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Objective The slow spatial encoding of MRI has precluded its application to rapid physiologic motion in the past. The purpose of this study is to introduce a new fast acquisition method and to demonstrate feasibility of encoding rapid two-dimensional motion of human vocal folds with sub-millisecond resolution. Method In our previous work, we achieved high temporal resolution by applying a rapidly switched phase encoding gradient along the direction of motion. In this work, we extend phase encoding to the second image direction by using single-point imaging with rapid encoding (SPIRE) to image the two-dimensional vocal fold oscillation in the coronal view. Image data were gated using electroglottography (EGG) and motion corrected. An iterative reconstruction with a total variation (TV) constraint was used and the sequence was also simulated using a motion phantom. Results Dynamic images of the vocal folds during phonation at pitches of 150 and 165 Hz were acquired in two volunteers and the periodic motion of the vocal folds at a temporal resolution of about 600 µs was shown. The simulations emphasize the necessity of SPIRE for two-dimensional motion encoding. Discussion SPIRE is a new MRI method to image rapidly oscillating structures and for the first time provides dynamic images of the vocal folds oscillations in the coronal plane.

Purpose In adults requiring treatment in an intensive care unit, probiotic therapy using Lactobacillus plantarum 299v may reduce nosocomial infection. The aim of this study was to determine whether early and sustained L. plantarum 299v therapy administered to adult ICU patients increased days alive and at home. Methods A multicentre, parallel group, placebo-controlled, randomised clinical trial was conducted. Adult patients within 48 h of intensive care admission and expected to require intensive care beyond the day after recruitment were eligible to participate. L plantarum 299v or placebo were administered immediately after enrolment and continued for 60 days. The primary outcome was days alive and out of hospital to Day 60 (DAOH60). Secondary outcomes included nosocomial infections. Results The median [interquartile range (IQR)] number of DAOH60 in the probiotic (n = 110) and placebo group (n = 108) was 49.5 (IQR 37.0–53.0) and 49.0 (IQR 43.8–53.0) respectively, between-group difference of 0.0 [95% confidence interval (CI) − 6.10 to 7.1, P = 0.55]. Nosocomial infection occurred in 8 (7.3%) and 5 (4.6%) of the probiotic and placebo group participants, respectively, odds ratio 1.62 (95% CI 0.51–5.10), P = 0.57. There were no serious, or probiotic-associated adverse events. Conclusion Early and sustained untargeted administration of probiotic therapy with Lactobacillus plantarum 299v to adult patients admitted to the ICU is safe, but not associated with improved patient outcomes. Electronic supplementary material The online version of this article (10.1007/s00134-020-06322-w) contains supplementary material, which is available to authorized users.

In current voice research, there is a growing interest in semi-occluded vocal tract exercises and their contribution to an increased vocal efficiency. However, there are only few studies on the lasting effects.Eight vocally healthy subjects were asked to sustain a phonation at a comfortable loudness on the vowel /i/, with a Fundamental Frequency of 250 Hz (females) or 125 Hz (males). During phonation the subjects were simultaneously recorded with transnasal High Speed Videoendoscopy (HSV, 20,000fps), electroglottography, and audio signals. The subjects then performed a water resistance therapy (WRT) for 10 min (tube: 30 cm length, 5 cm below water surface, diameter 9 mm). Repeated measurements of sustained phonation were performed 0, 5, 10, 20, and 30 min after exercising. From the HSV material the Glottal Area Waveform (GAW) was segmented and GAW parameters were computed.There were strong inter-individual differences concerning the changes of different measures over time after WRT. In general, directly after WRT there was a lowering of the GAW derived Period Perturbation Quotient, a lowering of the Closing Quotient and an increase of the Sound Pressure Level (SPL) in comparison to the pre-intervention measurement. However, only 5 min post WRT there was no longer a clear difference compared to baseline results before WRT. Other values such as Open Quotients exhibited no evident changes by WRT at any timepoint.WRT showed strong inter-individual effects concerning the changes in the evaluated measures post-intervention. General tendencies of some measures directly after the intervention showed a brief effect of only a few minutes.

Introduction Vocal loading capacity is an important aspect of vocal health and is measured using standardized vocal loading tests. However, it remains unclear how vocal fold oscillation patterns are influenced by a standardized vocal loading task. Methods 21 (10 male, 11 female) vocally healthy subjects were analyzed concerning the dysphonia severity index (DSI) and high speed videolaryngoscopy (HSV) on the vowel /i/ at a comfortable pitch and loudness before and after a standardized vocal loading test (10 min standardized text reading, at a level higher than 80 dB (A) measured at 30 cm from the mouth). Results Changes in DSI were statistically significant, diminishing by 1.2 points after the vocal loading test, which was mainly caused by an increase of the minimum intensity. However, the pre-post comparison of HSV derived measures failed to show any statistically significant changes. Conclusion It seems necessary to analyze the effects of a standardized vocal loading test on vocal fold oscillation patterns with respect to softest phonation and phonation threshold pressure rather than comfortable pitch and loudness. Level of evidence 2c

Early prognostication in post-cardiac arrest (CA) patients remains challenging and biomarkers have evolved as helpful tools in risk assessment. The stress-response cytokine growth differentiation factor-15 (GDF-15) is dramatically up-regulated during various kinds of tissue injury and predicts outcome in many pathological conditions. We aimed to assess the predictive value of circulating GDF-15 in post-CA patients.This prospective observational study included 128 consecutive patients (median age 60.3 years, 75.8% male) with return of spontaneous circulation after in- or out-of-hospital CA who were treated at a tertiary university hospital. GDF-15 serum levels were determined at admission.A total of 52 patients (40.6%) died during the 6-month follow-up. Median GDF-15 levels were significantly lower in survivors (1601 ng/L (interquartile range: 1114-2983 ng/L) than in non-survivors (3172 ng/L (1927-8340 ng/L); p 0.001). GDF-15 levels were also significantly lower in patients with favourable neurological 6-month outcome (cerebral performance category (CPC) 1-2) than in those with poor neurological outcome (CPC 3-5; p 0.001). GDF-15 significantly predicted 6-month mortality in univariate Cox regression analysis (hazard ratio (HR) per 1-standard deviation increase 1.76 [95% confidence interval (CI) 1.35-2.31; p 0.001] and remained significant after multivariable adjustment (HR 1.57 [95% CI 1.19-2.07; p = 0.001]). Subgroup analysis revealed that the association between GDF-15 and 6-month outcome was present both in patients with in- and out-of-hospital CA.GDF-15 predicts poor survival and neurological outcome in post-CA patients. GDF-15 may reflect the extent of hypoxic injury to the brain and other organs and might help to improve early risk stratification after CA.

