and reproduce (Heming 2018). This process is comprised of the synthesis of a new exoskeleton, followed by the exuviation of the old exoskeleton (Reynolds 1987). The arthropod exoskeleton (cuticle) can be divided into 2 layers, the thin and nonchitinous epicuticle, which is the outermost layer of the cuticle, and the underlying chitinous procuticle. A single layer of epithelial cells is responsible for the synthesis and secretion of both cuticular layers (Neville 1975). The cuticle protects arthropods from predators and desiccation, acts as a physical barrier against pathogens, and allows for locomotion by providing support for muscular function (Vincent and Wegst 2004). Because the procuticle mainly consists of chitin microfibrils embedded in a matrix of cuticular proteins supplemented by lipids and minerals in insects (Muthukrishnan et al. 2012) and crustaceans (Cribb et al. 2009; Nagasawa 2012), chitin is a determinant factor for the appropriate composition of the cuticle and successful molting (Cohen 2001). A detailed overview of the endocrine mechanisms regulating chitin synthesis is given in Supplemental Data, Figure S1. The shedding of the old exoskeleton in insects is mediated by a sequence of distinct muscular contractions, the ecdysis motor program (EMP; Ayali 2009; Song et al. 2017a). Like the expression of chitin synthase isoform 1 (CHS-1), the expression of peptide hormones regulating the EMP is also controlled by ecdysteroids (Antoniewski et al. 1993; Gagou et al. 2002; Ayali 2009). Cuticular chitin is polymerized from uridine diphosphate-N-acetylglucosamine (UDP-GlcNAc) by the transmembrane enzyme CHS-1, which is localized in the epithelial plasma membrane in insects (Locke and Huie 1979; Binnington 1985; Merzendorfer and Zimoch 2003; Merzendorfer 2006). Because crustaceans are also dependent on the synthesis of chitin, the underlying mechanisms are believed to be similar, although less is known about different CHS isoforms and their localization (Rocha et al. 2012; Qian et al. 2014; Uddowla et al. 2014; Harðardóttir et al. 2019). Disruption of either chitin synthesis or the upstream endocrine pathways can lead to lethal molting disruption (Arakawa et al. 2008; Merzendorfer et al. 2012; Song et al. 2017a, 2017b). In the case of chitin synthesis inhibition, molting disruption can be referred to as "premature molting." If ecdysis cannot be completed because of decreased chitin synthesis, the organism may not successfully molt. Even if ecdysis can be completed on inhibition of chitin synthesis, the organism may not survive because of the poor integrity of the new cuticle. These effects are observed in arthropods following molting, which fail to survive subsequent molts (Arakawa et al. 2008; Chen et al. 2008) or animals being stuck in their exuviae (Wang et al. 2019) and ultimately dying as a result of insufficient food or oxygen intake (Camp et al. 2014; Song et al. 2017a). The term "premature molting" is used to differentiate from the term "incomplete ecdysis," which describes inhibition of ecdysis on a behavioral level, namely through reduction of the EMP (Song et al. 2017a). The present AOP describes molting-associated mortality through direct inhibition of the enzyme CHS-1. It expands the small but increasing number of invertebrate AOPs that have relevance to arthropods, the largest phylum within the animal kingdom (Bar-On et al. 2018). The development of this AOP will be useful in further research and regulatory initiatives related to assessment of CHS inhibitors and identification of critical knowledge gaps and may suggest new strategies for ecotoxicity testing efforts. Environ Toxicol Chem 2021;40:2112-2120. © 2021 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

The neonicotinoid thiacloprid causes transcriptional alteration of genes associated with mitochondria at environmental concentrations in honey bees.

Thiacloprid is widely used in agriculture and may affect pollinators. However, its molecular effects are poorly known. Here, we report the global gene expression profile in the brain of honey bee foragers assessed by RNA-sequencing. Bees were exposed for 72 h to nominal concentrations of 25 and 250 ng/bee via sucrose solution. Determined residue concentrations by LC-MS/MS were 0.59 and 5.49 ng/bee, respectively. Thiacloprid exposure led to 5 and 71 differentially expressed genes (DEGs), respectively. Nuclear genes encoding mitochondrial ribosomal proteins and enzymes involved in oxidative phosphorylation, as well as metabolism enzymes and transporters were altered at 5.49 ng/bee. Kyoto Encylopedia of Genes and Genomes (KEGG) analysis revealed that mitochondrial ribosome proteins, mitochondrial oxidative phosphorylation, pyrimidine, nicotinate and nicotinamide metabolism and additional metabolic pathways were altered. Among 21 genes assessed by RT-qPCR, the transcript of farnesol dehydrogenase involved in juvenile hormone III synthesis was significantly down-regulated. Transcripts of cyp6a14-like and apolipophorin-II like protein, cytochrome oxidase (cox17) and the non-coding RNA (LOC102654625) were significantly up-regulated at 5.49 ng/bee. Our findings indicate that thiacloprid causes transcriptional changes of genes prominently associated with mitochondria, particularly oxidative phosphorylation. This highlight potential effects of this neonicotinoid on energy metabolism, which may compromise bee foraging and thriving populations at environmentally relevant concentrations.

