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This study systematically compared duration of untreated illness (DUI) with duration of untreated psychosis (DUP) in prediction of impairment at first-episode psychosis and investigated the extent to which these relationships are influenced by premorbid features. The Cavan-Monaghan First Episode Psychosis Study ascertained cases of first-episode psychosis in rural Ireland via all routes to care with limited variations in socioeconomic milieu. Cases were evaluated for DUI and DUP and assessed clinically for psychopathology, neuropsychology, neurology, insight and quality of life, together with premorbid features. Analyses then determined prediction of clinical assessments by DUI versus DUP. The study population consisted of 163 cases of first episode psychosis, among which 74 had a schizophrenia spectrum disorder. Shorter DUI but not DUP predicted less severe positive and general symptoms, while shorter DUP and particularly DUI predicted less severe negative symptoms; neither shorter DUP nor shorter DUI predicted less severe cognitive impairment or fewer neurological soft signs; shorter DUP and DUI predicted increased quality of life; shorter DUI but not DUP predicted greater insight. Only prediction of quality of life was weakened by consideration of premorbid features. Results were generally similar across the two diagnostic groupings. The present findings systematically delineate associations with DUI versus DUP across domains of impairment in first episode psychosis. They suggest that DUI may reflect a more insidious process than DUP and that reduction in DUI may be associated with more consistent and broader diminutions in impairment than for DUP.

Background Older patients with severe aortic stenosis (AS) are increasingly identified as having cardiac amyloidosis (CA). It is unknown whether concomitant AS-CA has worse outcomes or results in futility of transcatheter aortic valve replacement (TAVR). Objectives This study identified clinical characteristics and outcomes of AS-CA compared with lone AS. Methods Patients who were referred for TAVR at 3 international sites underwent blinded research core laboratory 99mtechnetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy (Perugini grade 0: negative; grades 1 to 3: increasingly positive) before intervention. Transthyretin-CA (ATTR) was diagnosed by DPD and absence of a clonal immunoglobulin, and light-chain CA (AL) was diagnosed via tissue biopsy. National registries captured all-cause mortality. Results A total of 407 patients (age 83.4 ± 6.5 years; 49.8% men) were recruited. DPD was positive in 48 patients (11.8%; grade 1: 3.9% [n = 16]; grade 2/3: 7.9% [n = 32]). AL was diagnosed in 1 patient with grade 1. Patients with grade 2/3 had worse functional capacity, biomarkers (N-terminal pro-brain natriuretic peptide and/or high-sensitivity troponin T), and biventricular remodeling. A clinical score (RAISE) that used left ventricular remodeling (hypertrophy/diastolic dysfunction), age, injury (high-sensitivity troponin T), systemic involvement, and electrical abnormalities (right bundle branch block/low voltages) was developed to predict the presence of AS-CA (area under the curve: 0.86; 95% confidence interval: 0.78 to 0.94; p Conclusions Concomitant pathology of AS-CA is common in older patients with AS and can be predicted clinically. AS-CA has worse clinical presentation and a trend toward worse prognosis, unless treated. Therefore, TAVR should not be withheld in AS-CA.

Objectives The purpose of this study was to validate computed tomography measured ECV (ECVCT) as part of routine evaluation for the detection of cardiac amyloid in patients with aortic stenosis (AS)-amyloid. Background AS-amyloid affects 1 in 7 elderly patients referred for transcatheter aortic valve replacement (TAVR). Bone scintigraphy with exclusion of a plasma cell dyscrasia can diagnose transthyretin-related cardiac amyloid noninvasively, for which novel treatments are emerging. Amyloid interstitial expansion increases the myocardial extracellular volume (ECV). Methods Patients with severe AS underwent bone scintigraphy (Perugini grade 0, negative; Perugini grades 1 to 3, increasingly positive) and routine TAVR evaluation CT imaging with ECVCT using 3- and 5-min post-contrast acquisitions. Twenty non-AS control patients also had ECVCT performed using the 5-min post-contrast acquisition. Results A total of 109 patients (43% male; mean age 86 ± 5 years) with severe AS and 20 control subjects were recruited. Sixteen (15%) had AS-amyloid on bone scintigraphy (grade 1, n = 5; grade 2, n = 11). ECVCT was 32 ± 3%, 34 ± 4%, and 43 ± 6% in Perugini grades 0, 1, and 2, respectively (p Conclusions ECVCT during routine CT TAVR evaluation can reliably detect AS-amyloid, and the measured ECVCT tracks the degree of infiltration. Another measure of interstitial expansion, the voltage/mass ratio, also performed well.

Aims Cardiac amyloidosis is common in elderly patients with aortic stenosis (AS) referred for transcatheter aortic valve implantation (TAVI). We hypothesized that patients with dual aortic stenosis and cardiac amyloid pathology (AS-amyloid) would have different baseline characteristics, periprocedural and mortality outcomes. Methods and results Patients aged ≥75 with severe AS referred for TAVI at two sites underwent blinded bone scintigraphy prior to intervention (Perugini Grade 0 negative, 1–3 increasingly positive). Baseline assessment included echocardiography, electrocardiogram (ECG), blood tests, 6-min walk test, and health questionnaire, with periprocedural complications and mortality follow-up. Two hundred patients were recruited (aged 85 ± 5 years, 50% male). AS-amyloid was found in 26 (13%): 8 Grade 1, 18 Grade 2. AS-amyloid patients were older (88 ± 5 vs. 85 ± 5 years, P = 0.001), with reduced quality of life (EQ-5D-5L 50 vs. 65, P = 0.04). Left ventricular wall thickness was higher (14 mm vs. 13 mm, P = 0.02), ECG voltages lower (Sokolow–Lyon 1.9 ± 0.7 vs. 2.5 ± 0.9 mV, P = 0.03) with lower voltage/mass ratio (0.017 vs. 0.025 mV/g/m2, P = 0.03). High-sensitivity troponin T and N-terminal pro-brain natriuretic peptide were higher (41 vs. 21 ng/L, P Conclusions AS-amyloid is common and differs from lone AS. Transcatheter aortic valve implantation significantly improved outcome in AS-amyloid, while periprocedural complications and mortality were similar to lone AS, suggesting that TAVI should not be denied to patients with AS-amyloid.