Introduction In addition to diagnosing acute myocardial infarction (MI), the electrocardiogram (ECG) may also predict the culprit coronary artery. We aimed to assess the diagnostic accuracy of ECG algorithms predicting the occluded vessel in inferior ST-segment elevation myocardial infarction (STEMI). Methods This retrospective cohort study included 300 consecutive patients with inferior STEMI undergoing acute coronary angiography. A new method based on the summation of ST-segment deviations in multiple leads from the first 12-lead-ECG was used to develop algorithms to discriminate between right coronary artery (RCA) and circumflex artery (CX) occlusion. Additionally, older algorithms were reassessed. Results The RCA was occluded in 235 patients (78%) and the CX in 65 (22%). ST-segment deviations differed significantly between RCA and CX occlusions in leads I, III, aVR, aVL, aVF and V1. ST-segment deviations in lead I showed the highest discriminatory ability of a single lead (area under the receiver operating curve (AUC): 0.77). The summation of multiple leads further increased the discriminatory ability ("III-II+aVF+aVR+V1": AUC=0.86; "III-II-I+aVF+V1": AUC=0.85). The best binary algorithm "III-II-I+aVF+V1>0.1 mV" classified 86% of cases correctly and was better than the best old algorithm (83.3%). The simpler algorithm "III+aVR+V1≥0.1mV" still predicted 85.0% correctly. All algorithms had higher sensitivities for RCA than for CX detection and performed better in right-dominant anatomy. Conclusions A new approach summating multiple ST-segment deviations generated ECG algorithms with higher diagnostic accuracy to predict the occluded vessel in inferior STEMI compared to previous studies. These algorithms may facilitate earlier risk stratification for patients at risk of post-infarct complications.

Vaccination is a significant preventive measure to contain the coronavirus disease-2019 (COVID-19) pandemic. Vaccination rates can provide useful information on the potential spread of infection in a given population. In this study, vaccination rates and attitudes towards vaccination in cultural sectors, specifically the music sector, have been investigated. In total, 4341 persons in four different areas, including visitors to performances of classical music and musicals, as well as professional and amateur musicians, have participated in this survey. Results show rates of 86% recovered from the COVID-19 virus or vaccinated at least once, with 54.5% fully vaccinated. These vaccination rates were considerably higher compared to the general population. An attitude of hesitation towards vaccination found in 6.4% of those sampled was half that of the general population. These findings drawn from a large sample indicate that in the field of music a high vaccination rate is to be found, as well as a low rejection rate of vaccination on the part of the audience and performers. The results can be used to provide insights into the vaccination status to be found at cultural events and, importantly, to assist in consideration of whether cultural events should be permitted to continue under pandemic circumstances.

The benefit of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in patients with heart failure (HF) with reduced ejection fraction (HFrEF) and type 2 diabetes mellitus (T2DM) has been unequivocally proven in randomized, controlled trials. However, real-world evidence assessing the implementation of SGLT2i in clinical practice and their benefit in HF outside of highly selected study populations is limited. Patients with HF and T2DM admitted to the cardiology ward of the Medical University of Vienna between 01/2014 and 04/2020 were included in the present analysis. All first-time prescriptions of SGLT2i were identified. The outcome of interest was cardiovascular mortality. The median follow-up time was 2.3 years. Out of 812 patients with T2DM and HF (median age 70.4 [IQR 62.4–76.9] years; 70.3% males), 17.3% received an SGLT2i. The frequency of SGLT2i prescriptions significantly increased over the past 6 years (+ 36.6%, p

Respiratory kinematics are important for the regulation of voice production. Dynamic MRI is an excellent tool to study respiratory motion providing high-resolution cross-sectional images. Unfortunately, in clinical MRI systems images can only be acquired in a horizontal subject position, which does not take into account gravitational effects on the respiratory apparatus. To study the effect of body posture on respiratory kinematics during phonation, 8 singers were examined both in an open-configuration MRI with a rotatable gantry and a conventional horizontal MRI system. During dynamic MRI the subjects sang sustained tones at different pitches in both supine and upright body positions. Sagittal images of the respiratory system were obtained at 1–3 images per second, from which 6 anatomically defined distances were extracted to characterize its movements in the anterior, medium and posterior section of the diaphragm as well as the rip cage (diameter at the height of the 3rd and 5th rip) and the anterior–posterior position of the diaphragm cupola. Regardless of body position, singers maintained their general principles of respiratory kinematics with combined diaphragm and thorax muscle activation for breath support. This was achieved by expanding their chest an additional 20% during inspiration when singing in the supine position but not for sole breathing. The diaphragm was cranially displaced in supine position for both singing and breathing and its motion range increased. These results facilitate a more realistic extrapolation of research data obtained in a supine position.

Blood urea nitrogen (BUN) has been shown to independently predict short- and intermediate-term outcomes in patients with acute myocardial infarction (AMI). We aimed to assess the additive predictive value of BUN beyond estimated glomerular filtration rate (eGFR) in AMI patients with an 8.6-year follow-up.This retrospective, observational single-centre study included 1332 consecutive AMI patients (median age 64 years, 58.4% male). BUN, creatinine and eGFR were determined at hospital admission.During a median follow-up of 8.6 years (interquartile range [IQR] 4.0-11.6), 408 patients (30.6%) experienced the study endpoint of cardiovascular mortality. BUN (median 17.0 mg/dL [IQR 13.5-22.7]) was a significant predictor of cardiovascular mortality in univariate Cox regression (hazard ratio (HR) per 1 standard deviation increase 2.10, 95% confidence interval [CI] 1.94-2.28, p .001). This association remained significant after multivariable adjustment for demographics, clinical variables and eGFR (adjusted HR 1.52 [CI 1.16-2.00, p = .003]). The association between BUN and outcome was more pronounced in patients with eGFR60 mL/min/1.73mCirculating BUN on admission is an independent predictor of long-term cardiovascular mortality in AMI patients and adds predictive power beyond eGFR. BUN reflects not only kidney function, but also acute haemodynamic and neurohumoral alterations during AMI, and may help to identify high-risk patients.

1.AbstractSince the Covid-19 virus spreads through airborne transmission, questions concerning the risk of spreading infectious droplets during singing and music making has arisen.To contribute to this question and to help clarify the possible risks, we analyzed 15 singing scenarios (1) qualitatively – by making airflows visible, while singing – and (2) quantitatively – by measuring air velocities at three distances (1m, 1.5m and 2m). Air movements were considered positive when lying above 0.1 m/s, which is the usual room air velocity in venue, such as the concert hall of the Bamberg Symphony, where our measurements with three professional singers (female classical style, male classic style, female popular music style) took place.Our findings highlight that high measurements for respiratory air velocity while singing are comparable to measurements of speaking and – by far – less than coughing. All measurements for singing stayed within a reach of 1.5m, while only direct voiceless blowing achieved measurements at the 2m sensor. Singing styles that use plosive sounds, i.e. using consonants more often as in rap, produced the highest air velocities of 0.17 m/s at the 1m sensor. Also, singing while wearing a facemask produces no air movements over 0.1 m/s.On the basis of our recent studies on measurements of airflows and air velocities of professional singers and wind instrument players, as well as further studies on CO□ measurements in room settings of music activities, we publish our results – in consideration of further up-to-date research – in our frequently updated risk assessment (first published in April 2020). On this behalf, we suggest 2m radial distances for singers, especially in choirs.

