The prognostic significance of stroke volume index in low gradient severe aortic stenosis: from the national echo database of Australia.

Approximately 50% of patients with severe aortic stenosis (AS) in clinical practice present with 'low-gradient' haemodynamics. Stroke Volume Index (SVI) is a measure of left ventricular output, with 'normal-flow' considered as > 35 ml/m2. The association between SVI and prognosis in severe low-gradient AS (LGAS) in currently not well-understood. We analysed the National Echo Database of Australia (NEDA) and identified 109,990 patients with sufficiently comprehensive echocardiographic data, linked to survival information. We identified 1,699 with severe LGAS and preserved ejection fraction (EF) (≥ 50%) and 774 with severe LGAS and reduced EF. One- and three-year survival in each subgroup were assessed (follow-up of 74 ± 43 months), according to SVI thresholds. In patients with preserved EF the mortality "threshold" was at SVI < 30 ml/m2; 1- and 3-year survival was worse for those with SVI < 30 ml/m2 relative to those with SVI > 35 ml/m2 (HR 1.80, 95% CI 1.32-2.47 and HR 1.38, 95% CI 1.12-1.70), while survival was similar between those with SVI 30-35 ml/m2 and SVI > 35 ml/m2. In patients with reduced EF the mortality "threshold" was 35 ml/m2; 1- and 3-year survival was worse for both those with SVI < 30 ml/m2 and 30-35 ml/m2 relative to those with SVI > 35 ml/m2 (HR 1.98, 95% CI 1.27-3.09 and HR 1.41, 95% CI 1.05-1.93 for SVI < 30 ml/m2 and HR 2.02, 95% CI 1.23-3.31 and HR 1.56, 95% CI 1.10-2.21 for SVI 30-35 ml/m2). The SVI prognostic threshold for medium-term mortality in severe LGAS patients is different for those with preserved LVEF (< 30 ml/m2) compared to those with reduced LVEF (< 35 ml/m2).

Prevalence and Outcomes of Low-Gradient Severe Aortic Stenosis-From the National Echo Database of Australia.

Background The prevalence and outcomes of the different subtypes of severe low-gradient aortic stenosis (AS) in routine clinical cardiology practice have not been well characterized. Methods and Results Data were derived from the National Echocardiography Database of Australia. Of 192 060 adults (aged 62.8±17.8 [mean±SD] years) with native aortic valve profiling between 2000 and 2019, 12 013 (6.3%) had severe AS. Of these, 5601 patients (47%) had high-gradient and 6412 patients (53%) had low-gradient severe AS. The stroke volume index was documented in 2741 (42.7%) patients with low gradient; 1750 patients (64%) with low flow, low gradient (LFLG); and 991 patients with normal flow, low gradient. Of the patients with LFLG, 1570 (89.7%) had left ventricular ejection fraction recorded; 959 (61%) had paradoxical LFLG (preserved left ventricular ejection fraction), and 611 (39%) had classical LFLG (reduced left ventricular ejection fraction). All-cause and cardiovascular-related mortality were assessed in the 8162 patients with classifiable severe AS subtype during a mean±SD follow-up of 88±45 months. Actual 1-year and 5-year all-cause mortality rates varied across these groups and were 15.8% and 49.2% among patients with high-gradient severe AS, 11.6% and 53.6% in patients with normal-flow, low-gradient severe AS, 16.9% and 58.8% in patients with paradoxical LFLG severe AS, and 30.5% and 72.9% in patients with classical LFLG severe AS. Compared with patients with high-gradient severe AS, the 5-year age-adjusted and sex-adjusted mortality risk hazard ratios were 0.94 (95% CI, 0.85-1.03) in patients with normal-flow, low-gradient severe AS; 1.01 (95% CI, 0.92-1.12) in patients with paradoxical LFLG severe AS; and 1.65 (95% CI, 1.48-1.84) in patients with classical LFLG severe AS. Conclusions Approximately half of those patients with echocardiographic features of severe AS in routine clinical practice have low-gradient hemodynamics, which is associated with long-term mortality comparable with or worse than high-gradient severe AS. The poorest survival was associated with classical LFLG severe AS.