Objectives To assess whether single-photon emission computed tomography (SPECT/CT) quantification of bone scintigraphy would improve diagnostic accuracy and offer a means of quantifying amyloid burden. Background Transthyretin-related cardiac amyloidosis is common and can be diagnosed noninvasively using bone scintigraphy; interpretation, however, relies on planar images. SPECT/CT imaging offers 3-dimensional visualization. Methods This was a single-center, retrospective analysis of 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scans reported using the Perugini grading system (0 = negative; 1 to 3 = increasingly positive). Conventional planar quantification techniques (heart/contralateral lung, and heart/whole-body retention ratios) were performed. Heart, adjacent vertebra, paraspinal muscle and liver peak standardized uptake values (SUVpeak) were recorded from SPECT/CT acquisitions. An SUV retention index was also calculated: (cardiac SUVpeak/vertebral SUVpeak) × paraspinal muscle SUVpeak. In a subgroup of patients, SPECT/CT quantification was compared with myocardial extracellular volume quantification by CT imaging (ECVCT). Results A total of 100 DPD scans were analyzed (patient age 84 ± 9 years; 52% male): 40 were Perugini grade 0, 12 were grade 1, 41 were grade 2, and 7 were grade 3. Cardiac SUVpeak increased from grade 0 to grade 2; however, it plateaued between grades 2 and 3 (p, Central Illustration

Cardiac involvement drives prognosis and treatment choices in cardiac amyloidosis. Echocardiography is the first-line examination for patients presenting with heart failure, and it is the imaging modality that most often raises the suspicion of cardiac amyloidosis. Echocardiography can provide an assessment of the likelihood of cardiac amyloid infiltration versus other hypertrophic phenocopies and can assess the severity of cardiac involvement. Visualizing myocardial amyloid infiltration is challenging and, until recently, was restricted to the domain of the pathologist. Two tests are transforming this: cardiac magnetic resonance (CMR) imaging and bone scintigraphy. After the administration of contrast, CMR is highly sensitive and specific for the 2 main types of ventricular myocardial amyloidosis, light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR). CMR structural and functional assessment combined with tissue characterization can redefine cardiac involvement by tracking different disease processes, ranging from amyloid infiltration, to the myocardial response associated with amyloid deposition, through the visualization and quantification of myocardial edema and myocyte response. Bone scintigraphy (paired with exclusion of serum free light chains) is emerging as the technique of choice for distinguishing ATTR from light chain cardiac amyloidosis and other cardiomyopathies; it has transformed the diagnostic pathway for ATTR, allowing noninvasive diagnosis of ATTR without the need for a tissue biopsy in the majority of patients. CMR with tissue characterization and bone scintigraphy are rewriting disease understanding, classification, and definition, and leading to a change in patient care.

ObjectiveThe coexistence of wild-type transthyretin cardiac amyloidosis (ATTR) is common in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). However, the impact of ATTR and AS on the resultant AS-ATTR is unclear and poses diagnostic and management challenges. We therefore used a multicohort approach to evaluate myocardial structure, function, stress and damage by assessing age-related, afterload-related and amyloid-related remodelling on the resultant AS-ATTR phenotype.MethodsWe compared four samples (n=583): 359 patients with AS, 107 with ATTR (97% Perugini grade 2), 36 with AS-ATTR (92% Perugini grade 2) and 81 age-matched and ethnicity-matched controls. 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy was used to diagnose amyloidosis (Perugini grade 1 was excluded). The primary end-point was NT-pro Brain Natriuretic Peptide (BNP) and secondary end-points related to myocardial structure, function and damage.ResultsCompared with older age controls, the three disease cohorts had greater cardiac remodelling, worse function and elevated NT-proBNP/high-sensitivity Troponin-T (hsTnT). NT-proBNP was higher in AS-ATTR (2844 (1745, 4635) ng/dL) compared with AS (1294 (1077, 1554)ng/dL; p=0.002) and not significantly different to ATTR (3272 (2552, 4197) ng/dL; p=0.63). Diastology, hsTnT and prevalence of carpal tunnel syndrome were statistically similar between AS-ATTR and ATTR and higher than AS. The left ventricular mass indexed in AS-ATTR was lower than ATTR (139 (112, 167) vs 180 (167, 194) g; p=0.013) and non-significantly different to AS (120 (109, 130) g; p=0.179).ConclusionsThe AS-ATTR phenotype likely reflects an early stage of amyloid infiltration, but the combined insult resembles ATTR. Even after treatment of AS, ATTR-specific therapy is therefore likely to be beneficial.

Infective endocarditis (ie, the infection of a native or prosthetic heart valve, the endocardium or implanted cardiac device1) is a clinical chameleon whose epidemiology and natural history are in constant evolution, reflecting the complex interaction between an ageing population, elusive microorganisms, evolving patterns of healthcare, available therapies and the application of aggressive surgery. Despite overall advances in treatment, there is no consistent signal of falling incidence and clinical outcomes remain poor. IE is uncommon with a generally accepted overall annual incidence of 3–10 cases per 100 000 people.1 However, recent data indicate that this incidence has increased significantly in England where IE admissions (primary ICD-10 diagnostic code I33) remained stable between 1998–1999 (26.6 cases/million) and 2009–2010 (26.9 cases/million) but rose dramatically (by 86%) to 50.0 cases/million in 2018–2019 (figure 1).2 While some of this increase may partly relate to recommendations by the National Institute for Health and Care Excellence in 2008 regarding the cessation of antibiotic prophylaxis in at-risk individuals undergoing selected dental and other invasive medical procedures,3 this association cannot be confirmed in the absence of microbiological data. Indeed, multiple contributory factors are likely, including (A) an ageing population, (B) increased use of both intra-cardiac (including permanent pacemakers, implantable cardioverter-defibrillators, surgical and transcatheter heart valves) and vascular devices (including those used for chronic haemodialysis), (C) epidemic levels of opioid addiction and associated injection drug use, (D) emergence of staphylococci and enterococci (neither of which are targeted by current antibiotic prophylaxis strategies) as more common causative organisms, and (E) greater clinical awareness of IE. Nevertheless, these findings are disturbing and contrast with reports of falling incidence in the USA4 and falling or more modest increases in Europe.5 European guidelines …

Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Background Myocardial extracellular volume (ECV) increases with fibrosis, oedema or infiltration. ECV by CMR predicts all-cause and cardiovascular mortality in severe AS after valve intervention. Previous studies have shown that ECV can be reliably quantified by computed tomography (ECVCT), but these studies have not differentiated between ECV elevation due to fibrosis or cardiac amyloid deposition (13-16% of patients with severe AS). Purpose We hypothesised that ECVCT quantification, performed as part of a transcatheter aortic valve implantation (TAVI) work-up CT, predicts survival in patients with severe AS without cardiac amyloid (lone AS). Methods Patients aged ≥75, with severe AS, referred for TAVI at Barts Heart Centre (as part of ATTRact-AS (NCT03029026)) underwent CT as part of their clinical work-up. All patients had 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy and those with a positive result were excluded. CT was performed on a 128-slice dual-source 3rdgeneration scanner (Siemens Somatom FORCE) and ECVCT was acquired during the TAVI work-up CT using additional pre- and 3-minute post-contrast ‘axial shuttle mode’ acquisitions (no additional contrast). ECVCT was calculated from the Hounsfield units (HU) and a venous haematocrit (HCT): ECVCT = (1-HCT) x (ΔHUmyo/ΔHUblood). Results Following exclusion of 16 patients with cardiac uptake on DPD, 93 patients (41% male, aged 85 ± 5 years) were included in the study. All patients had severe AS (AV Vmax 4.12 ± 0.63m/s, mean AV gradient 42 ± 14mmHg, AVA 0.71 ± 0.23cm2). The mean HCT was 0.38 ± 0.04 and total dose-length product for additional research scans was 364 ± 41 mGy.cm. 76 patients (82%) underwent TAVI. ECVCT was 32 ± 3% in the entire cohort, which we then split into those with a ‘higher’ ECVCT (>34%, n = 23, representing the highest quartile) and those with a ‘lower’ ECVCT (≤34%, n = 70, representing the lower quartiles). Over a median follow-up of 25 months (IQR 17-34 months) there were 27 deaths (29%), of whom 11 did not undergo TAVI (41%). There were 10 deaths in the 23 patients (44%) with a higher ECVCT, compared to 17 in the 70 patients (24%) with a lower ECVCT (p = 0.03, figure 1). This mortality difference remained significant when those patients who did not undergo TAVI were excluded (p = 0.03). Conclusions Myocardial fibrosis quantified by ECVCT is associated with a significantly worse prognosis in lone AS, even after patients with AS-amyloid are excluded. ECVCT can be performed as a simple addition to the TAVI work-up CT and provides additional prognostic information. Abstract Figure.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation Barts Cardiovascular Biomedical Research Centre onbehalf The Marathon Study Consortium Introduction Cardiovascular function depends on the inter-relation between heart and vasculature. The contribution of aorta and peripheral vessels to the total systolic load of the left ventricle (LV) can be represented respectively by a "pulsatile" and a "resistive" component. We sought to understand their interrelation by exploring how LV remodelling occurred with altered load associated with an external stimulus (training). Methods: 237 untrained healthy male and female subjects volunteering for their first-time marathon were recruited. At baseline and after 6 months of unsupervised training, race completers underwent 1.5T cardiac magnetic resonance, brachial and non-invasive central blood pressure assessment. For analysis, runners were divided into 4 groups according to the variation (positive versus null or negative) in Total Arterial Compliance Index (TACi), representing the pulsatile component of the LV load, and in Systemic Vascular Resistance Index (SVRI), representing the resistive component of the LV load. Results: 138runners (age 21-69 years; F: 51%) completed the race. Data are reported for each variable as Δ mean [95% Confidence Interval]. In the whole cohort, training was associated with a small increase in LV mass index (+3g/m2, [0, 6 g/m2]), indexed LV end-diastolic volume (EDVi) (+3ml/m2, [-2, 5 3ml/m2]), in LV mass/LVEDV ratio (+0.02g/ml, [0.00, 0.04 g/ml]) and in TACi (+0.02ml/m2, [0.02, 0.38 ml/m2]). SVRi mildly fell (-43dyn·s/cm2[-103, 17dyn·s/cm2]). TACi increase was associated with LVEDVi increase and no change in LV mass/EDV (eccentric remodelling). On the other hand, both TACi reduction and SVRi increase were associated with increase in LV mass/EDV and no significant change in LVEDVi (concentric remodelling). A similar increase in LV mass was observed in all groups. See Table. Conclusion: Cardiac remodelling observed after mild, medium term, unsupervised training seems to be related to the modifications of aorta and peripheral vessels. In particular, a reduction in pulsatile load seems associated with eccentric LV remodelling, while an increase in both pulsatile and resistive with concentric LV remodelling. Further research is needed to understand the interaction between TACi and SVRi. Table 1 LV EDVi (ml/m2) LV mass index (g/m2) LV mass/EDV TACi increase (n = 75) +4 [0, 9] +3 [0, 7] 0 [-0.03, 0.03] TACi decrease (n = 62) -1 [-6, 4] +3 [0, 8] 0.04 [0.01, 0.07] SVRi increase (n = 63) 0 [-4,4] +3 [0, 7] +0.03 [0, 0.06] SVRi decrease (n = 73) +3 [-3, 7] +3 [-1, 6] +0.01 [-0.02, 0.04]

Background: Measurement of myocardial T1 is increasingly incorporated into standard cardiovascular magnetic resonance (CMR) protocols, however accuracy may be reduced in patients with metallic cardiovascular implants. Measurement is feasible in segments free from visual artifact, but there may still be off-resonance induced error.Aim: To quantify off-resonance induced T1 error in patients with metallic cardiovascular implants, and validate a method for error correction for a conventional MOLLI pulse sequence.Methods: Twenty-four patients with cardiac implantable electronic devices (CIEDs: 46% permanent pacemakers, PPMs; 33% implantable loop recorders, ILRs; and 21% implantable cardioverter-defibrillators, ICDs); and 31 patients with aortic valve replacement (AVR) (45% metallic) were studied. Paired mid-myocardial short-axis MOLLI and single breath-hold off-resonance field maps were acquired at 1.5 T. T1 values were measured by AHA segment, and segments with visual artifact were excluded. T1 correction was applied using a published relationship between off-resonance and T1. The accuracy of the correction was assessed in 10 healthy volunteers by measuring T1 before and after external placement of an ICD generator next to the chest to generate off-resonance.Results: T1 values in healthy volunteers with an ICD were underestimated compared to without (967 ± 52 vs. 997 ± 26 ms respectively, p = 0.0001), but were similar after correction (p = 0.57, residual difference 2 ± 27 ms). Artifact was visible in 4 ± 12, 42 ± 31, and 53 ± 27% of AHA segments in patients with ILRs, PPMs, and ICDs, respectively. In segments without artifact, T1 was underestimated by 63 ms (interquartile range: 7–143) per patient. The greatest error for patients with ILRs, PPMs and ICDs were 79, 146, and 191 ms, respectively. The presence of an AVR did not generate T1 error.Conclusion: Even when there is no visual artifact, there is error in T1 in patients with CIEDs, but not AVRs. Off-resonance field map acquisition can detect error in measured T1, and a correction can be applied to quantify T1 MOLLI accurately.

Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart Foundation onbehalf AS-Amyloidosis consortium Background The coexistence of severe aortic stenosis (lone AS) and transthyretin cardiac amyloidosis (lone amyloidosis) is common, but the resultant AS-amyloidosis phenotype is unclear. Purpose We characterised AS-amyloidosis, hypothesizing that the dual insult of AS-amyloidosis results is a severe phenotype. Methods We compared four cohorts with deep phenotyping: 81 older age controls, 359 lone AS, 36 AS-amyloidosis (Perugini grade 2 and 3) and 107 lone amyloidosis (Perugini grade 2 and 3). Results AS-amyloidosis was similar to lone AS with respect to left ventricular mass and LVEF (57 (45, 64)%). It was similar to lone amyloidosis with respect to lateral S" (0.04 (0.03, 0.06) m/s), NT-proBNP (4149 (1449, 6459) ng/L) and troponin T (56 (34, 100) ng/L). Whilst, prevalence of carpal tunnel syndrome (CTS) (17%) and diastolic function (E/A ratio 1.1 (0.8, 2.8)) were intermediate. Conclusion AS-amyloidosis is not a double insult from AS and amyloidosis, but a mixed phenotype with features similar to lone amyloidosis (cardiac biomarkers), lone AS (remodelling and LVEF) or intermediate (diastology and CTS). Characteristics across all 4 groups Variable Older age controls (n = 81) Lone AS (n = 359) AS-amyloidosis (n = 36) Lone amyloidosis (n = 107) P value Age (years) 82 (80, 84)*†‡ 85 (80, 88)§∞ 88 (85, 92)# 80 (75, 84)