Background: After successful cardiopulmonary resuscitation (CPR) with return of spontaneous circulation (ROSC), many patients show signs of an overactive immune activation. Monocytes are a heterogeneous cell population that can be distinguished into three subsets. The aim of this prospective, observational study was to analyse whether monocyte subset distribution is associated with mortality at 6 months in patients after cardiac arrest (CA). Methods: We included 53 patients admitted to our medical intensive care unit (ICU) after CA. Blood was taken on admission and after 72 hours and monocyte subset distribution was analysed by flow cytometry and distinguished into classical monocytes (CD14++CD16-), intermediate monocytes (CD14++CD16+CCR2+) and non-classical monocytes (CD14+CD16++CCR2-). Results: Median age was 64.5 (interquartile range (IQR) 49.8-74.3) years and 75.5% were male. Six-month mortality was 50.9% and survival with good neurological outcome was 37.7%. Monocyte subset distribution upon admission to the ICU did not differ according to survival. However, patients who died within 6 months showed a more pronounced increase in the pro-inflammatory subset of intermediate monocytes (8.3% (3.8-14.6)% vs. 4.1% (1.5-8.2)%; p=0.025), and a decrease of classical monocytes (87.5% (79.9-89.0)% vs. 90.8% (85.9-92.7)%; p=0.036) 72 hours after admission. In addition, intermediate monocytes were predictive of outcome independent of time to ROSC and witnessed cardiac arrest, and correlated with the cerebral performance category (CPC)-score at 6 months (R=0.32; p=0.043). Discussion: Monocyte subset distribution is associated with outcome in patients surviving a CA. The activation of the innate immune system may play a significant role in CA patients.

Background After successful cardiopulmonary resuscitation with return of spontaneous circulation (ROSC), many patients show signs of an overactive immune activation. Monocytes are a heterogenous cell population that can be distinguished into three subsets. Purpose The aim of this prospective, observational study was to analyze whether monocyte subset distribution is associated with mortality at 6 months in patients after cardiac arrest. Methods We included 53 patients admitted to our medical ICU after cardiac arrest. Blood was taken on admission and monocyte subset distribution was analyzed by flow cytometry and distinguished into classical monocytes (CM; CD14++CD16-), intermediate monocytes (IM; CD14++CD16+CCR2+) and non-classical monocytes (NCM; CD14+CD16++CCR2-). Results Median age was 64.5 (IQR 49.8–74.3) years and 75.5% of patients were male. Mortality at 6 months was 50.9% and survival with good neurological outcome was 37.7%. Of interest, monocyte subset distribution upon admission to the ICU did not differ according to survival. However, patients that died within 6 months showed a strong increase in the pro-inflammatory subset of intermediate monocytes (8.3% (3.8–14.6)% vs. 4.1% (1.5–8.2)%; p=0.025), and a decrease of classical monocytes (87.5% (79.9–89.0)% vs. 90.8% (85.9–92.7)%; p=0.036) 72 hours after admission. In addition, intermediate monocytes were predictive of outcome independent of initial rhythm and time to ROSC and correlated with the CPC-score at 6 months (R=0.32; p=0.043). Discussion Monocyte subset distribution is associated with outcome in patients surviving a cardiac arrest. This suggests that activation of the innate immune system may play a significant role in patient outcome after cardiac arrest. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): FWF - Fonds zur Förderung der wissenschaftlichen Forschung

Contaminated aerosols in room air are one of the transmission routes of the coronavirus. The amount of contaminated aerosols in the room seems to play an important role for the infection risk. In rooms without technical air refreshing systems, the aerosol concentration can be reduced with simple natural ventilation activity. Instrumental and vocal lessons and rehearsals take place in closed indoor rooms. Therefore it is important to optimize the necessary ventilation activity in order to keep the infection risk for musicians low. Therefore, knowledge about the maximum duration of the lesson or rehearsal for ventilation intervals are necessary. In this study, carbon dioxide concentration (CO2) as an indicator of the indoor air quality (IAQ) was measured during 47 music lessons and rehearsals at a university of music including 141 persons. From these measurements, the air exchange rates of the rooms and the CO2 emission rates per person were extracted. The results show that the CO2 emission in musical activities can be assigned to light and moderate activities between 28 l/h and 39 l/h. Wind instruments had the highest CO2 emissions. Singers showed low CO2 emission rates comparable to the control group which only spoke and listened. Recommendations for the frequency of ventilation breaks were derived from empirical data and allow for an individual risk assessment of instrumental and vocal lessons and rehearsals depending on room size and number of musicians.

IntroductionThe effect of early and sustained administration of daily probiotic therapy on patients admitted to the intensive care unit (ICU) remains uncertain.Methods and analysisThe Restoration Of gut microflora in Critical Illness Trial (ROCIT) study is a multicentre, randomised, placebo-controlled, parallel-group, two-sided superiority trial that will enrol 220 patients in five ICUs. Adult patients who are within 48 hours of admission to an ICU and are expected to require intensive care beyond the next calendar day will be randomised in a 1:1 ratio to receive early and sustained Lactobacillus plantarum 299v probiotic therapy in addition to usual care or placebo in addition to usual care. The primary endpoint is days alive and out of hospital to day 60.Ethics and disseminationROCIT has been approved by the South Metropolitan Health Service Human Research Ethics Committee (ref: RGS00000004) and the St John of God Health Care Human Research Ethics Committee (ref: 1183). The trial results will be submitted for publication in a peer-reviewed journal.Trial registration numberAustralian and New Zealand Clinical Trials Registry (ANZCTR12617000783325); Pre-results.