Effects of environmental steroid mixtures are regulated by individual steroid receptor signaling.

Fish are exposed to steroids of different classes in contaminated waters, but their effects are not sufficiently understood. Here we employed an anti-sense technique using morpholino oligonucleotides to knockdown the glucocorticoid receptors (GRs, GRα and GRß) and androgen receptor (AR) to investigate their role in physiological and transcriptional responses. To this end, zebrafish embryos were exposed to clobetasol propionate (CLO), androstenedione (A4) and mixtures containing different classes of steroids. CLO caused a decrease of spontaneous muscle contraction and increase of heart rate, as well as transcriptional induction of pepck1, fkbp5, sult2st3 and vitellogenin (vtg1) at 24 and/or 48 h post fertilization (hpf). Knockdown of GRs eliminated these effects, while knockdown of AR decreased the ar transcript but caused no expressional changes, except induction of sult2st3 after exposure to A4 at 24 hpf. Exposure to a mixture of 6 steroids comprising progesterone (P4) and three progestins, cyproterone acetate, dienogest, drospirenone, 17ß-estradiol (E2) and CLO caused a significant induction of pepck1, sult2st3, vtg1 and per1a. Knockdown of GRs eliminated the physiological effects and the up-regulation of vtg1, sult2st3, pepck1, fkbp5 and per1a. Thus, as with CLO, responses in mixtures were regulated by GRs independently from the presence of other steroids. Exposure to a mixture comprising A4, CLO, E2 and P4 caused induction of vtg1, cyp19b, sult2st3 and fkbp5. Knockdown of AR had no effect, indicating that regulation of these genes occurred by the GRs and estrogen receptor (ER). Our findings show that in early embryos GRs cause vtg1 and sult2st3 induction in addition to known glucocorticoid target genes. Each steroid receptor regulated its own target genes in steroid mixtures independently from other steroids. However, enhanced expressional induction occurred for vtg1 and fkbp5 in steroid mixtures, indicating an interaction/cross-talk between GRs and ER. These findings have importance for the understanding of molecular effects of steroid mixtures.

Taurolidine Acts on Bacterial Virulence Factors and Does Not Induce Resistance in Periodontitis-Associated Bacteria-An In-Vitro Study.

The aims of the present study were: (a) to determine the mechanism of action of taurolidine against bacterial species associated with periodontal disease, and (b) to evaluate the potential development of resistance against taurolidine as compared with minocycline. After visualizing the mode of action of taurolidine by transmission electron micrographs, the interaction with most important virulence factors (lipopolysaccharide (LPS), Porphyromonas gingivalis gingipains, Aggregatibacter actinomycetemcomitans leukotoxin), was analyzed. Then, 14 clinical isolates from subgingival biofilm samples were transferred on agar plates containing subinhibitory concentrations of taurolidine or minocycline up to 50 passages. Before and after each 10 passages, minimal inhibitory concentrations (MICs) were determined. Increasing MICs were screened for efflux mechanism. Taurolidine inhibited in a concentration-dependent manner the activities of LPS and of the arginine-specific gingipains; however, an effect on A. actinomycetemcomitans leukotoxin was not detected. One P. gingivalis strain developed a resistance against taurolidine, which was probably linked with efflux mechanisms. An increase of MIC values of minocycline occurred in five of the 14 included strains after exposure to subinhibitory concentrations of the antibiotic. The present results indicate that: a) taurolidine interacts with LPS and gingipains, and b) development of resistance seems to be a rare event when using taurolidine.

Effects of new generation progestins, including as mixtures and in combination with other classes of steroid hormones, on zebrafish early life stages.