Background: Elderly patients with severe aortic stenosis (AS) are increasingly diagnosed with cardiac amyloidosis (CA). It is unclear whether dual AS-CA has worse outcomes or may even result in futility of transcatheter aortic valve replacement (TAVR). Objective: To identify diagnostic predictors and outcomes of AS-CA compared to lone AS. Methods: Severe AS TAVR referrals at three international sites underwent clinical and laboratory assessment, six-minute walk test, ECG, transthoracic echocardiography with strain analysis, and blinded research 99mTc-DPD bone scintigraphy (Perugini Grade-0 negative, 1-3 increasingly positive) prior to intervention. Transthyretin CA (ATTR) was diagnosed by bone scintigraphy, unremarkable serum/urine free light chain assessment; light-chain CA (AL) was diagnosis by endomyocardial biopsy. All-cause mortality was captured from national registries. Results: 408 patients (age 83.4±6.5 years, 49.8% male) were recruited. DPD bone scintigraphy was positive in 11.6% (n=47, Grade-1 3.7%[15]) Grade-2/3 7.9%[32]). Positivity was associated with QRS duration (OR 2.5, 95%CI 1.1-5.5, p=0.02), voltage/mass-ratio (OR 0.4, 95%CI 0.2-0.9, p=0.02), history of carpal tunnel syndrome (OR 1.6, 95%CI 1.1-2.3, p=0.02). An additional two cases had biopsy proven AL-CA. Heart Team decision (blinded to bone scintigraphy) resulted in TAVR in 333 (81.6%), surgical aortic valve replacement in 10 (2.5%) and medical management in 65 (15.9%). After a median of 1.7 years, 22.9% of patients had died. AS-CA had a worse 1-year mortality than lone AS (24.5 vs 13.9%, p=0.045, Figure 1A), but there was no difference post valve intervention (p=0.7), which improved outcomes in both lone AS and AS-CA compared to medical management (Figure 1B+C). Discussion: Dual pathology of AS-CA is common in elderly AS patients. AS-CA is prognostically slightly worse than lone AS, but not if treated by valve intervention. Based on this data, TAVR should not be witheld in AS-CA.

Coronavirus disease 2019 (COVID-19) is a debilitating viral infection and, to date, 628,903 people have died from it, numbers that cannot yet be compared to the 50 million who died in the 1918 flu pandemic. As COVID-19 became better understood, cardiovascular manifestations associated with it were identified. This led to a complete healthcare restructuring with virtual clinics and changes to the triaging of critically ill patients. There are a lot of questions over how COVID-19 affects patients with heart failure (HF) as this condition is a leading cause of cardiovascular death. This review describes the cardiovascular implications of COVID-19 and new practices surrounding the use of telehealth to follow up and triage patients with HF. Current practices supported by medical societies, the role of angiotensin-converting enzyme inhibitors and, finally, a brief note regarding the management of advanced HF patients will also be discussed.

Background Wave intensity analysis (WIA) in the aorta offers important clinical and mechanistic insight into ventriculo-arterial coupling, but is difficult to measure non-invasively. We performed WIA by combining standard cardiovascular magnetic resonance (CMR) flow-velocity and non-invasive central blood pressure (cBP) waveforms. Methods and results Two hundred and six healthy volunteers (age range 21–73 years, 47% male) underwent sequential phase contrast CMR (Siemens Aera 1.5 T, 1.97 × 1.77 mm2, 9.2 ms temporal resolution) and supra-systolic oscillometric cBP measurement (200 Hz). Velocity (U) and central pressure (P) waveforms were aligned using the waveform foot, and local wave speed was calculated both from the PU-loop (c) and the sum of squares method (cSS). These were compared with CMR transit time derived aortic arch pulse wave velocity (PWVtt). Associations were examined using multivariable regression. The peak intensity of the initial compression wave, backward compression wave, and forward decompression wave were 69.5 ± 28, −6.6 ± 4.2, and 6.2 ± 2.5 × 104 W/m2/cycle2, respectively; reflection index was 0.10 ± 0.06. PWVtt correlated with c or cSS (r = 0.60 and 0.68, respectively, P Conclusion This novel non-invasive technique permits straightforward measurement of wave intensity at scale. Local wave speed showed good agreement with PWVtt, and correlation was stronger using the cSS than the PU-loop. Ageing and female sex were associated with poorer ventriculo-arterial coupling in healthy individuals.

BackgroundPregnancy in women with type 1 diabetes mellitus (T1DM) is associated with an increased risk of congenital malformations, obstetric complications and neonatal morbidity. This study aims to investigate maternal, perinatal and neonatal outcomes of pregnancies in women with onset of T1DM less than 18 years of age.MethodsThis retrospective cohort study extracted data regarding prenatal, intrapartum and postnatal outcomes of pregnancies in women with onset of T1DMResultsSeventeen women with onset of T1DM ConclusionThe high prevalence of unplanned pregnancy and poor uptake of prepregnancy care must be improved on in order to improve outcomes for this high-risk group.

Aims: Marathon running is a popular ambition in modern societies inclusive of non-athletes. Previous studies have highlighted concerning transient myocardial dysfunction and biomarker release immediately after the race. Whether this method of increasing physical activity is beneficial or harmful remains a matter of debate. We examine in detail the real-world cardiovascular remodeling response following competition in a first marathon. Methods: Sixty-eight novice marathon runners (36 men and 32 women) aged 30 ± 3 years were investigated 6 months before and 2 weeks after the 2016 London Marathon race in a prospective observational study. Evaluation included electrocardiography, cardiopulmonary exercise testing, echocardiography, and cardiovascular magnetic resonance imaging. Results: After 17 weeks unsupervised marathon training, runners revealed a symmetrical, eccentric remodeling response with 3-5% increases in left and right ventricular cavity sizes, respectively. Blood pressure (BP) fell by 4/2 mmHg (P < 0.01) with reduction in arterial stiffness, despite only 11% demonstrating a clinically meaningful improvement in peak oxygen consumption with an overall non-significant 0.4 ml/min/kg increase in peak oxygen consumption (P = 0.14). Conclusion: In the absence of supervised training, exercise-induced cardiovascular remodeling in real-world novice marathon runners is more modest than previously described and occurs even without improvement in cardiorespiratory fitness. The responses are similar in men and women, who experience a beneficial BP reduction and no evidence of myocardial fibrosis or persistent edema, when achieving average finishing times.

Aims Remodelling of the cardiovascular system (including heart and vasculature) is a dynamic process influenced by multiple physiological and pathological factors. We sought to understand whether remodelling in response to a stimulus, exercise training, altered with healthy ageing. Methods A total of 237 untrained healthy male and female subjects volunteering for their first time marathon were recruited. At baseline and after 6 months of unsupervised training, race completers underwent tests including 1.5T cardiac magnetic resonance, brachial and non-invasive central blood pressure assessment. For analysis, runners were divided by age into under or over 35 years (U35, O35). Results Injury and completion rates were similar among the groups; 138 runners (U35: n = 71, women 49%; O35: n = 67, women 51%) completed the race. On average, U35 were faster by 37 minutes (12%). Training induced a small increase in left ventricular mass in both groups (3 g/m2, P Conclusion Medium-term, unsupervised physical training in healthy sedentary individuals induces measurable remodelling of both heart and vasculature. This amount is age dependent, with predominant cardiac remodelling when younger and predominantly vascular remodelling when older.

