Left ventricular false tendons.

Left ventricular false tendons (LVFTs) are fibromuscular structures, connecting the left ventricular free wall or papillary muscle and the ventricular septum.There is some discussion about safety issues during intense exercise in athletes with LVFTs, as these bands have been associated with ventricular arrhythmias and abnormal cardiac remodelling. However, presence of LVFTs appears to be much more common than previously noted as imaging techniques have improved and the association between LVFTs and abnormal remodelling could very well be explained by better visibility in a dilated left ventricular lumen.Although LVFTs may result in electrocardiographic abnormalities and could form a substrate for ventricular arrhythmias, it should be considered as a normal anatomic variant. Persons with LVFTs do not appear to have increased risk for ventricular arrhythmias or sudden cardiac death.

Large intrinsic anomalous Hall effect in SrIrO3 induced by magnetic proximity effect.

The anomalous Hall effect (AHE) is an intriguing transport phenomenon occurring typically in ferromagnets as a consequence of broken time reversal symmetry and spin-orbit interaction. It can be caused by two microscopically distinct mechanisms, namely, by skew or side-jump scattering due to chiral features of the disorder scattering, or by an intrinsic contribution directly linked to the topological properties of the Bloch states. Here we show that the AHE can be artificially engineered in materials in which it is originally absent by combining the effects of symmetry breaking, spin orbit interaction and proximity-induced magnetism. In particular, we find a strikingly large AHE that emerges at the interface between a ferromagnetic manganite (La0.7Sr0.3MnO3) and a semimetallic iridate (SrIrO3). It is intrinsic and originates in the proximity-induced magnetism present in the narrow bands of strong spin-orbit coupling material SrIrO3, which yields values of anomalous Hall conductivity and Hall angle as high as those observed in bulk transition-metal ferromagnets. These results demonstrate the interplay between correlated electron physics and topological phenomena at interfaces between 3d ferromagnets and strong spin-orbit coupling 5d oxides and trace an exciting path towards future topological spintronics at oxide interfaces.

Sodium-glucose cotransporter 2 inhibitors: a practical guide for the Dutch cardiologist based on real-world experience.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors include a relatively new class of glucose-lowering drugs that reduce plasma glucose concentrations by inhibiting proximal tubular reabsorption of glucose in the kidney, while increasing its excretion in urine. Recent large randomised controlled trials have demonstrated that many of these agents reduce the occurrence of major adverse cardiovascular events, hospitalisation for heart failure, cardiovascular death and/or chronic kidney disease progression in patients with and without type 2 diabetes mellitus (DM2). Given their unique insulin-independent mode of action and favourable efficacy and adverse-event profile, SGLT2 inhibitors are promising and they offer an interesting therapeutic approach for the cardiologist to incorporate into routine practice. However, despite accumulating data supporting this class of therapy, cardiologists infrequently prescribe SGLT2 inhibitors, potentially due to a lack of familiarity with their use and the reticence to change DM medication. Here, we provide an up-to-date practical guide highlighting important elements of treatment initiation based on real-world evidence and expert opinion. We describe how to change DM medication, including insulin dosing when appropriate, and how to anticipate any adverse events based on real-world experience in patients with DM2 in the Meander Medical Centre in Amersfoort, the Netherlands. This includes a simple algorithm showing how to initiate SGLT2 inhibitor treatment safely, while considering the consequence of the glucosuric effects of these inhibitors for the individual patient.

Values and beliefs on trainee selection: What counts in the eye of the selector? A qualitative study exploring the program director's perspective.

OBJECTIVES: Postgraduate trainee selection is a high-stakes process. While many studies focused on selection methods and psychometrics, little is known about the influence of selectors' personal values and beliefs in the judgment and decision-making process. A better understanding of these factors is vital since selectors determine the future workforce. METHODS: We interviewed programme directors (PDs) from 11 specialties in one University Hospital. Thematic analysis was conducted with a combined approach of generic and in-vivo coding. RESULTS: PDs value excellence, 'fit' and personal characteristics. The content of these values are subject to personal interpretation and differ between PDs. PDs use various 'proxies' as alternative indicators of performance. They consider intuition, teamwork and autonomy important in judgement and decision-making. PDs find selection challenging and feel great accountability towards candidates and society. CONCLUSIONS: Selectors criteria of judgement- and decision-making often remain implicit and focus on prior achievements and 'fit' with the current trainee-pool, possibly compromising the workforce's diversity. Implicit 'proxies' and intuitive decision-making may be an unwitting source of judgemental bias. 'Making the implicit explicit', by increasing awareness of personal values and beliefs and structuring the selection interview, may improve the quality of trainee selection.