Fish are exposed to progestins and steroid mixtures in contaminated waters but the ecotoxicological implications are not sufficiently known. Here we analyze effects of the new generation progestin dienogest (DNG) followed by investigating effects of mixtures of new generation progestins containing DNG, cyproterone acetate and drospirenone and the hormone progesterone. Furthermore, effects of this mixture were studied after adding 17ß-estradiol (E2) and clobetasol propionate (CLO) in zebrafish embryos and larvae at concentrations between 0.01 and 10 µg/L. DNG showed only very minor transcriptional alterations among the 24 assessed genes with downregulation of the fshb transcript only. The progestin mixture caused weak induction of the lhb, cyp2k22 and sult2st3 transcripts. Addition of E2 to the mixture caused strong induction vtg1, cyp19b, esr1 and lhb, as well as downregulation of fshb from 0.01 µg/L onwards. Besides altering the same transcripts, addition of CLO altered glucocorticoid regulated genes mmp-9, mmp-13, g6pca, fkbp5 and irg1l. While each steroid class exhibited its specific activity independently in the mixture, sult2st3 and cyp2k22 were regulated by both E2 and CLO. Furthermore, CLO alone and in mixtures decreased spontaneous muscle contractions, increased heartrate and induced edema. Our study highlights the prominent effects of E2 and CLO in environmental steroid mixtures, while new generation progestins show relatively low activity.

17ß-Estradiol and the glucocorticoid clobetasol propionate affect the blood coagulation cascade in zebrafish.

Fish are exposed to estrogens, progestins and glucocorticoids in the aquatic environment but effects on the blood coagulation cascade are unknown. Here we analyzed effects of 17ß-estradiol (E2) alone and in combination with mixtures of new generation progestins and the glucocorticoid clobetasol propionate (CLO) in zebrafish embryos to assess their effects on the blood coagulation system. We assessed transcripts of 13 genes, such as coagulation factors, and genes involved in the anticoagulation and fibrinolytic system upon exposure to concentrations of 0.01-10 µg/L at 144 h post fertilization. Transcripts of genes encoding coagulation factors VII, X and fibrinogen, as well as protein C from the anticoagulation system, and serpine1 from the fibrinolytic system were upregulated by 10 µg/L, and factor II by 1 µg/L E2, as well as in mixtures containing E2 with progestins. CLO alone or in mixtures with progestins and E2 induced genes encoding factor VII, IX and fibrinogen. Progestins induced expression of genes encoding factor IX (f9b) only, but in mixtures with E2 and CLO, also factor VII (f7) and fibrinogen (fga) were induced. Our study demonstrates that exogenous exposure to E2 and CLO alone and in mixtures with new generation progestins used in contraception alter the expression of blood coagulation genes. This ultimately may lead to adverse effects on blood coagulation in fish.

Improvement in health status with once-daily indacaterol/glycopyrronium 110/50 µg in COPD patients: real-world evidence from an observational study in Ireland.

AIMS: Indacaterol/glycopyrronium (IND/GLY) 110/50 µg is a once-daily (o.d.) fixed-dose combination of long-acting ß2-agonist/long-acting muscarinic antagonist approved in over 90 countries, including Ireland, for the management of COPD. The present study was conducted to evaluate health status of COPD patients, initiated on IND/GLY 110/50 µg o.d., using the Clinical COPD Questionnaire (CCQ) tool in a real-world primary care setting in Ireland. METHODS: This was a real-world, prospective, open-label study. COPD patients aged > 40 years and with a smoking history of > 10 pack-years were included and switched to once-daily IND/GLY 110/50 µg. Enrolment of patients into the study occurred only after the decision had been made by the physician to prescribe IND/GLY 110/50 µg. Data were collected at baseline and Week 26. Health status was assessed using the validated CCQ. RESULTS: A total of 200 patients were included in study. The mean CCQ total score decreased from 2.36 at baseline to 1.44 at Week 26 (Δ, 0.92; P < 0.0005). Of the 156 patients who completed study, 113 (72.4%) achieved minimum clinically important difference in CCQ total score with IND/GLY 110/50 µg. CCQ domain scores also decreased during the study. Improvement in health status was observed across all GOLD groups and irrespective of prior COPD treatment. Adverse events were reported by 20% of patients with COPD exacerbation/infected COPD being the most common AE, reported by 11 patients. CONCLUSIONS: In real-life clinical practice in Ireland, IND/GLY 110/50 µg o.d. demonstrated statistically significant and clinically important improvement in health status in patients with COPD.

Comparison of multi-leaf collimator tracking and treatment-couch tracking during stereotactic body radiation therapy of prostate cancer.