BackgroundResearch on psychotic illness is loosening emphasis on diagnostic stringency in favour of including a more dimensionally based conceptualization of psychopathology and pathobiology. However, to clarify these notions requires investigation of the full scope of psychotic diagnoses.MethodsThe Cavan–Monaghan First Episode Psychosis Study ascertained cases of first episode psychosis across all 12 DSM-IV psychotic diagnoses via all routes to care: public, private or forensic; home-based, outpatient or inpatient. There was no arbitrary upper age cut-off and minimal impact of factors associated with variations in social milieu, ethnicity or urbanicity. Cases were evaluated epidemiologically and assessed for psychopathology, neuropsychology, neurology, antecedent factors, insight and quality of life.ResultsAmong 432 cases, the annual incidence of any DSM-IV psychotic diagnosis was 34.1/100 000 of population and encompassed functional psychotic diagnoses, substance-induced psychopathology and psychopathology due to general medical conditions, through to psychotic illness that defied contemporary diagnostic algorithms. These 12 DSM-IV diagnostic categories, including psychotic disorder not otherwise specified, showed clinical profiles that were consistently more similar than distinct.ConclusionsThere are considerable similarities and overlaps across a broad range of diagnostic categories in the absence of robust discontinuities between them. Thus, psychotic illness may be of such continuity that it cannot be fully captured by operational diagnostic algorithms that, at least in part, assume discontinuities. This may reflect the impact of diverse factors each of which acts on one or more overlapping components of a common, dysfunctional neuronal network implicated in the pathobiology of psychotic illness.

Aims Exercise and physical activity is an important component of a healthy lifestyle in all individuals with T1DM. However, despite efforts to promote an active lifestyle, a significant proportion of children with diabetes remain inactive and do not reach the recommended guidelines for exercise and physical activity. The aim of the current study was to examine barriers to undertaking physical activity in young people with T1DM. Methods The study was a regional level observational clinical one within the University Hospital Limerick T1DM outpatient clinic, focusing on the perceived barriers to exercise and physical activity using the modified Barriers to physical activity in patient with Diabetes type 1 (BAPAD1) questionnaire. Questionnaires were completed between June and August 2018 and analysed using SPSS statistical software. Results 55 children completed the survey. 55% of respondents were female and age range was from 5–17 years, with all respondents been diagnosed a minimum of 2 years previously. 5% of respondents felt that having diabetes was a barrier to undertaking physical activity. Half of respondents stated that the risk of hypoglycaemia would be likely or very likely to be a barrier to undertaking physical activity. 29% of respondents said that loss of control of their diabetes was not a barrier to undertaking physical activity. About 30% of respondents felt that the risk of hyperglycaemia was a barrier to undertaking physical activity. 15% of respondents felt that their school schedule was a barrier to undertaking physical activity. Conclusion The results from this study show that a high proportion of children felt that having T1DM was not a barrier to physical activity. The risk of hypoglycaemia was a significant barrier to activity. Future work should focus on addressing these barriers in more detail and the creation of guidance documents regarding overcoming such barriers.

Aims T1DM is one of the most prevalent chronic health conditions in youth with a rising incidence. Management regimes are often complex and demanding, being a source of significant stress for children and their families. The aim of this current study was to examine quality of life dimensions amongst young people with T1DM. Methods The study was a regional level observational study within the University Hospital Limerick T1DM outpatient clinic, focusing on Quality of life dimensions measured using KIDSCREEN generic quality of life measures, a project funded by the European Commission. Questionnaires were completed between June and August 2018 and analysed using SPSS statistical software. Results 55 children completed the survey. 55% of respondents were female and age range was from 5 – 17 years, with all respondents being diagnosed a minimum of 2 years previously. 92% of respondents stated that their general level of health was good, very good or excellent, with two-thirds being either very or extremely fit and well. 90% of respondents stated that life has been either very or extremely enjoyable with about 15% saying they were quiet often or very often sad. 85% of respondents stated that they would not change anything about their body. Over three-quarters stated that they were always or very often able to do the things they wanted to do. Over 80% of respondents felt that their parents were very or extremely understanding with 96% feeling very or extremely loved. Over 80% of respondents were very or extremely happy at school with 5% stated that they felt quite often bullied by other girls and boys. Conclusion The results from this study show that despite the diagnosis and implications regarding T1DM, the children interviewed showed a high level of positivity and enthusiasm regarding home and school life as well as undertaking activities.

Aims A physically active lifestyle helps with managing diabetes by improving cardiovascular fitness, increasing insulin sensitivity, improving school performance, cognition, and enhancing quality of life. However, despite efforts to promote an active lifestyle, a significant proportion of children with T1DM remain inactive. The aim of this study was to examine exercise and activities undertaken by young people with T1DM. Methods The study was a regional level observational clinical trial within the University Hospital Limerick T1DM outpatient clinic, focusing on self-reporting of activity using the Children’s sport participation and physical activity study (CSPPA) questionnaire. Questionnaires were completed between June and August 2018 and analysed using SPSS statistical software. Results 55 children completed the survey. 55% of respondents were female and age range was from 5 – 17 years, with all respondents being diagnosed a minimum of 2 years previously. 64% of respondents were based in a rural location. Almost two-thirds of respondents undertook between 60 and 180 min of physical activity per weekday. 83% of respondents watched television with one-third watching daily. 57% of respondents used computers with two-thirds daily. 20% of respondents used a mobile phone with one-third using daily. 83% of respondents travelled to school by car or bus with two-thirds living within 5k of school. The most common reason for using a car or bus was for road safety reasons with only 4% stating becoming hypoglycaemic was an issue. Conclusion The results from this study show that there was a variable level of activity amongst children with T1DM. The majority watched television on a daily basis while most were transported to school on the basis of road safety. Future work in this area should be to further promote undertaking activity, including the provision of schemes to help promote activities such as walking or cycling to school.

Introduction Childhood obesity is a major risk factor for developing metabolic syndromes, with these patients five times as likely to develop type 2 diabetes compared to those without metabolic syndromes. Significant contributors to obesity include decreased physical activity, poor diet, and sedentary behaviours, especially television viewing. Current guidelines recommend no more than 2-hours non-educational screen-time per day. Aims Examining parental knowledge regarding food-types on children’s programming and ascertain self-reporting of television viewing and parental concerns regarding nutritional influence of television. Methods Cross-sectional survey on parents of children aged 4–16 years old, presenting to University Hospital Limerick, October-April,2018. Surveys regarding demographics, television viewing, perceptions of television portrayal of nutrition. Data analysed on SPSS. Results Sixty parents completed the surveys with 15% reporting their children watched over 2 hours of television during weekdays, increasing 35% during weekends. Whilst the majority(55%) reported sweet snacks the most commonly depicted on television. 10% of children always watched television during meals with half of children regularly watching television during meals. 80% of parents admitted concern regarding advertising of unhealthy foods with 85% doubting the advertising industry would protect children. 75% of parents were concerned regarding children nutrition, with various concerns expressed. Conclusions Results showed high level of concern regarding advertising and children eating habits. Overall results showed significant proportion of children spending greater than the recommended time watching television, with a significant portrayal of unhealthy food types during this period. Future work in this area should fully explore the influence of screen time on food choice and nutritional intake of children.