Current guidelines suggest the use of epinephrine in patients with cardiac arrest (CA). However, evidence for increased survival in good neurological condition is lacking. In experimental settings, epinephrine-induced impairment of microvascular flow was shown. The aim of our study was to analyze the association between epinephrine treatment and intestinal injury in patients after CA.We have included 52 patients with return of spontaneous circulation (ROSC) after CA admitted to our medical intensive care unit (ICU). Blood was taken on admission and levels of circulating intestinal fatty acid binding protein (iFABP) were analyzed.Patients were 64 (49.8-73.8) years old and predominantly male (76.9%). After six months, 50% of patients died and 38.5% of patients had a cerebral performance category (CPC)-score of 1-2. iFABP levels were lower in survivors (234 IQR 90-399 pg/mL) as compared to non-survivors (283, IQR 86-11500 pg/mL; p 0.05). Plasma levels of iFABP were not associated with time to ROSC but correlated with epinephrine-dose (R = 0.32; p 0.05). 40% of patients receiving ≥3 mg of epinephrine as compared to 10.5% of patients treated with3 mg (p 0.05) developed iFABP plasma levels1500 pg/mL, which was associated with dramatically increased mortality (HR4.87, 95%CI 1.95-12.1; p 0.001). iFABP levels predicted mortality independent from time to ROSC and the disease severity score SAPS II. In contrast to mortality, iFABP plasma levels were not associated with neurological outcome.In this small, single centre study, cumulative dose of epinephrine used in cardiac arrest patients was associated with an increase in biomarker indicative of intestinal injury and 6-month mortality.

Background. Heart failure with reduced ejection fraction (HFrEF) constitutes a global health issue. While proinflammatory cytokines proved to have a pivotal role in the development and progression of HFrEF, less attention has been paid to the cellular immunity. Regulatory T lymphocytes (Tregs) seem to have an important role in the induction and maintenance of immune homeostasis. Therefore, we aimed to investigate the impact of Tregs on the outcome in HFrEF. Methods. We prospectively enrolled 112 patients with HFrEF and performed flow cytometry for cell phenotyping. Individuals were stratified in ischemic (iHFrEF, n=57) and nonischemic etiology (niHFrEF, n=55). Cox regression hazard analysis was used to assess the influence of Tregs on survival. Results. Comparing patients with iHFrEF to niHFrEF, we found a significantly lower fraction of Tregs within lymphocytes in the ischemic subgroup (0.42% vs. 0.56%; p=0.009). After a mean follow-up time of 4.5 years, 32 (28.6%) patients died due to cardiovascular causes. We found that Tregs were significantly associated with cardiovascular survival in the entire study cohort with an adjusted HR per one standard deviation (1-SD) of 0.60 (95% CI: 0.39-0.92; p=0.017). A significant inverse association of Tregs and cardiovascular mortality in patients with iHFrEF with an adj. HR per 1-SD of 0.59 (95% CI: 0.36-0.96; p=0.034) has been observed, while this association was not evident in the nonischemic subgroup (adj. HR per 1-SD of 0.62 (95% CI: 0.17-2.31); p=0.486). Conclusion. Our results indicate a potential influence of Tregs in the pathogenesis and progression of iHFrEF, fostering the implication of cellular immunity in iHFrEF pathophysiology and proving Tregs as a predictor for long-term survival among iHFrEF patients. A preview of this study has been presented at a meeting of the European Society of Cardiology earlier this year.

The chapter reflects the main clinical manifestations of voice disorders, the wide diversity and multiple sociocultural interrelations of which contrast with a consistent systematic order of aetiological or symptomatic categories. Instead, the compilation follows prevailing purposes to provide a useful overview for application in everyday practice. Functional dysphonias, psychosomatic voice dysfunction and singing voice disorders are closely related to each other but nevertheless require individual consideration regarding special diagnostic procedures as well as therapeutic or rehabilitative consequences, including occupational perspectives. Organic manifestations comprise benign lesions of the mucosa of the vocal folds, gastro-oesophageal reflux influences, central and peripheral neurogenic disorders and laryngeal sensory neuropathy. A section on hormone-related dysphonias is followed by a survey on gender vocology focused on the demands of male-to-female as well as female-to-male adaptation of transsexuals. Voice disorders in systematic diseases and also as consequences of environmental influences and allergy complete the chapter that includes paying attention to special aspects of the voices in childhood and adolescence and the elderly population. Malign lesions are not part of this chapter.

Zusammenfassung Hintergrund Der Fragebogen zur Erfassung des stimmlichen Selbstkonzepts (FESS) bildet in drei Skalen das persönliche Erleben der eigenen Stimme ab. Dabei werden die Beziehung zur eigenen Stimme, die Bewusstheit im Umgang mit der Stimme und der Zusammenhang zwischen Stimme und Emotion bestimmt. Für die Auswertung des Fragebogens fehlte bisher eine skalenübergreifende Betrachtungsweise, um eine vereinfachte Interpretation der Ergebnisse zu ermöglichen. Material und Methoden Der FESS Fragebogen wurde bei 536 Lehrkräften eingesetzt und mittels einer Diskriminanz analyse auf gemeinsame Ausprägungsmerkmale in den Skalen untersucht. Für eine differenzierte Betrachtung von Zusammenhängen mit Stimmgesundheit, psychischer und körperlicher Gesundheit wurden ebenfalls der Voice Handicap Index (VHI), der Fragebogen zum arbeitsbezogenen Verhaltens- und Erlebensmuster (AVEM) und der Fragebogen zur gesundheitsbezogenen Lebensqualität (SF-12) herangezogen. Ergebnisse Die Analyse ergab vier verschiedene Gruppen des stimmlichen Selbstkonzepts: die Gruppe 1) mit stimmlich und psychisch gesunden Werten, die Gruppe 2) mit einem eher wenig ausgeprägtem stimmlichen Selbstkonzept und durchschnittlicher psychischer Gesundheit, die Gruppe 3) mit einer hohen Bewusstheit im Umgang mit der Stimme und durchschnittlicher psychischer Gesundheit und die Gruppe 4) mit hohen stimmlichen und psychischen Belastungen. Schlussfolgerung Die Ergebnisse zeigen, dass für eine Gesamtauswertung des Fragebogens zur Erfassung des stimmlichen Selbstkonzepts eine gemeinsame Betrachtung aller drei Skalen in Betracht gezogen werden kann. Die dargestellten Gruppen stellen dafür eine geeignete Herangehensweise zur Unterstützung in der Diagnostik zur Verfügung.