Cardiac Damage Staging Classification Predicts Prognosis in All the Major Subtypes of Severe Aortic Stenosis: Insights from the National Echo Database Australia.

BACKGROUND: There are currently no established prognostic models for "low-gradient" severe aortic stenosis (AS), including those with low-flow, low-gradient (LFLG) or normal-flow, low-gradient (NFLG) severe AS. The "cardiac damage staging classification" has been validated as a clinically useful prognostic tool for high-gradient severe AS but not yet for these other common subtypes of severe AS, LFLG and NFLG. METHODS: The authors analyzed data from the National Echo Database of Australia, a large national, multicenter registry with individual data linkage to mortality. Of 192,060 adults (mean age, 62.8 ± 17.8 years) with comprehensive ultrasound profiling of the native aortic valve studied between 2000 and 2019, 12,013 (6.3%) had severe AS. On the basis of standard echocardiographic parameters, 5,601 patients with high-gradient, 611 with classical and 959 with paradoxical LFLG, and 911 with NFLG severe AS were identified. Mean follow-up was 88 ± 45 months. All-cause and cardiovascular-related mortality were assessed for each group on an adjusted basis (age and sex) and analyzed by cardiac damage stage. RESULTS: Patients with LFLG AS had greater associated cardiac damage at diagnosis (stages 3 and 4 in 34% of those with classical LFLG, 22.5% of those with paradoxical LFLG, 15.5% of those with NFLG, and 14% of those with high-gradient AS; P < .001). For all four major subtypes of severe AS, there was a progressive increase in 1- and 5-year mortality with increasing cardiac damage score. For example, for paradoxical LFLG severe AS, compared with stage 0 patients, adjusted 1-year all-cause mortality was 22% higher in stage 1 patients, 55% higher in stage 2 patients (P = .095), and 155% higher in stage 3 and 4 patients (P < .001). Among patients with classical LFLG severe AS, compared with stage 1 patients, adjusted 1-year all-cause mortality was 55% higher in stage 2 patients (P = .018) and 100% higher in stage 3 and 4 patients (P < .001). CONCLUSIONS: Regardless of severe AS subtype, increasing severity denoted by the cardiac damage staging classification is strongly associated with increasing mortality risk.

Current Controversies and Challenges in Brugada Syndrome.

More than three decades since its initial description in 1993, Brugada syndrome remains engulfed in controversy. This review aims to shed light on the main challenges surrounding the diagnostic pathway and criteria, risk stratification of asymptomatic patients, pharmacological and interventional risk modification strategies as well as our current pathophysiological understanding of the disease.

Vitamin D deficiency promotes prostate cancer growth in bone.

BACKGROUND: Vitamin D is considered as an important determinant of bone turnover as well as cancer growth. Using a murine model of bone metastasis, we investigated the effect of vitamin D deficiency on prostate cancer cell growth in bone. METHODS: Three-week-old male nude mice were fed either normal chow (control) or a diet deficient in vitamin D. The latter diet resulted in severe hypovitaminosis D within 6 weeks. At this point of time, 5 × 10(4) cells of the prostate cancer cell line, PC-3, were injected either into the bone marrow (tibia) or subcutaneously into soft tissues. Osteoprotegerin (OPG) was co-administered in subgroups of mice to suppress bone remodeling. Osteolytic lesions were monitored by serial X-ray, while soft tissue tumor growth was measured by caliper. All tissues were analyzed by micro-CT and histology at endpoint. RESULTS: Bone turnover was significantly accelerated in vitamin D deficient compared to vitamin D sufficient mice from week 6 onwards. Intra-tibially implanted PC-3 cells resulted in mixed osteolytic and osteosclerotic lesion. At endpoint, osteolytic and osteosclerotic lesion areas, total tumor area, and tumor mitotic activity were all significantly increased in vitamin D deficient mice compared to controls. Regardless of diet, OPG reduced bone turnover, total tumor, and osteosclerotic area as well as tumor mitotic activity, while promoting cell apoptosis. In contrast, vitamin D deficiency did not alter tumor growth in soft tissues. CONCLUSION: Vitamin D deficiency stimulates prostate cancer growth in bone through modulating the bone microenvironment.