Introduction Childhood obesity is a risk factor for developing metabolic syndromes, with these patients five times as likely to develop type 2 diabetes compared to those without metabolic syndromes. Significant contributors to obesity include decreased physical activity, poor diet, and sedentary behaviours, especially television viewing. Current guidelines recommend no more than 2-hours non-educational screen-time per day. Aims Examining parental knowledge regarding exercise guidelines, the portrayal of exercise on television and to ascertain self-reporting of physical activity and any relevant barriers. Methods Cross-sectional survey on parents of children aged 4–16 years old, presenting to University Hospital Limerick, October-April,2018. Surveys regarding television viewing and perceptions of television portrayal of exercise. Data analysed on SPSS. Results Sixty parents completed the surveys and the majority of were aware that 60 minutes is the recommended guideline (50%), despite a wide answer range (20–240 min). Most parents believed dancing was the most common exercise depicted on television (40%). 60% of children met activity guidelines during weekdays, with this increasing to 75% at weekends. Two-thirds of parents surveyed were not concerned regarding their child’s activity levels. Commonly reported barriers to exercise were time involved and cost. Conclusions Results showed parents were aware of physical activity guidelines and of exercise portrayal on television. Self-reporting indicated two-thirds of children were meeting minimum recommended activity guidelines during the week. Results show that despite parental knowledge regarding guidelines, many children do not meet recommendations, which is associated with increased sedentary television viewing. Future work in this area should fully explore mechanisms underpinning reduced activity and relevant interventions.

Background Pregnancy in women with type 1 diabetes mellitus is associated with an increased risk of congenital malformations, obstetric complications, and neonatal morbidity. In order to minimise morbidity for both mothers and infants there needs to be good interdisciplinary care between diabetologists, obstetricians, neonatologists and relevant nursing specialists. Aim To investigate maternal, perinatal, and neonatal outcomes of pregnancies in women with type 1 diabetes in the University Maternity Hospital Limerick, Ireland. Methods This retrospective descriptive study was conducted from charts identified from the diabetes in pregnancy register from 1st July 2007 to 1st July 2017 at University Maternity Hospital Limerick. Results 17 women were identified from the register with juvenile onset ( Conclusion Neonates born to mothers with juvenile onset T1DM should be considered a high risk group and clinicians should have a low threshold for admission to the neonatal unit.

Childhood obesity is complex and multifactorial with significant short-term morbidity and long-term morbidity and mortality. It is now considered that successful long-term management of this condition will require a multifaceted approach with a significant translational component and involvement of governmental and nongovernmental agencies, policy makers, and the commitment of the media, community groups, and families. In this chapter, approaches to the management of childhood obesity are examined in relation to eight thematic clusters of obesity. We examine what is currently known and unknown in relation to a number of contributing factors and evaluate a variety of interventions from behavioral changes to policy-maker contributions as a means to address current levels of obesity to halt progression of this growing epidemic. Throughout the chapter, a number of gaps in our current level of knowledge are highlighted as areas of current research and directions required for further investigation that will further our overall knowledge base of this growing problem. The future of childhood obesity includes improvements in clinical care, accelerated research efforts, careful monitoring of the prevalence of obesity, and integrated thinking among the various parties involved to overcome the current approaches which, to date, have been unsuccessful.

Background: Clozapine is the prototype atypical antipsychotic used for treatment-resistant schizophrenia, but its use has been limited by the well-established association with agranulocytosis. An increased risk of other serious adverse events such as myocarditis and thromboembolism has also been suggested to be associated with clozapine therapy.Aims: We describe an Irish case of multiple pulmonary emboli detected by CT pulmonary angiogram thought to be secondary to clozapine therapy.Conclusion: Although clozapine is a very efficacious antipsychotic its many side-effects limit its use. Pulmonary embolism must be remembered as a potential rare side-effect in clozapine therapy. Underlying mechanisms are still unclear although several have been proposed.

Paul Scully,1 Orlaith Reid,1 Alan P Macken,1–3 Mark Healy,4 Jean Saunders,4 Des Leddin,3,5 Walter Cullen,3 Colum P Dunne,3 Clodagh S O’Gorman1–3,5 1The Children’s Ark, University Hospital Limerick, Limerick, 2National Children’s Research Centre, Dublin, 3Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, 4C-Star, University of Limerick, Limerick, Ireland; 5Department of Medicine, Dalhousie University, Halifax, Canada Background: Television watching is obesogenic due to its sedentary nature and programming content, which influences children. Few studies have examined exercise placement within children-specific programming. This study aimed to investigate the frequency and type of exercise placement in children-specific television broadcasts and to compare placements on the UK and Irish television channels.Methods: Content analysis for five weekdays’ worth of children-specific television broadcasting totaling 82.5hours on both the UK (British Broadcasting Corporation) and Irish (Radió Teilifís Éireann) television channels was performed. For the purposes of comparing the UK and Irish placements, analysis was restricted to programming broadcast between 6 am and 11.30 am. Exercise placements were coded based on type of activity, activity context, activity motivating factors and outcome, and characters involved.Results: A total of 780 cues were recorded during the total recording period. A wide variety of sports were depicted, but dancing-related cues were most commonly seen (n=163, 23.3%), with the majority of cues being of mild (n=365, 65.9%) or moderate (n=172, 31.0%) intensity. The majority of cues were associated with a positive outcome (n=404, 61.4%), and social motivations were most commonly seen (n=289, 30.3%). The Irish and the UK portrayals were broadly similar.Conclusion: This study highlights the wide variety of sports portrayed and the active effort undertaken by television stations to depict physical exercise and recreation in a positive light. Keywords: television, exercise, children, obesity

Health information has a major role in the planning of future healthcare provision. With current reconfiguration and cost saving measures, further demands are being placed on acute hospitals. To examine the elderly admissions and the referral documentation of older patients admitted to a tertiary level hospital. A retrospective analysis of primary care referral documentation for all acute admissions of patients over 75 years to University Hospital Limerick (UHL) over a 2-month period. Documentation was analysed on the basis of patient demographics, presenting complaint and referral source. Primary care referral documentation was then analysed on the basis of presenting complaint, patient demographics, referrer details, and the clinical information provided. Over the 2-month period there were a total of 381 elderly admissions through the Emergency department. The most common presenting complaint was with shortness of breath (21.5 %). 42.5 % of admissions were from a primary care setting. 31.1 % of referrals were typed and 47.0 % handwritten. Over 90 % of referrals contained the patient’s name, date of birth and address. 98.7 % of referrals included a presenting complaint and 54 % included a past medical history. 20 % of referrals listed known drug allergies, while 9.3 % documented social history or baseline functional status. Referral letters from general practice and after-hour services were largely similar. Almost all primary care referrals included the required details as per recent HIQA guidelines. The further inclusion of optional information relating to patient social or functional status, which are of particular relevance to the older population may help patient management.