Ferroelectric Control of Interface Spin Filtering in Multiferroic Tunnel Junctions.

The electronic reconstruction occurring at oxide interfaces may be the source of interesting device concepts for future oxide electronics. Among oxide devices, multiferroic tunnel junctions are being actively investigated as they offer the possibility to modulate the junction current by independently controlling the switching of the magnetization of the electrodes and of the ferroelectric polarization of the barrier. In this Letter, we show that the spin reconstruction at the interfaces of a La_{0.7}Sr_{0.3}MnO_{3}/BaTiO_{3}/La_{0.7}Sr_{0.3}MnO_{3} multiferroic tunnel junction is the origin of a spin filtering functionality that can be turned on and off by reversing the ferroelectric polarization. The ferroelectrically controlled interface spin filter enables a giant electrical modulation of the tunneling magnetoresistance between values of 10% and 1000%, which could inspire device concepts in oxides-based low dissipation spintronics.

Reproducibility of right-to-left shunt quantification using transthoracic contrast echocardiography in hereditary haemorrhagic telangiectasia.

AIM: Transthoracic contrast echocardiography (TTCE) is recommended for screening of pulmonary arteriovenous malformations (PAVMs) in hereditary haemorrhagic telangiectasia. Shunt quantification is used to find treatable PAVMs. So far, there has been no study investigating the reproducibility of this diagnostic test. Therefore, this study aimed to describe inter-observer and inter-injection variability of TTCE. METHODS: We conducted a prospective single centre study. We included all consecutive persons screened for presence of PAVMs in association with hereditary haemorrhagic telangiectasia in 2015. The videos of two contrast injections per patient were divided and reviewed by two cardiologists blinded for patient data. Pulmonary right-to-left shunts were graded using a three-grade scale. Inter-observer and inter-injection agreement was calculated with κ statistics for the presence and grade of pulmonary right-to-left shunts. RESULTS: We included 107 persons (accounting for 214 injections) (49.5% male, mean age 45.0 ± 16.6 years). A pulmonary right-to-left shunt was present in 136 (63.6%) and 131 (61.2%) injections for observer 1 and 2, respectively. Inter-injection agreement for the presence of pulmonary right-to-left shunts was 0.96 (95% confidence interval (CI) 0.9-1.0) and 0.98 (95% CI 0.94-1.00) for observer 1 and 2, respectively. Inter-injection agreement for pulmonary right-to-left shunt grade was 0.96 (95% CI 0.93-0.99) and 0.95 (95% CI 0.92-0.98) respectively. There was disagreement in right-to-left shunt grade between the contrast injections in 11 patients (10.3%). Inter-observer variability for presence and grade of the pulmonary right-to-left shunt was 0.95 (95% CI 0.91-0.99) and 0.97 (95% CI 0.95-0.99) respectively. CONCLUSION: TTCE has an excellent inter-injection and inter-observer agreement for both the presence and grade of pulmonary right-to-left shunts.

SMAD4 gene mutation increases the risk of aortic dilation in patients with hereditary haemorrhagic telangiectasia.