A simplified ingestion procedure for esophageal capsule endoscopy: initial evaluation in healthy volunteers.

BACKGROUND AND STUDY AIMS: Initial studies on esophageal capsule endoscopy (PillCam ESO) reported excellent sensitivity and specificity, but these were followed by mixed results in several subsequent studies, probably due to deviations from the recommended ingestion protocol and the inconvenience of capsule ingestion in the supine position. The aim of this study was therefore to test a simplified ingestion procedure (SIP) for PillCam ESO. PATIENTS AND METHODS: Using a cross-over study design, the SIP was prospectively compared with the original ingestion procedure for PillCam ESO in 24 healthy volunteers (15 men, nine women; mean age 44, range 27 - 70) and evaluated for: bubbles/saliva interference at the Z-line, Z-line circumferential visualization (quadrants), and convenience and ease of the ingestion procedure. All Rapid 4 videos were reviewed in a randomized manner and read by an experienced PillCam ESO reader blinded to the ingestion procedure used. RESULTS: It was found that the SIP significantly improved visualization in comparison with the original ingestion procedure, with less interference due to bubbles/saliva observed at the gastroesophageal junction ( P = 0.002) and improved visualization of the Z-line ( P = 0.025). Although the esophageal transit time was significantly faster with the SIP (3 : 45 min vs. 0 : 38 min; P = 0.0001), there were no differences in the number of Z-line frames/images captured. CONCLUSIONS: This new, simplified ingestion procedure for PillCam ESO provides significantly improved visualization of the Z-line in healthy volunteers. The overall test characteristics of PillCam ESO using SIP should be tested in patients with esophageal disease.

Intestinal nutrient uptake measurements and tissue damage: validating the everted sleeves method.

The reliability of methods for nutrient uptake measurements across the intestinal epithelium relies on the integrity of the mucosal epithelium and the enterocytes. We tested effects of tissue handling during the "everted sleeves method" on the length of intestinal villi, the surface magnification, the circumference of the gut, and the thickness of the muscle layer in sunbirds (Nectarinia osea), chicken (Gallus gallus), and mice (Mus domesticus). The sunbird has thin and delicate intestinal villi that are greatly affected by the everted sleeves method. After eversion and incubation, villi lost 30% of their original length. The severe tissue damage coincides with uptake measurements for glucose that were an order of magnitude lower than in other nectar-feeding (nectarivorous) birds of similar body size. Tissue handling during the everted sleeves method had significant effects on morphometric parameters of chicken and mouse intestines, but on a light-microscopical level, the tissue integrity and the cytology of the enterocytes were not altered. Therefore, we think that the everted sleeves method renders reliable and reproducible measurements of nutrient uptake in those species. We conclude that a histological evaluation is necessary to assess the reliability of the method before it is applied to adults or to the developmental stage of any species.

Dietary modulation of intestinal enzymes of the house sparrow (Passer domesticus): testing an adaptive hypothesis.

Insectivorous/frugivorous passerine species studied so far lack the ability to modulate intestinal maltase activity, in contrast to galliformes. We tested for dietary modulation of small intestine (SI) enzymes including maltase in house sparrows to understand whether the difference between the galliformes on the one hand, and the passerines on the other, reflects a phylogenetic pattern (maltase modulated in galliformes but not passerines), a dietary pattern (maltase modulated in granivores but not insectivore/frugivores), some other pattern, or chance. We also tested the prediction that intestinal peptidase activity would be increased on a high protein (HP) diet. Birds were fed three diets high in starch, protein, or lipid for 10 days. For birds on the HP diet (60.3% protein) we observed the predicted upward modulation of aminopeptidase-N activity, as compared with the lower-protein, high starch (HS) (12.8% protein) diet. In contrast, birds eating the HS diet had similar maltase and sucrase activities, and only slightly higher isomaltase activity, compared with birds eating the high protein (HP), starch-free diet. Birds eating high lipid (HL) diet had low activities of both carbohydrases and peptidase. Considering that the statistical power of our tests was adequate, we conclude that house sparrows show little or no increase in carbohydrases in response to elevated dietary carbohydrate. We cannot reject the hypothesis that maltase lability among avian species has a phylogenetic component, or that high dietary fat has a depressing effect on both carbohydrase and peptidase activities.