Supplemental Digital Content is available in the text., Background: Aortic stenosis is accompanied by progressive left ventricular hypertrophy and fibrosis. We investigated the natural history of these processes in asymptomatic patients and their potential reversal post-aortic valve replacement (AVR). Methods: Asymptomatic and symptomatic patients with aortic stenosis underwent repeat echocardiography and magnetic resonance imaging. Changes in peak aortic-jet velocity, left ventricular mass index, diffuse fibrosis (indexed extracellular volume), and replacement fibrosis (late gadolinium enhancement [LGE]) were quantified. Results: In 61 asymptomatic patients (43% mild, 34% moderate, and 23% severe aortic stenosis), significant increases in peak aortic-jet velocity, left ventricular mass index, indexed extracellular volume, and LGE mass were observed after 2.1±0.7 years, with the most rapid progression observed in patients with most severe stenosis. Patients with baseline midwall LGE (n=16 [26%]; LGE mass, 2.5 g [0.8–4.8 g]) demonstrated particularly rapid increases in scar burden (78% [50%–158%] increase in LGE mass per year). In 38 symptomatic patients (age, 66±8 years; 76% men) who underwent AVR, there was a 19% (11%–25%) reduction in left ventricular mass index (P

Introduction 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy offers a sensitive, non-invasive test for cardiac transthyretin amyloid. The Perugini grading system relies on a visual score of the planar image – from grade 0 (negative) to 3 (strongly positive). SPECT allows the 3D visualisation of radioactivity within the body. SPECT/CT quantification may improve diagnostic accuracy and offer a means of measuring amyloid burden. Methods The software algorithm (Hermes Medical) converts recorded counts per voxel into activity per unit volume, enabling quantitative reconstructions and display of standardised uptake values (SUV). Volumes of interest were placed over the heart, adjacent vertebra, paraspinal muscle and liver and peak SUV (SUVpeak) recorded. P-values were calculated using a one-way ANOVA. Results We identified 32 patients (aged 82±9 years, 59% male), with a range of DPD results (10 grade 0, 6 grade 1, 12 grade 2, 4 grade 3). Cardiac SUVpeak increased from Perugini grade 0 to 2, but plateaued at 3 (1.39±0.47 vs 3.82±1.66 vs 12.89±4.39 vs 10.79±1.12; p Vertebral SUVpeak decreased from Perugini grade 0 to 3 (11.75±3.79 vs 9.60±2.28 vs 8.34±2.25 vs 5.85±1.53; p Conclusion SPECT/CT quantification in DPD scintigraphy has diagnostic and discriminatory power. Competition for tracer between skeletal muscle and the heart in grade 3 cases may confound quantification of cardiac amyloid burden.

Introduction Exercise training has beneficial effects on blood pressure (BP), however the physiological mechanisms remain unclear, and the impact on regional aortic haemodynamics is unexplored. We studied the effects of exercise training on central BP (cBP) and regional aortic stiffness using cardiovascular magnetic resonance (CMR). Methods Untrained healthy volunteers were recruited prior to starting an exercise training programme for the London Marathon. Assessment pre-training and up to three weeks post-marathon included cBP; anthropometry, maximum oxygen consumption (VO2max) and CMR. Phase contrast imaging (1.97×1.77 mm2, 9.24 ms temporal resolution) at the pulmonary artery and diaphragm levels was used to calculate regional aortic distensibility and pulse wave velocity (PWV). Data are means (95% confidence intervals). Results 136 marathon finishers (median age 34 (range 21–69 years), 49% male) were studied. Following exercise training, cBP reduced by 4.2 (2.6, 5.9)/2.6 (1.6, 3.5) mmHg and heart rate by 2.4 (0.3, 4.3) min-1. Total aortic PWV reduced by −0.21 (-0.01,–0.42) m/s and proximal descending aortic distensibility increased by 0.83 (0.2, 1.46) 10–3 mmHg-1. Older age and higher baseline BP (but not change in weight or VO2max) were associated with greater reduction in cBP. Reduction in cBP was correlated with PWV reduction (or increased distensibility) in the proximal but not the distal aorta (r=0.18 (0.02, 0.32) and 0.03 (-0.14, 0.20) respectively). Conclusion Exercise training results in a reduction in central blood pressure; which can be explained, at least partially, by reduction in aortic stiffness in the proximal aorta. This benefit appears greatest in older subjects and those with higher baseline blood pressures.

Background Aortic stenosis (AS) is common, affecting nearly 3% of those aged over 75. Once symptomatic with severe AS outcomes are poor without intervention. An under-recognised restrictive cardiomyopathy in the elderly is wild-type transthyretin amyloid, with deposits found in up to 25% of those aged over 85 at autopsy. Bone scintigraphy offers a reliable non-invasive method of diagnosis. Dual pathology is likely to be an important disease modifier in the elderly undergoing transcatheter aortic valve implantation (TAVI). Methods This work forms part of the ATTRact-AS multi-centre study (NCT03029026), which seeks the prevalence of cardiac amyloid in the elderly (aged ≥75) with severe AS referred for TAVI. Participants underwent 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy prior to TAVI, which was graded using the Perugini scoring system. All DPD-positive patients were referred onto the National Amyloidosis Centre. Results 125 patients were recruited between October 2016 and January 2018 (aged 86±5 years, 44% male). At baseline the aortic valve peak velocity was 4.19±0.66 m/s, mean gradient 43±15 mmHg and area 0.40±0.11 cm2. Left ventricular ejection fraction was 53%±11% and mean septal wall thickness 13±2 mm (range 6–21 mm). DPD scintigraphy was positive in 16 patients (13%, 95% CI: 8% to 20%). Perugini grade was 1 (n=5) and 2 (n=11). In the DPD-positive cohort 44% were male (aged 88±5 years) and those genotyped were all wild-type (n=7). Discussion We have built on the recently published interim results of the ATTRact-AS study. Our findings from two centres suggest that 13% of elderly patients referred for TAVI with AS have occult cardiac amyloidosis.

Introduction We performed a service evaluation as the first stage of a quality improvement project to assess the use of gatekeeper tests prior to cardiac catheterisation in patients with suspected stable chest pain, prior to and after the introduction of the revised NICE Clinical guidelines. Methods A retrospective review over 14 days at two time points, Nov/Dec 2016 and Nov/Dec 2017, of cath labs activity via the Electronic Health Record. Data were collected on the referral reasons, whether and which gatekeeper tests had been performed within 1 year of the invasive procedure, and whether and what kind of revascularisation ensued. Results A total of 151 catheterisation cases were assessed. 99 were excluded on the basis of presenting with acute coronary syndrome or catheterisation being planned as part of a staged procedure or research. Mean age: 61.8 years (SD 11.3 years). 32.7% female. More gatekeeping tests were performed in 2017 (72%) compared to 2016 (48.1%) [X2 (1, n=52)=3.01, p=0.08]. 33% and 48% [p>0.27] of cases in 2016 and 2017 respectively had subsequent revascularisation. Across both time-points, 14/52 patients (26.9%) underwent neither gatekeeper test nor revascularisation. CTCA was used much more as a gatekeeper test in 2017. Conclusion A year after the NICE guideline update, 36% of cases had not undergone appropriate gatekeeper testing. 27% of all cases underwent neither gatekeeper test nor subsequent revascularisation. The increased use of CTCA in 2017 is in line with the predicted rise in CT referrals as per the new guidelines. This change has implications for service provision.