Study objective Postoperative atrial fibrillation (POAF) is a frequent complication after cardiac valve- or coronary artery bypass (CABG) surgery and is associated with increased mortality. While it is known that prolonged postoperative invasive ventilation triggers POAF, the impact of ventilatory settings on POAF development has not been studied yet. Design Prospective observational study. Setting Postoperative Intensive Care Unit. Patients Patients having undergone elective CABG and/or cardiac valve surgery. Measurements Screening for the development of POAF. Patients' clinical data and postoperative ventilatory settings (driving pressure, controlled pressure above positive endexpiratory pressure (PEEP), respiration rate, and FiO2) were investigated to elucidate their impact on POAF. Main results Out of 441 enrolled individuals, a total of 192 participants developed POAF (43.5%). We observed that POAF patients received a higher peak driving pressure, and a higher peak respiration rate than non-POAF individuals. Within the multivariate regression model, plateau pressure (adjusted OR 1.199 [1.038–1.661], p = 0.019), driving pressure (adjusted OR 1.244 [1.103–1.713], p = 0.021), and peak respiration rate (adjusted OR 1.206 [1.005–1.601], p = 0.040) proved to be independently associated with the development of POAF. CART analysis revealed a cut-off of ≥17.5 cmH2O of plateau pressure, ≥11.5 cmH2O of driving pressure and ≥ 17 respirations per minute as high-risk for POAF development. Conclusions The ventilatory settings of plateau pressure, driving pressure, and respiration rate after cardiac surgery influence POAF occurrence probability. Optimized postoperative care such as lung-protective ventilation and increased awareness towards postoperative ventilatory efforts should be considered to prevent POAF development and poor patient outcome.

Summary Introduction It is generally assumed that when singing across the region where registration events for untrained voices occur (the passaggio), singers modify the voice production system in order to avoid changes of voice quality. In this context, it has been postulated that nasalance could be used to stabilize vocal function throughout the passaggio. However, whether nasalance is frequently used by professional singers and if so, if it has a stabilizing effect on vocal fold oscillation patterns, is not yet fully understood. Material and Methods Eight western classically trained professional male singers (6 tenors and 2 baritones) were asked to perform transitions (1) from modal to falsetto register and (2) from modal to stage voice above the passaggio (SVaP) during ascending pitch glides from A3 (ƒo approx. 220 Hz) to A4 (ƒo approx. 440 Hz) on the vowel /i/. Transnasal high-speed videoendoscopy at 20.000 fps was captured simultaneously with electroglottographic, nasal and oral flow, and audio signals, recorded using the same frame rate. The nasalance was calculated from both oral and nasal DC-flow signals. Results Transitions to SVaP showed greater periodicity and regularity than transitions to falsetto. For 5 subjects, nasalance was increased during the passaggio for the transition to SVaP. For 4 subjects the increase of nasalance for the SVaP was associated with a stabilization of the open quotient and occurred at a comparable fundamental frequency as the increase of the open quotient for the transition to falsetto. Conclusions Nasalance can be used in order to stabilize oscillatory regularity and open quotient in male singers for singing across the passaggio.

Purpose Recently, efforts have been made to investigate the vocal tract using magnetic resonance imaging (MRI). Due to technical limitations, teeth were omitted in many previous studies on vocal tract acoustics. However, the knowledge of how teeth influence vocal tract acoustics might be important in order to estimate the necessity of implementing teeth in vocal tract models. The aim of this study was therefore to estimate the effect of teeth on vocal tract acoustics. Method The acoustic properties of 18 solid (3-dimensional printed) vocal tract models without teeth were compared to the same 18 models including teeth in terms of resonance frequencies ( f Rn ). The f Rn were obtained from the transfer functions of these models excited by white noise at the glottis level. The models were derived from MRI data of 2 trained singers performing 3 different vowel conditions (/i/, /a/, and /u/) in speech and low-pitched and high-pitched singing. Results Depending on the oral configuration, models exhibiting side cavities or side branches were characterized by major changes in the transfer function when teeth were implemented via the introduction of pole-zero pairs. Conclusions To avoid errors in modeling, teeth should be included in 3-dimensional vocal tract models for acoustic evaluation. Supplemental Material https://doi.org/10.23641/asha.5386771

This study investigated the predictive value of soluble urokinase-type plasminogen activator receptor (suPAR) in patients with chronic heart failure (CHF).SuPAR originates from proteolytic cleavage of the membrane-bound receptor from activated immune and endothelial cells and reflects the level of immune activation. As inflammation plays a crucial role in the complex pathophysiology of CHF, we hypothesized that suPAR might be a suitable prognostic biomarker in patients with CHF.SuPAR levels were determined in 319 patients with CHF admitted to our outpatient department for heart failure and in a second cohort consisting of 346 patients with CHF, for validation.During a median follow-up time of 3.2 years, 119 patients (37.3%) died. SuPAR was a strong predictor of mortality with a crude hazard ratio (HR) per increase of 1 SD (HR per 1 SD) of 1.96 (95% confidence interval [CI]: 1.63 to 2.35; p 0.001) in univariate analysis and remained significant after comprehensive multivariate adjustment with an adjusted HR per 1 SD of 1.38 (95% CI: 1.04 to 1.83; p = 0.026). SuPAR added prognostic value beyond the multivariate model indicated by improvements in C-statistics (area under the curve: 0.72 vs 0.74, respectively; p = 0.02), the category-free net reclassification index (24.9%; p = 0.032), and the integrated discrimination improvement (0.011; p = 0.05). Validation in the second cohort yielded consistent results.SuPAR is a strong and independent predictor of mortality in patients with CHF, potentially suitable to refine risk assessment in this vulnerable group of patients. Our results emphasize the impact of immune activation on survival in patients with CHF.

BACKGROUND Risk of arrhythmic death is considered highest in ischemic heart disease with severe left ventricular ejection fraction (LVEF) reduction. Non-invasive testing should improve decision-making of prophylactic defibrillator (ICD) implantation. DESIGN We enrolled 120 patients with ischemic heart disease and LVEF

SummaryAtrial fibrillation (AF) represents the most common cardiac arrhythmia. Especially in patients with chronic heart failure (CHF) the development of AF represents a severe complication resulting in haemodynamic deterioration. While pro-inflammatory cytokines proved to have a pivotal role in the development and progression of both AF and CHF, less attention has been paid to the cellular immunity. Therefore we prospectively enrolled 112 patients with CHF and performed fluorescein-activated cell sorting (FACS). Patients were stratified in two subgroups according to patients presenting with AF (n=56) and patients free of AF (n=56). Comparing AF to non-AF patients we found a significantly lower fraction of regulatory T cells (pSupplementary Material to this article is available online at www.thrombosis-online.com.

Zur Untersuchung der Bauelemente des Instruments Stimme (Atemapparat, Kehlkopf und Vokaltrakt) ist eine bildgebende Diagnostik des Korperinneren notig, um Aufschluss uber die organische Beschaffenheit und die Funktion zu erhalten. Im vorliegenden Ubersichtsartikel werden 3 technisch sehr unterschiedlichen Verfahren zur bildlichen Darstellung der physiologischen und pathophysiologischen Vorgange bei der Stimmproduktion – Video-Laryngo-Stroboskopie, Hochgeschwindigkeitsglottografie sowie dynamische Magnetresonanztomografie – vorgestellt und ihr gegenwartiger Stellenwert und Nutzen in der Stimmfunktionsdiagnostik diskutiert.