PURPOSE AND BACKGROUND: Motion mitigation during prostate stereotactic body radiation therapy (SBRT) ensures optimal target coverage while reducing the risk of overdosage of nearby organs. The geometrical and dosimetrical performance of motion mitigation with the multileaf-collimator (MLC tracking) or the treatment couch (couch tracking) were compared. MATERIAL AND METHODS: For ten prostate patients, SBRT treatment plans with integrated boosts were prepared using volumetric modulated arc technique. For the geometrical evaluation, a lead sphere at the beam isocenter was moved according to five prostate motion curves (i) without mitigation, (ii) with MLC tracking or (iii) with couch tracking. During irradiation, MV images were taken and the over-/underexposed areas were evaluated. For the dosimetrical evaluation, the plans were applied to a dosimetric phantom. Dose distributions with and without mitigation were evaluated inside the target structure and organs at risk. RESULTS: The median over-/underexposed area was reduced significantly from 2.02cm2 without mitigation to 1.00cm2 and 0.45cm2 with MLC and couch tracking. Closest dosimetrical agreement to the static references was achieved with couch tracking. CONCLUSIONS: MLC and couch tracking at a conventional linear accelerator significantly improved the accuracy of prostate SBRT in the presence of motion, whereby couch tracking showed slightly better performance than MLC tracking.

Validation of dynamic treatment-couch tracking for prostate SBRT.

PURPOSE: In stereotactic body radiation therapy (SBRT) of prostatic cancer, a high dose per fraction is applied to the target with steep dose gradients. Intrafractional prostate motion can occur unpredictably during the treatment and lead to target miss. This work investigated the dosimetric benefit of motion compensation with dynamic treatment-couch tracking for prostate SBRT treatments in the presence of prostatic motion. METHODS: Ten SBRT treatment plans for prostate cancer patients with integrated boosts to their index lesion were prepared. The treatment plans were applied with a TrueBeam linear accelerator to a phantom in (a) static reference position, (b) moved with five prostate motion trajectories without any motion compensation, and (c) with real-time compensation using transponder-guided couch tracking. The geometrical position of the electromagnetic transponder was evaluated in the tracked and untracked situation. The dosimetric performance of couch tracking was evaluated, using Gamma agreement indices (GAI) and other dose parameters. These were evaluated within the phantoms biplanar diode array, as well as target- and organ-specific. RESULTS: The root-mean-square error of the motion traces (range: 0.8-4.4 mm) was drastically reduced with couch tracking (0.2-0.4 mm). Residual motion was mainly observed at abrupt direction changes with steep motion gradients. The phantom measurements showed significantly better GAI1%/1mm with tracked (range: 83.4%-100.0%) than with untracked motion (28.9%-99.7%). Also GAI2%/2mm was significantly superior for the tracked (98.4%-100.0%) than the untracked motion (52.3%-100.0%). The organ-specific evaluation showed significantly better target coverage with tracking. The dose to the rectum and bladder showed a dependency on the anterior-posterior motion direction. CONCLUSIONS: Couch tracking clearly improved the dosimetric accuracy of prostate SBRT treatments. The treatment couch was able to compensate the prostatic motion with only some minor residual motion. Therefore, couch tracking combined with electromagnetic position monitoring for prostate SBRT is feasible and improves the accuracy in treatment delivery when prostate motion is present.

Duplex ultrasound assessment of native stenoses in the superficial femoral and popliteal arteries: a comparative study examining the influence of multisegment lesions.

PURPOSE: To evaluate duplex ultrasonography (DUS) in the assessment of femoropopliteal stenoses comparing a single native stenosis (SNS) to multisegmental native stenoses (MNS). METHODS: Among the 1284 patients treated for atherosclerotic occlusive disease involving the femoropopliteal segment between November 2002 and November 2012, 139 patients (97 men; mean age 68±8 years) with 142 SNS or 143 MNS in 79 and 60 patients, respectively, were eligible for this retrospective analysis. The peak systolic velocity ratios with proximal (PSVRprox) and distal (PSVRdist) reference for the 285 lesions were compared with their respective angiographic stenosis grade as measured by 2 independent readers using quantitative vascular analysis to ensure objectivity. Receiver operating characteristic curve analysis was used to evaluate sensitivity, specificity, and the optimal thresholds of PSV and PSVR for detection of stenoses by grade (>50%, >70%, or >80% diameter stenosis). The area under the curve (AUC) values of dependent and independent receiver operating characteristic curves were compared. RESULTS: For SNS, correlation of PSVRprox to diameter stenosis (R=0.88) was higher (p<0.001) than the correlation for MNS (R=0.78). In the SNS group, the AUC for detecting a >50% (0.99±0.01), >70% (0.98±0.01), and >80% (0.96±0.01) stenosis with PSVRprox was significantly higher than in the MNS group [AUC50% 0.93±0.02 (p=0.01), AUC70% 0.92±0.02 (p=0.02), and AUC80% 0.87±0.03 (p=0.003)]. The optimal thresholds for detecting >50%, >70%, and >80% stenoses for SNS using PSVRprox were 2.6, 3.3, and 3.9, respectively. For MNS, the optimal thresholds of PSVRprox were 2.6, 3.4, and 3.9, respectively, with respective sensitivities of 87%, 81%, and 75%; respective specificities of 93%, 90%, and 82%; negative predictive values of 45%, 64%, and 74%; and positive predictive values of 99%, 95%, and 83%. CONCLUSION: DUS is an optimal tool for quantification of SNS. However, a multisegment setting has a significant negative impact on the quantification of femoropopliteal artery stenosis.