Purpose of review This review article discusses the evolution of extracellular volume (ECV) quantification using both cardiovascular magnetic resonance (CMR) and computed tomography (CT). Recent findings Visualizing diffuse myocardial fibrosis is challenging and until recently, was restricted to the domain of the pathologist. CMR and CT both use extravascular, extracellular contrast agents, permitting ECV measurement. The evidence base around ECV quantification by CMR is growing rapidly and just starting in CT. In conditions with high ECV (amyloid, oedema and fibrosis), this technique is already being used clinically and as a surrogate endpoint. Non-invasive diffuse fibrosis quantification is also generating new biological insights into key cardiac diseases. Summary CMR and CT can estimate ECV and in turn diffuse myocardial fibrosis, obviating the need for invasive endomyocardial biopsy. CT is an attractive alternative to CMR particularly in those individuals with contraindications to the latter. Further studies are needed, particularly in CT.

Pacemaker infection in pacing-dependent patients is challenging. After extraction, temporary pacing usually is utilized before delayed reimplantation (after an appropriate course of antibiotics), resulting in prolonged hospital stays. A single combined procedure of epicardial (EPI) pacemaker implantation and system extraction may prevent this.The purpose of this study was to evaluate the feasibility and safety of these 2 approaches by comparing clinical outcome for both strategies over 1 year.In center 1, 80 consecutive pacemaker-dependent patients underwent extraction with an externalized pacemaker and delayed implantation on the contralateral side (ENDO group). In center 2, 80 consecutive patients had 2 epicardial ventricular leads surgically implanted with extraction of the infected pacemaker during the same procedure (EPI group). Patients were followed-up for 12 months.One hundred sixty pacing-dependent patients were successfully implanted and extracted (ENDO group 71 ± 13 years vs EPI group 73 ± 14, P = NS). In the EPI group, 2 patients developed significant pericardial bleeding. In-hospital mortality was 0% in the ENDO group and 2.5% in the EPI group. Total hospitalization time was 15 ± 7 days in the ENDO group vs 9 ± 6 days in the EPI group (P.001). At 1 year, no infection recurrences occurred in either group, and mortality was equal (5% in each group). Median 1-year pacing thresholds were lower in the ENDO vs the EPI group (0.8 ± 0.6 V vs 1.1 ± 0.6 V, P = .02).The ENDO and EPI strategies had an excellent success rate and low risk of complications. A single procedure using surgical epicardial lead implantation was associated with a shorter duration of hospital stay.

Objectives Increased time in which children spend watching television is a well-described contributor to paediatric obesity. This study investigated the frequency and type of food and beverage placement in children-specific television broadcasts and compared data from UK (UK) and Irish television stations. Design Content analysis, totalling 82.5 h, reflecting 5 weekdays of children-specific television broadcasting on UK and Irish television channels was performed. To allow comparison between UK and Irish food and beverage cues, only broadcasts between 06.00 and 11.30 were analysed. Data were coded separately by two analysts and transferred to SPSS for analyses. Food and beverage cues were coded based on type of product, product placement, product use, motivation, outcome and characters involved. Results A total of 1155 food and beverage cues were recorded. Sweet snacks were the most frequent food cue (13.3%), followed by sweets/candy (11.4%). Tea/coffee was the most frequent beverage cue (13.5%), followed by sugar-sweetened beverages (13.0%). The outcome of the cue was positive in 32.6%, negative in 19.8%, and neutral in 47.5% of cases. The most common motivating factor associated with each cue was celebratory/social (25.2%), followed by hunger/thirst (25.0%). Comparison of UK and Irish placements showed both to portray high levels of unhealthy food cues. However, placements for sugar-sweetened beverages were relatively low on both channels. Conclusions This study provides further evidence of the prominence of unhealthy foods in children9s programming. These data may provide guidance for healthcare professionals, regulators and programme makers in planning for a healthier portrayal of food and beverage in children9s television.

While recent research on psychotic illness has focussed on the nosological, clinical, and biological relationships between schizophrenia and bipolar disorder, little attention has been directed to the most common other psychotic diagnosis, major depressive disorder with psychotic features (MDDP). As this diagnostic category captures the confluence between dimensions of psychotic and affective psychopathology, it is of unappreciated heuristic potential to inform on the nature of psychotic illness. Therefore, the epidemiology and clinical characteristics of MDDP were compared with those of schizophrenia and bipolar disorder within the Cavan-Monaghan First Episode Psychosis Study (n = 370). Epidemiologically, the first psychotic episode of MDDP (n = 77) was uniformly distributed across the adult life span, while schizophrenia (n = 73) and bipolar disorder (n = 73) were primarily disorders of young adulthood; the incidence of MDDP, like bipolar disorder, did not differ between the sexes, while the incidence of schizophrenia was more common in males than in females. Clinically, MDDP was characterized by negative symptoms, executive dysfunction, neurological soft signs (NSS), premorbid intellectual function, premorbid adjustment, and quality of life similar to those for schizophrenia, while bipolar disorder was characterized by less prominent negative symptoms, executive dysfunction and NSS, and better quality of life. These findings suggest that what we currently categorize as MDDP may be more closely aligned with other psychotic diagnoses than has been considered previously. They indicate that differences in how psychosis is manifested vis-à-vis depression and mania may be quantitative rather than qualitative and occur within a dimensional space, rather than validating categorical distinctions.

BackgroundThe boundaries of psychotic illness and the extent to which operational diagnostic categories are distinct in the long term remain poorly understood. Clarification of these issues requires prospective evaluation of diagnostic trajectory, interplay and convergence/divergence across psychotic illness, without a priori diagnostic or other restrictions.MethodThe Cavan-Monaghan First Episode Psychosis Study (CAMFEPS), conducted using methods to attain the closest approximation to epidemiological completeness, incepts all 12 DSM-IV psychotic diagnoses. In this study we applied methodologies to achieve diagnostic reassessments on follow-up, at a mean of 6.4 years after first presentation, for 196 (97%) of the first 202 cases, with quantification of prospective and retrospective consistency.ResultsOver 6 years, the 12 initial psychotic diagnoses were characterized by numerous transitions but only limited convergence towards a smaller number of more stable diagnostic nodes. In particular, for initial brief psychotic disorder (BrP), in 85% of cases this was the harbinger of long-term evolution to serious psychotic illness of diagnostic diversity; for initial major depressive disorder with psychotic features (MDDP), in 18% of cases this was associated with mortality of diverse causality; and for initial psychotic disorder not otherwise specified (PNOS), 31% of cases continued to defy DSM-IV criteria.ConclusionsCAMFEPS methodology revealed, on an individual case basis, a diversity of stabilities in, and transitions between, all 12 DSM-IV psychotic diagnoses over 6 years; thus, psychotic illness showed longitudinal disrespect to current nosology and may be better accommodated by a dimensional model. In particular, a first episode of BrP or MDDP may benefit from more vigorous, sustained interventions.