PURPOSE To enable three-dimensional (3D) vocal tract imaging of dynamic singing or speech tasks at voxel sizes of 1.6 × 1.6 × 1.3 mm3 at 1.3 s per image. MATERIALS AND METHODS A Stack-of-Stars method was implemented and enhanced to allow for fast and efficient k-space sampling of the box-shaped vocal tract using a 3 Tesla MRI system. Images were reconstructed using an off-line image reconstruction using compressed sensing theory, leading to the abovementioned spatial and temporal resolutions. To validate spatial resolution, a phantom with holes of defined sizes was measured. The applicability of the imaging method was validated in an eight-subject study of amateur singers that were required to sustain phonation at a constant pitch, past their comfortable expiratory level. A segmentation of the vocal tract over all phonation time steps was done for one subject. Anatomical distances (larynx position and pharynx width) were calculated and compared for all subjects. RESULTS Analysis of the phantom study revealed that the imaging method could provide at least 1.6 mm isotropic resolution. Visual inspection of the segmented vocal tract during phonation showed modifications of the lips, tongue, and larynx position in all three dimensions. The mean larynx position per subject amounted to 52-85 mm, deviating up to 5% over phonation time. Parameter pharynx width was 32-181 mm2 on average per subject, deviating up to 16% over phonation time. Visual inspection of the parameter course revealed no common compensation strategy for long sustained phonation. CONCLUSION The results of both phantom and in vivo measurements show the applicability of the fast 3D imaging method for voice research and indicate that modifications in all three dimensions can be observed and quantified. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 1 J. MAGN. RESON. IMAGING 2017;46:94-101.

Objectives/Hypothesis In professional classical singing, an even voice quality throughout the entire singing voice range is essential. Transitions between vocal registers (passaggio) are the technically most challenging aspects in classical singing. It is hypothesized that they are most affected by vocal fold mass lesions (VFML). Study Design Cohort study. Methods In this study, the effect of VFML on vocal fold vibration in the passaggio regions was analyzed in four female and three male singers suffering from organic dysphonia. The singers were asked to sing an ascending glissando through the passaggio regions, before and after treatment. The vocal fold vibration was documented with transnasal endoscopic high-speed imaging recordings at 20,000 frames per second, supplemented by synchronized acoustic and electroglottographic recordings. Results Major irregularities were found in the passaggio region of four singers before treatment, whereas the respective phonations below the passaggio were almost regular. In two female singers only the upper, but not the lower passaggio was affected. In all four of these participants, the passaggio region was more regular after treatment. In the remaining three participants, the VFML showed no effect on the passaggio region. However, the singers' ability to reach higher pitches was impaired, but was resolved after treatment. Conclusions The data in this case study strongly suggest that the passaggio region could be affected by VFML, even if phonation outside the passaggio regions is unimpaired. When planning surgical procedures for professional singers, clinical examination protocols should therefore include phonatory tests across the passaggio regions. Level of Evidence 4 Laryngoscope, 127:1392–1401, 2017

Purpose The temporal resolution of the MRI acquisition is intrinsically limited by the duration of the spatial encoding, which is typically on the order of milliseconds. Faster motion such as the vibration of the vocal folds during phonation cannot be imaged with conventional MRI as this would require sampling frequencies in the kilo-Hertz range. Here, a faster MRI acquisition strategy is presented that encodes a 1D periodic motion at a temporal resolution that is an order of magnitude higher compared to conventional MRI. Methods The proposed method encodes the position of an object moving along 1 dimension by applying very short phase encoding gradients along the same direction. This reduces the temporal resolution from the repetition time (TR) to the duration of the phase encoding gradients, which in this work was well below 1 ms. The technique is applied to the vocal fold oscillations and the position of the vocal folds is measured simultaneously using electroglottography (EGG). Simulations of the point spread function for regular encoding and the proposed method are performed as well. Results With this new phase, encoding strategy oscillations of the human vocal folds up to a frequency of 145 Hz could be dynamically imaged at 10 images per cycle. Simulations show the advantage of this method over conventional imaging of fast moving objects. Conclusion A new method for MR imaging of fast moving spins is presented allowing a temporal resolution below 1 ms at a spatial resolution below 1 mm, circumventing TR as the limit for temporal resolution.

In the cases of uncertainty, even if the patient has no complaints about his voice quality, sometimes, benign vocal fold mass lesions are removed to exclude malignancy with the risk of resultant dysphonia. Narrow Band Imaging (NBI) enables a specific visualization of vessel structures in the superficial tissue. Benign lesions of the larynx are frequently characterized by abnormal vessel configuration or an absence of vessels in the area of the lesion. It was hypothesized that, in the primary diagnosis of patients with these benign lesions, the combination of white light and NBI endoscopy enables a better detection compared with white light endoscopy alone. Twenty-nine patients (eight patients with a cyst on a vocal fold, eight with a polyp, seven with a Reinke´s edema, two with a leukoplakia, one with a carcinoma, one with a granuloma, and two without any pathologic finding) were examined with normal white light and NBI endoscopy. 87 video sequences (29 white, 29 NBI, and 29 white/NBI) were generated and randomized and presented to 20 otolaryngologists who rated the videos in terms of the suspected diagnosis. Results were compared with the histopathologic findings of microlaryngoscopy. The probability of detecting benign lesions of the vocal folds was higher using NBI in combination with white light endoscopy compared with white light endoscopy alone. For vocal fold cysts, this difference was statistically significant. NBI endoscopy in combination with normal white light endoscopy improves the detection rate of benign lesions of the larynx, especially of vocal fold cysts.

Einleitung: Die multidimensionale Stimmdiagnostik gilt als Goldstandard in der Stimmmedizin. Zur standardisierten Evaluation wurde diesbezuglich ein Protokoll der Europaisch Laryngologischen Gesellschaft (ELS-Protokoll) vorgeschlagen. Hinsichtlich der Beurteilung von Therapieverlaufen liegen nach wie vor wenige Daten vor. Material und Methoden: 276 Patienten (136 mit phonochirurgischer Operation, 81 mit Stimmtherapie und 59 als stimmgesunde Kontrollgruppe) wurden hinsichtlich der Stimmfunktion vor und nach Stimmtherapie bzw. phonochirurgischer Intervention anhand dieses Protokolls evaluiert. Ergebnisse: In den Kennwerten des ELS-Protokolls liesen sich hinsichtlich DSI, VHI und RBH-System deutliche Verbesserungen durch die Therapie darstellen. Somit konnte die Eignung dieser statistisch signifikanten Messwerte zur Verlaufseinschatzung von dysphonen Patienten sowohl bei organischen als auch funktionellen Stimmstorungen bestatigt werden. Allerdings zeigten sich in der Detailanalyse aller erhobenen Parameter zum Teil schwache bis keine Korrelationen bei Werten, die eigentlich ahnliche Informationen geben sollten wie z. B. Perturbationswerten oder Werten, die sich aus dem Schallspektrum ableiten. Diskussion: Die multidimensionale Stimmmessung, wie sie im ELS-Protokoll vorgeschlagen wird, ist unabhangig vom gewahlten Therapieverfahren in der Lage, Therapieerfolge gut zu dokumentieren. Die zum Teil ungenugenden Korrelationen von Werten, die eigentlich etwas vergleichbares Ausdrucken sollten, zeigen, dass eine Optimierung bzw. Vereinheitlichung von Messgeratschaft, Computer Hard- und Software dringend erforderlich ist.