A test for passive absorption of glucose in yellow-rumped warblers and its ecological implications.

In an earlier study, we found that yellow-rumped warblers had in vitro active uptake rates of D-glucose that were only a few percent of the glucose absorption rate achieved at the whole-animal level. Here we used a pharmacokinetic technique to test whether a substantial amount of sugar can be absorbed passively. We used yellow-rumped warblers (Dendroica coronata), known for their seasonal frugivory, freely feeding on a synthetic mash formulated with naturally occurring concentrations of D-glucose. Birds absorbed 89.8% +/- 1.0% (SE) of the D-glucose in the mash. When fed the same mash with trace-labeled 3H L-glucose, the stereoisomer that does not interact with the intestinal Na(+)-glucose cotransporter, 3H appeared in plasma, an indication that this stereoisomer of glucose was absorbed. We used 3H levels in plasma and excreta in a pharmacokinetic model to calculate L-glucose extraction efficiency (i.e., the percent absorbed). Calculated mean extraction efficiency for the passively absorbed L-glucose averaged 91% +/- 23%. Our finding of considerable passive absorption reconciles the in vitro and in vivo results for D-glucose absorption and is in concert with results from five other avian species. The passive pathway appears to provide birds with an absorptive process that can respond quickly to changing luminal concentration and that is energetically inexpensive to maintain and modulate in real time but that may bear a cost. Less discriminate passive absorption might increase vulnerability to toxins and thus constrain foraging behavior and limit the breadth of the dietary niche.

Is diet shifting facilitated by modulation of intestinal nutrient uptake? Test of an adaptational hypothesis in yellow-rumped warblers.

Yellow-rumped warblers (Dendroica coronata) are one of many avian species that change their diet seasonally. Using them, we tested the predictions that uptake of D-glucose and the amino acid L-leucine will increase as dietary levels of carbohydrate and protein, respectively, are increased and that mediated uptake capacity of the entire small intestine will match nutrient loads from daily food intake. Birds were fed three semisynthetic diets, formulated from fruit, insects, or seeds, for 7 d. Mediated D-glucose uptake in vitro was affected by diet, but contrary to our a priori prediction, fruit eaters eating the diet highest in carbohydrates had the lowest uptake rate. Na(+)-dependent L-leucine uptake at a low concentration (0.01 mmol L-1) was higher in insect and seed eaters, which is consistent with the prediction of adaptation to dietary protein, though dietary fat may also play a role. Mediated D-glucose uptake summed over small intestine length could explain only a small percentage of the estimated whole-animal absorption rate. We thus reject the predictions for carbohydrate but suggest an alternative interpretation of our results that is consistent with economical design.

Dietary modulation of intestinal hydrolytic enzymes in yellow-rumped warblers.

Many birds exhibit seasonal switches in diet and thus alter the nutrients predominating their food intake. We tested for dietary modulation of small intestine (SI) enzymes in yellow-rumped warblers, a species for which such diet changes are well documented. Birds were fed three diets formulated from either fruit, insect, or seed. We predicted that SI carbohydrases and peptidases would be modulated in direct correlation with relative levels of dietary carbohydrate and protein, respectively. Aminopeptidase N activity was about twice as high in birds eating the highest protein content diet. In contrast, there was no significant dietary effect on any of the carbohydrase activities. There was a proximal-to-distal decrease in activities of all the carbohydrases but not aminopeptidase N. The carbohydrase levels of yellow-rumps are relatively low when compared with other species in the same family and most similar to lower levels found in primarily insectivorous birds rather than in primarily granivorous or nectarivorous species. Considering this and the fact that they do not exhibit dietary modulation of carbohydrase levels, we conclude that yellow-rumps are not highly adapted for handling dietary carbohydrates, especially starch, although they might still efficiently break down and absorb sucrose and maltose if retention time were sufficiently long.