Total knee arthroplasty using anatomic alignment can produce mid-flexion laxity.

BACKGROUND: Modern total knee arthroplasty offers two different alignment techniques, anatomic or mechanical, based on the bone axes selected for implantation of the prosthetic components. This study examined the axes of both during simulated physiologic knee joint motion, as well as the relationship between these axes and the implication of medial-lateral soft tissue balance in total knee arthroplasty. METHODS: Seven fresh-frozen, lower limb specimens were stripped at a level 15 cm from joint line, leaving the joint capsule, quadriceps muscle, hamstring tendons and ligamentous structures intact. Specimens were anatomically marked to track precise movements of the tibia and femur--from which both alignment axes were determined. Medial and lateral joint spacings were tracked to determine collateral ligament laxity. A kneeling simulator jig produced physiologic knee motion. FINDINGS: Measurements of medial and lateral joint spacings revealed statistically significant differences at all flexion angles between the two alignment axes. The anatomic alignment axes' pattern demonstrates mid-flexion lateral opening and late-flexion medial joint space opening--mechanical axes revealing a consistent 2-3 mm larger lateral than medial joint space. INTERPRETATION: In an effort to produce a more natural feeling knee replacement, understanding the normal kinematic soft tissue balance can serve as a useful reference point, and mid flexion laxity is an important clinical concern. With currently available total knee arthroplasty designs, mechanical alignment is preferable to anatomic alignment because it creates consistent spacing, which can be addressed by ligament lengthening or adjustments in femoral component positioning.

Increased brain beta-amyloid load, phosphorylated tau, and risk of Alzheimer disease associated with an intronic CYP46 polymorphism.

BACKGROUND: CYP46, the gene encoding cholesterol 24-hydroxylase, plays a key role in the hydroxylation of cholesterol and thereby mediates its removal from brain. OBJECTIVE: To study the association of polymorphic sites on CYP46 with Alzheimer disease (AD) traits and with the risk of the development of AD. DESIGN: Alzheimer disease traits (beta-amyloid load, beta-amyloid peptides, hyperphosphorylated tau protein) were assessed in brain tissues and in the cerebrospinal fluid of patients with AD and control subjects. Genetic associations were studied in 2 independent populations. SETTING: Specialized centers for memory disorders in Switzerland, Greece, and Italy. PARTICIPANTS: Fifty-five brain tissues from nondemented elderly patients for the histopathological studies; 38 patients with AD and 25 control subjects for the cerebrospinal fluid studies; 201 patients with AD and 248 control subjects for the genetic association studies. RESULTS: A polymorphism of CYP46 was associated with increased beta-amyloid load in brain tissues as well as with increased cerebrospinal fluid levels of beta-amyloid peptides and phosphorylated tau protein. Moreover, this CYP46 polymorphism was associated with higher risk of late-onset sporadic AD in 2 independent populations (odds ratio, 2.16; 95% confidence interval [CI], 1.41-3.32; P<.001). The additional presence of 1 or 2 apolipoprotein E epsilon4 alleles synergistically increased the risk of AD to an odds ratio of 9.6 (95% CI, 4.9-18.9; P<.001) as compared with 4.4 for apolipoprotein E epsilon4 alone (95% CI, 2.8-6.8; P<.001). CONCLUSION: CYP46 influences brain beta-amyloid load, cerebrospinal fluid levels of beta-amyloid peptides and phosphorylated tau, and the genetic risk of late-onset sporadic AD.