PURPOSE To combine vocal tract measurements with dynamic MRI of the lungs to provide fundamental insights into the lung physiology during singing. METHODS To analyze vocal fold oscillatory patterns during dynamic lung MRI, an electroglottography (EGG) system was modified to allow for simultaneous EGG measurements during MR image acquisitions. A low-pass filter was introduced to suppress residual radiofrequency (RF) coupling into the EGG signal. RF heating was tested in a gel phantom to ensure MR safety, and functionality of the EGG device was assessed in a volunteer experiment at singing frequencies from A5 to A3. In the recorded EGG signals, remaining RF interferences were removed by independent component analysis post processing, and standard EGG parameters such as fundamental frequency, contact quotient and jitter were calculated. In a second volunteer experiment, EGG recordings were compared with lung diameter measurements from 2D time-resolved trueFISP acquisitions. RESULTS RF heating measurements resulted in less than 1.2°C temperature increase in the gel phantom. EGG parameters measured during MR imaging are within the range of ideal values. In the lung measurement, both the lung diameter and the EGG recordings could be successfully performed with only minimal interference. CONCLUSION EGG recording is pos sible during dynamic lung MRI, and glottal activity can be studied safely at 1.5T. Magn Reson Med 76:1629-1635, 2016. © 2015 International Society for Magnetic Resonance in Medicine.

Der Einfluss funktioneller Phonationsverdickungen auf das Schwingungsverhalten der Stimmlippen bei stimmlich herausfordernden Aufgaben ist noch nicht im Detail verstanden. In dieser Studie wurden Glissandi von 220 bis 440 Hz und von 440 bis 880 Hz auf dem Vokal [a:] bei je 4 professionellen Sangerinnen zum einen ohne organischen Befund und ohne Dysphonie (Gruppe A), zum anderen mit funktionellen Phonationsverdickungen (Gruppe B) und zum Dritten mit organischer Dysphonie (Gruppe C) mittels Hochgeschwindigkeitsendoskopie („high speed digital imaging“, HSDI, 20.000 Bilder/s), akustischen und elektroglottographischen (EGG-)Signalen untersucht. Anhand der EGG-Stichprobenentropie („sample entropy“) wurden Zeitfenster zur Analyse von Registerubergangsphanomen gebildet. Ferner wurden alle Stimmsignale („glottal area waveform“, GAW; akustisches und EGG-Signal) einer perzeptiven Bewertung hinsichtlich der Wahrnehmbarkeit von Registrierungsvorgangen unterzogen. Die absolute „sample entropy“ zeigte Maxima in Grundfrequenzbereichen, in denen typischerweise Registerubergange zu finden sind. Gruppe B unterschied sich weder im Rating noch in den Werten der „sample entropy“ deutlich von Gruppe A. Die absoluten Werte der „sample entropy“ lagen fur die Gruppe C nur fur das untere Glissando oberhalb der beiden anderen Gruppen. Die groseren Irregularitaten der Stimmlippenschwingungen waren in dieser Gruppe jedoch im oberen Glissando zu beobachten. Funktionelle Phonationsverdickungen wirken sich nicht negativ in Hinblick auf die Biomechanik in stimmtechnisch herausfordernden Bereichen wie Registerubergangen aus. Die Verwendung der „sample entropy“ als Kriterium zur Detektion von Registerubergangen ist vielversprechend, bedarf jedoch weiterer Validierung.

Objectives: Narrow band imaging (NBI) is supposed to be a technique for a better visualization of vessel structures in superficial tissue as it selects the wavelengths of hemoglobin. It was hypothesized that, in the regular follow-up examination of patients with recurrent laryngeal papillomatosis, NBI enables a better detection of laryngeal papillomatosis in contrast to normal white light endoscopy. Methods: Eleven patients, 10 with a known recurrent papillomatosis (8 with a relapse, 2 without) and 1 with a primary diagnosis of papillomatosis, were examined with normal white light and NBI endoscopy. Twenty-six video sequences (11 white, 11 NBI, 4 doubled for validity) were generated and randomly presented to 20 otolaryngologists who rated the videos in terms of lesions seen and number of lesions identified. Results were compared with the histopathologic findings of microlaryngoscopy. Results: Detection of papillomatosis and the correct number of lesions identified were more accurate with NBI than with normal white light endoscopy. There was a significantly higher probability of detecting laryngeal papillomata with NBI. Conclusions: NBI endoscopy enables a more accurate detection of laryngeal papillomatosis than white light endoscopy.

Purpose To accelerate dynamic imaging of the vocal tract during articulation. Materials and Methods Five subjects were imaged by magnetic resonance imaging (MRI) while repeating the word "Partikel" at 90 beats per minute, using both a radio-frequency-spoiled radial gradient echo sequence with golden angle projection rotation and a previously applied real-time Cartesian sequence. The acquired data were reconstructed using a CG-SENSE method and Cartesian reconstruction. The images from both methods were compared by measuring distances between anatomical landmarks that are important for resonance behavior of the vocal tract. Only commonly available hardware and software were used. Results With the presented radial method a spatial resolution of 1.8 mm at 25 frames per second could be achieved. Overall, the morphometric measurements of the vocal tract showed less deviation for the radial sequence both across repetitions and for all subjects. Fast modifications, such as complete lip closing, could be analyzed with greater fidelity using the high temporal resolution of the radial sequence. Conclusion The results indicate that higher temporal resolution is a necessity to catch fast morphometric changes in the vocal tract. J. Magn. Reson. Imaging 2015;42:925–935.

Hintergrund Fragebogen zur Selbsteinschatzung der Stimme fokussieren uberwiegend auf die physiologische Funktionalitat der Stimme und die Auswirkungen auf die subjektive Lebensqualitat. Personlichkeitsbezogene Aspekte wie die Beziehung zur eigenen Stimme und deren Selbstwahrnehmung bleiben dabei weitgehend unberucksichtigt. Fragebogeninstrumente hierzu liegen bislang nicht vor.