BACKGROUND: Mutations in the genes ENG, ACVRL1 and SMAD4 that are part of the transforming growth factor-beta signalling pathway cause hereditary haemorrhagic telangiectasia (HHT). Mutations in non-HHT genes within this same pathway have been found to associate with aortic dilation. Therefore, we investigated the presence of aortic dilation in a large cohort of HHT patients as compared to non-HHT controls. METHODS: Chest computed tomography of consecutive HHT patients (ENG, ACVRL1 and SMAD4 mutation carriers) and non-HHT controls were reviewed. Aortic root dilation was defined as a z-score>1.96. Ascending and descending aorta dimensions were corrected for age, gender and body surface area. RESULTS: In total 178 subjects (57.3% female, mean age 43.9±14.9years) were included (32 SMAD4, 47 ENG, 50 ACVRL1 mutation carriers and 49 non-HHT controls). Aortopathy was present in a total of 42 subjects (24% of total). Aortic root dilatation was found in 31% of SMAD4, 2% of ENG, 6% of ACVRL1 mutation carriers, and 4% in non-HHT controls (p<0.001). The aortic root diameter was 36.3±5.2mm in SMAD4 versus 32.7±3.9mm in the non-SMAD4 group (p=0.001). SMAD4 was an independent predictor for increased aortic root (ß-coefficient 3.5, p<0.001) and ascending aorta diameter (ß-coefficient 1.6, p=0.04). CONCLUSIONS: SMAD4 gene mutation in HHT patients is independently associated with a higher risk of aortic root and ascending aortic dilation as compared to other HHT patients and non-HHT controls.

Transanal total mesorectal excision for rectal carcinoma: short-term outcomes and experience after 80 cases.

BACKGROUND: Low anterior resection for distal and mid-rectal cancer is associated with high positive resection margins. Transanal total mesorectal excision (TaTME) is a new treatment in which the rectum is dissected transanally according to TME principles. The short-term results and oncological follow-up of the first 80 patients were described. METHODS: Between June 2012 and September 2014, all patients in the Gelderse Vallei Hospital and the VU University Medical Center with histologically proven distal or mid-rectal carcinomas without evidence of distant metastases underwent TaTME. Patients with T4 tumors were excluded. Transanal mobilization was performed with the aid of a single port and endoscopic instruments according to TME criteria. RESULTS: Eighty patients were operated in a period of 2 years. Laparotomy was recommended and performed in four patients. Postoperative morbidity was 39%. Ten (12%) complications were graded as severe (Clavien-Dindo grade 3, 4 and 5) and needed re-intervention. Median operative time was 204 min (range 91-447). Median hospital stay was 8 days (range 3-41). Specimens were graded as complete in 88% of the patients, nearly complete in 9% and incomplete in 3%. A positive circumferential resection margin (<2 mm) was observed in two patients. During the two and half years study period, a local recurrence was observed in two patients. CONCLUSION: TaTME is a safe alternative to standard laparoscopic TME in selected low-risk patients with rectal carcinoma when treated by an experienced colorectal team. In the future, randomized trials are necessary to prove its oncological safety.

The value of non echo planar, diffusion-weighted magnetic resonance imaging for the detection of residual or recurrent middle-ear cholesteatoma.

OBJECTIVE: To determine the value of non echo planar, diffusion-weighted magnetic resonance imaging for detection of residual and recurrent middle-ear cholesteatoma after combined-approach tympanoplasty. METHOD: The magnetic resonance imaging findings after primary surgery for cholesteatoma were compared with intra-operative findings at 'second-look' surgery or with clinical follow-up findings. RESULTS: Forty-eight magnetic resonance imaging studies were performed in 38 patients. Second-look surgery was performed 21 times in 18 patients. The remaining patients were followed up at the out-patient clinic. There were no false-positive findings with non echo planar, diffusion-weighted magnetic resonance imaging; however, there were four false-negative findings. The mean maximum diameter of recurrent cholesteatoma, as assessed using magnetic resonance imaging, was 11.7 mm (range, 4.4-25.3 mm). The sensitivity of non echo planar, diffusion-weighted magnetic resonance imaging for detecting cholesteatoma prior to second-look surgery was 0.76, with a specificity of 1.00. When clinical follow up of the non-operated ears was included in the analysis, sensitivity was 0.81 and specificity was 1.00. CONCLUSION: Recurrent cholesteatoma can be accurately detected using non echo planar, diffusion-weighted magnetic resonance imaging. Our study, however, also showed some false-negative results. Therefore, strict out-patient follow up is mandatory for those considering using this technique instead of standard second-look surgery.

Reversible electric-field control of magnetization at oxide interfaces.

Electric-field control of magnetism has remained a major challenge which would greatly impact data storage technology. Although progress in this direction has been recently achieved, reversible magnetization switching by an electric field requires the assistance of a bias magnetic field. Here we take advantage of the novel electronic phenomena emerging at interfaces between correlated oxides and demonstrate reversible, voltage-driven magnetization switching without magnetic field. Sandwiching a non-superconducting cuprate between two manganese oxide layers, we find a novel form of magnetoelectric coupling arising from the orbital reconstruction at the interface between interfacial Mn spins and localized states in the CuO2 planes. This results in a ferromagnetic coupling between the manganite layers that can be controlled by a voltage. Consequently, magnetic tunnel junctions can be electrically toggled between two magnetization states, and the corresponding spin-dependent resistance states, in the absence of a magnetic field.

Direct haemodynamic effects of pulmonary arteriovenous malformation embolisation.

BACKGROUND: Transcatheter embolisation is widely used to close pulmonary arteriovenous malformations (PAVMs) in patients with hereditary haemorrhagic telangiectasia (HHT). Data on the direct cardiovascular haemodynamic changes induced by this treatment are scarce. OBJECTIVES: We investigated the direct haemodynamic effects of transcatheter embolisation of PAVMs, using non-invasive finger pressure measurements. METHODS: During the procedure, blood pressure, heart rate (HR), stroke volume (SV), cardiac output (CO), total peripheral resistance (TPR) and delta pressure/delta time (dP/dt) were continuously monitored using a Finometer®. Potential changes in these haemodynamic parameters were calculated from the pressure registrations using Modelflow® methodology. Absolute and relative changes were calculated and compared using the paired sample t-test. RESULTS: The present study includes 29 HHT patients (mean age 39 ± 15 years, 11 men) who underwent transcatheter embolotherapy of PAVMs. The total number of embolisations was 72 (mean per patient 2.5). Directly after PAVM closure, SV and CO decreased significantly by -11.9 % (p = 0.01) and -9.5 % (p = 0.01) respectively, without a significant change in HR (1.8 %). Mean arterial blood pressure increased by 4.1 % (p = 0.02), while the TPR and dP/dt did not increase significantly (5.8 % and 0.2 %, respectively). CONCLUSIONS: Significant haemodynamic changes occur directly after transcatheter embolisation of PAVMs, amongst which a decrease in stroke volume and cardiac output are most important.

Reversible control of Co magnetism by voltage-induced oxidation.

We demonstrate that magnetic properties of ultrathin Co films adjacent to Gd2O3 gate oxides can be directly manipulated by voltage. The Co films can be reversibly changed from an optimally oxidized state with a strong perpendicular magnetic anisotropy to a metallic state with an in-plane magnetic anisotropy or to an oxidized state with nearly zero magnetization, depending on the polarity and time duration of the applied electric fields. Consequently, an unprecedentedly large change of magnetic anisotropy energy up to 0.73 erg/cm(2) has been realized in a nonvolatile manner using gate voltages of only a few volts. These results open a new route to achieve ultralow energy magnetization manipulation in spintronic devices.

Unanticipated proximity behavior in ferromagnet-superconductor heterostructures with controlled magnetic noncollinearity.

Magnetization noncollinearity in ferromagnet-superconductor (F/S) heterostructures is expected to enhance the superconducting transition temperature (T(c)) according to the domain-wall superconductivity theory, or to suppress T(c) when spin-triplet Cooper pairs are explicitly considered. We study the proximity effect in F/S structures where the F layer is a Sm-Co/Py exchange-spring bilayer and the S layer is Nb. The exchange-spring contains a single, controllable and quantifiable domain wall in the Py layer. We observe an enhancement of superconductivity that is nonmonotonic as the Py domain wall is increasingly twisted via rotating a magnetic field, different from theoretical predictions. We have excluded magnetic fields and vortex motion as the source of the nonmonotonic behavior. This unanticipated proximity behavior suggests that new physics is yet to be captured in the theoretical treatments of F/S systems containing noncollinear magnetization.

Feasibility study of transanal total mesorectal excision.