Background— Prophylactic defibrillator implantation is recommended in dilated, nonischemic heart disease and left ventricular ejection fraction of ≤0.30 to 0.35. Noninvasive testing should improve accuracy in decision making of prophylactic defibrillator implantation. Methods and Results— We enrolled 60 patients (median age, 57 years) with dilated cardiomyopathy and left ventricular ejection fraction ≤0.50, and 30 control subjects (median age, 59 years) with left ventricular ejection fraction >0.50. The protocol included an initial assessment, a second assessment after 3 years, and a final follow-up: pharmacological baroreflex testing (baroreceptor reflex sensitivity), short-term spectral analysis of heart rate variability (low frequency/high frequency), and long-term time domain analysis (SD of all normal-to-normal R–R intervals), exercise microvolt T wave alternans, and signal-averaged ECG, and corrected QT-time. The median follow-up was 7 years. End points were cardiac death, resuscitated cardiac arrest, and arrhythmic death. Cardiac death was observed in 21 patients. Resuscitated cardiac arrest and arrhythmic death caused by ventricular tachyarrhythmias ≥240 per minute was observed in 7 and 10 patients, respectively. In the single time point analysis, microvolt T wave alternans, baroreceptor reflex sensitivity, and SD of all normal-to-normal R–R intervals at initial testing added significant information regarding cardiac death. Microvolt T wave alternans added information on resuscitated cardiac arrest or arrhythmic death at multiple time points ( P Conclusions— Noninvasive testing and left ventricular ejection fraction could not reliably identify patients with dilated cardiomyopathy at risk of fatal ventricular tachyarrhythmias. Therefore, the strategy to confine prophylactic implantable cardioverter-defibrillator implantation to patients with dilated cardiomyopathy and severely reduced LV function should be reconsidered.

Vocal loading capacity is an important aspect of vocal health, especially for people in vocally demanding occupations such as teaching. To analyze vocal loading, vocal loading tests (VLTs) or portable voice devices such as accelerometers have been used. However, it remains unclear how much a VLT in a clinical setup reflects the vocal effort of a real situation, in particular for teachers in a given classroom lesson. In this study of vocally healthy 101 student teachers, we analyzed different vocal doses for a 10-min VLT (80 dB at a distance of 30 cm) and a real 45-min teaching lesson. The phonation time, fundamental frequency, sound pressure level, and noise level were recorded using the VoxLog accelerometer/microphone system for both conditions. From these measurements the time dose, cycle dose, distance dose, energy dissipation dose, and radiated energy dose were calculated. The VLT was associated with a higher fundamental frequency, a higher sound pressure level, and higher relative phonation time compared to the real teaching lesson. Nevertheless, most vocal doses did not differ significantly between the conditions. A VLT of 10 min with >80 dB at 30 cm distance shows only small differences of vocal doses in comparison to a real teaching situation of 45 min. Thus, for clinical vocal assessment the vocal load of a VLT can be related to an approximately 45-min teaching situation.

Aim Radiofrequency catheter ablation is a standard treatment for tachyarrhythmia in children. Recently, several centres using cryoenergy for ablation have reported high success and low complication rates, but an increased risk of recurrence of arrhythmia. The aim of this study was to report success, complications and recurrence rates for radiofrequency catheter ablation in children under current conditions. Methods A retrospective cohort study of 333 consecutive children undergoing radiofrequency catheter ablation over the last two decades. Results Radiofrequency catheter ablation was performed successfully in 96.7% of patients, but was significantly less successful in patients with a right anterior or right anterolateral accessory pathway (81.8%). Overall mortality was 0%; there was only one (0.3%) major complication, a pericardial haemorrhage, and only 2.8% of the patients developed minor vascular complications at the puncture site. None of the patients developed a persistent atrioventricular block. Over a median observation time of 4.3 years (0.1; 17.8), recurrence of arrhythmia occurred in 9.3% of all patients, but 50% of children with right lateral accessory pathways. Conclusion Radiofrequency catheter ablation can be performed with high success and very low complication rates in children. Recurrence rates are substantially lower than those reported for cryoablation in the literature.

Clusterin/apolipoprotein J (CLU) is a ubiquitous expressed glycoprotein with cytoprotective properties capable to prevent myocardial injury in experimental studies. We hypothesized that decreasing levels of CLU might be involved in progression of chronic heart failure (HF) and therefore represent a potential biomarker for prognosis in this vulnerable group of patient.We aimed to determine the prognostic value of plasma CLU in patients with HF.Plasma CLU levels were determined in a prospectively recruited cohort comprising 318 patients with chronic HF and validated in a second cohort comprising 346 patients with advanced HF.During a median follow-up time of 3.2 years (interquartile range 2.0-4.9), 119 patients (37.3%) deceased including 83 patients (26.1%), who died from cardiovascular events. CLU was an inverse predictor of mortality with a crude hazard ratio (HR) per increase of 1 standard deviation (1 SD) of 0.75 (95% confidence interval [CI]: 0.62 to 0.9, P = .002) and specifically cardiovascular mortality with an HR per 1 SD of 0.67 (95% CI: 0.53-0.84, P .001). CLU remained significantly associated with cardiovascular mortality after comprehensive adjustment for established HF-related risk factors and potential confounders with an adjusted HR per 1 SD of 0.79 (95% CI: 0.63-0.99, P = .042). Validation in the second cohort yielded similar results and confirmed CLU as independent prognosticator in patients with chronic HF.Our results point toward an ongoing consumption of CLU involved in the complex pathophysiology of HF and suggest CLU as novel and promising biomarker for prognosis in patients with chronic HF.

Voiced speech is the result of a fluid-structure-acoustic interaction in larynx and vocal tract (VT). Previous studies show a strong influence of the VT on this interaction process, but are limited to individually obtained VT geometries. In order to overcome this restriction and to provide a more general VT replica, we computed a simplified, averaged VT geometry for the vowel /a/. The basis for that were MRI-derived cross-sections along the straightened VT centerline of six professional tenors. The resulting mean VT replica, as well as realistic and simplified VT replicas of each tenor were 3D-printed for experiments with silicone vocal folds that show flow-induced oscillations. Our results reveal that all replicas, including the mean VT, reproduce the characteristic formants with mean deviations of 12% when compared with the subjects&rsquo, audio recordings. The overall formant structure neither is impaired by the averaging process, nor by the simplified geometry. Nonetheless, alterations in the broadband, non-harmonic portions of the sound spectrum indicate changed aerodynamic characteristics within the simplified VT. In conclusion, our mean VT replica shows similar formant properties as found in vivo. This indicates that the mean VT geometry is suitable for further investigations of the fluid-structure-acoustic interaction during phonation.