BACKGROUND: Laparoscopic resection of colorectal cancers is a safe alternative to open surgery. The conversion rate to open surgery remains fairly constant but is associated with increased morbidity. A new approach to the surgical excision of rectal cancer is transanal total mesorectal excision (TME), in which the rectum is mobilized peranally using endoscopic instruments. This feasibility study describes initial results with transanal TME. METHODS: Between June and August 2012, five consecutive unselected patients with rectal carcinoma underwent surgical excision of rectal tumours by means of transanal TME. RESULTS: Transanal endoscopic dissection of the complete rectum was possible in all patients. Histopathological examination confirmed clear surgical margins and an intact mesorectal fascia in all patients. One patient developed a presacral abscess. Median duration of operation was 175 (range 160-194) min. CONCLUSION: Transanal TME using the down-to-up principle is feasible. Whether the oncological and clinical results are comparable with those of standard laparoscopic or open TME has yet to be proven.

Emergent spin filter at the interface between ferromagnetic and insulating layered oxides.

We report a strong effect of interface-induced magnetization on the transport properties of magnetic tunnel junctions consisting of ferromagnetic manganite La0.7Ca0.3MnO3 and insulating cuprate PrBa2Cu3O7. Contrary to the typically observed steady increase of the tunnel magnetoresistance with decreasing temperature, this system exhibits a sudden anomalous decrease at low temperatures. Interestingly, this anomalous behavior can be attributed to the competition between the positive spin polarization of the manganite contacts and the negative spin-filter effect from the interface-induced Cu magnetization.

Effect of interface-induced exchange fields on cuprate-manganite spin switches.

We examine the anomalous inverse spin switch behavior in La0.7Ca0.3MnO3(LCMO)/YBa2Cu3O7-δ (YBCO)/LCMO trilayers by combined transport studies and polarized neutron reflectometry. Measuring magnetization profiles and magnetoresistance in an in-plane rotating magnetic field, we prove that, contrary to many accepted theoretical scenarios, the relative orientation between the two LCMO's magnetizations is not sufficient to determine the magnetoresistance. Rather the field dependence of magnetoresistance is explained by the interplay between the applied magnetic field and the (exponential tail of the) induced exchange field in YBCO, the latter originating from the electronic reconstruction at the LCMO/YBCO interfaces.

Delta doping of ferromagnetism in antiferromagnetic manganite superlattices.

We demonstrate that delta doping can be used to create a dimensionally confined region of metallic ferromagnetism in an antiferromagnetic (AFM) manganite host, without introducing any explicit disorder due to dopants or frustration of spins. Theoretical consideration of these additional carriers shows that they cause a local enhancement of ferromagnetic double exchange with respect to AFM superexchange, resulting in local canting of the AFM spins. This leads to a highly modulated magnetization, as measured by polarized neutron reflectometry. The spatial modulation of the canting is related to the spreading of charge from the doped layer and establishes a fundamental length scale for charge transfer, transformation of orbital occupancy, and magnetic order in these manganites. Furthermore, we confirm the existence of the canted, AFM state as was predicted by de Gennes [Phys. Rev. 118, 141 (1960)] but had remained elusive.

Phase and microphase separation of polymer thin films dewetted from silicon--a spin-echo resolved grazing incidence neutron scattering study.

An understanding of the structure of ultrathin polymer films on solid substrates has scientific importance in applications as well as in fundamental studies of polymer diffusion or adsorption. We present studies of the organization of dewetted droplets of polymers on a silicon surface using a new neutron scattering technique, spin-echo resolved grazing incidence scattering (SERGIS), that has the potential to address at the same time the droplet-droplet correlations and the chemical configuration inside each droplet. For the seminal experiments, the polarized neutron reflectometer EVA at the Institut Laue-Langevin, Grenoble, France, was equipped with a spin-echo setup, and measurements were taken on surface structures previously characterized by different techniques. The dewetted polymers used in our studies were pure polystyrene, a mixture of polystyrene and polyparamethylstyrene, and a diblock copolymer of the two homopolymers. Even with a provisional setup SERGIS, we were able to determine the correlation between the droplets, providing results in excellent agreement with those obtained by atomic force microscopy and grazing incidence small-angle X-ray and neutron scattering. In addition, it was confirmed that the correlation function for diblock copolymer droplets is more complex than for polymer mixtures, exhibiting partial ordering of the copolymer within each droplet.