Houston Methodist

The last decade has seen a sharp increase in the number of scientific publications describing physiological and pathological functions of extracellular vesicles (EVs), a collective term covering various subtypes of cell-released, membranous structures, called exosomes, microvesicles, microparticles, ectosomes, oncosomes, apoptotic bodies, and many other names. However, specific issues arise when working with these entities, whose size and amount often make them difficult to obtain as relatively pure preparations, and to characterize properly. The International Society for Extracellular Vesicles (ISEV) proposed Minimal Information for Studies of Extracellular Vesicles ("MISEV") guidelines for the field in 2014. We now update these "MISEV2014" guidelines based on evolution of the collective knowledge in the last four years. An important point to consider is that ascribing a specific function to EVs in general, or to subtypes of EVs, requires reporting of specific information beyond mere description of function in a crude, potentially contaminated, and heterogeneous preparation. For example, claims that exosomes are endowed with exquisite and specific activities remain difficult to support experimentally, given our still limited knowledge of their specific molecular machineries of biogenesis and release, as compared with other biophysically similar EVs. The MISEV2018 guidelines include tables and outlines of suggested protocols and steps to follow to document specific EV-associated functional activities. Finally, a checklist is provided with summaries of key points.

In 2008 we published the first set of guidelines for standardizing research in autophagy. Since then, research on this topic has continued to accelerate, and many new scientists have entered the field. Our knowledge base and relevant new technologies have also been expanding. Accordingly, it is important to update these guidelines for monitoring autophagy in different organisms. Various reviews have described the range of assays that have been used for this purpose. Nevertheless, there continues to be confusion regarding acceptable methods to measure autophagy, especially in multicellular eukaryotes. For example, a key point that needs to be emphasized is thatthere is a difference between measurements that monitor the numbers or volume of autophagic elements (e.g., autophagosomes or autolysosomes) at any stage of the autophagic process versus those that measure flux through the autophagy pathway (i.e., the completeprocess including the amount and rate of cargo sequestered and degraded). In particular, a block in macroautophagy that results in autophagosome accumulation must be differentiated from stimuli that increase autophagic activity, defined as increasedautophagy induction coupled with increased delivery to, and degradation within, lysosomes (inmost higher eukaryotes and some protists such as Dictyostelium) or the vacuole (in plants and fungi). In other words, it is especially important that investigators new to the field understand that the appearance of more autophagosomes does not necessarily equate with more autophagy. In fact, in manycases, autophagosomes accumulate because of a block in trafficking to lysosomes without a concomitant change in autophagosome biogenesis, whereas an increase in autolysosomes may reflect a reduction in degradative activity. It is worth emphasizing here that lysosomal digestion is a stage of autophagy and evaluating its competence is a crucial part of the evaluation of autophagic flux, or complete autophagy. Here, we present a set of guidelines for the selection and interpretation of methods for use by investigators who aim to examine macroautophagy and related processes, as well as forreviewers who need to provide realistic and reasonable critiques of papers that are focused on these processes. These guidelines are not meant to be a formulaic set of rules, because the appropriate assays depend in part on the question being asked and the system being used. In addition, we emphasize that no individual assay is guaranteed to be the most appropriate one in every situation, and we strongly recommend the use of multipleassays to monitor autophagy. Along these lines, because of the potential for pleiotropic effects due to blocking autophagy through genetic manipulation, it is imperative to target by gene knockout or RNA interference more than one autophagyrelated protein. In addition, some individual Atg proteins, or groups of proteins, are involved in other cellular pathways implying that not all Atg proteins can be used as a specific marker for an autophagic process. In these guidelines, we consider these various methods of assessing autophagy and what information can, or cannot, be obtained from them. Finally, by discussing the merits and limits of particular assays, we hope to encourage technical innovation in the field.

BACKGROUND: Ranibizumab--a recombinant, humanized, monoclonal antibody Fab that neutralizes all active forms of vascular endothelial growth factor A--has been evaluated for the treatment of neovascular age-related macular degeneration. METHODS: In this multicenter, 2-year, double-blind, sham-controlled study, we randomly assigned patients with age-related macular degeneration with either minimally classic or occult (with no classic lesions) choroidal neovascularization to receive 24 monthly intravitreal injections of ranibizumab (either 0.3 mg or 0.5 mg) or sham injections. The primary end point was the proportion of patients losing fewer than 15 letters from baseline visual acuity at 12 months. RESULTS: We enrolled 716 patients in the study. At 12 months, 94.5% of the group given 0.3 mg of ranibizumab and 94.6% of those given 0.5 mg lost fewer than 15 letters, as compared with 62.2% of patients receiving sham injections (P<0.001 for both comparisons). Visual acuity improved by 15 or more letters in 24.8% of the 0.3-mg group and 33.8% of the 0.5-mg group, as compared with 5.0% of the sham-injection group (P<0.001 for both doses). Mean increases in visual acuity were 6.5 letters in the 0.3-mg group and 7.2 letters in the 0.5-mg group, as compared with a decrease of 10.4 letters in the sham-injection group (P<0.001 for both comparisons). The benefit in visual acuity was maintained at 24 months. During 24 months, presumed endophthalmitis was identified in five patients (1.0%) and serious uveitis in six patients (1.3%) given ranibizumab. CONCLUSIONS: Intravitreal administration of ranibizumab for 2 years prevented vision loss and improved mean visual acuity, with low rates of serious adverse events, in patients with minimally classic or occult (with no classic lesions) choroidal neovascularization secondary to age-related macular degeneration. (ClinicalTrials.gov number, NCT00056836 [ClinicalTrials.gov].).

CONTEXT: Patients who have atrial fibrillation (AF) have an increased risk of stroke, but their absolute rate of stroke depends on age and comorbid conditions. OBJECTIVE: To assess the predictive value of classification schemes that estimate stroke risk in patients with AF. DESIGN, SETTING, AND PATIENTS: Two existing classification schemes were combined into a new stroke-risk scheme, the CHADS( 2) index, and all 3 classification schemes were validated. The CHADS( 2) was formed by assigning 1 point each for the presence of congestive heart failure, hypertension, age 75 years or older, and diabetes mellitus and by assigning 2 points for history of stroke or transient ischemic attack. Data from peer review organizations representing 7 states were used to assemble a National Registry of AF (NRAF) consisting of 1733 Medicare beneficiaries aged 65 to 95 years who had nonrheumatic AF and were not prescribed warfarin at hospital discharge. MAIN OUTCOME MEASURE: Hospitalization for ischemic stroke, determined by Medicare claims data. RESULTS: During 2121 patient-years of follow-up, 94 patients were readmitted to the hospital for ischemic stroke (stroke rate, 4.4 per 100 patient-years). As indicated by a c statistic greater than 0.5, the 2 existing classification schemes predicted stroke better than chance: c of 0.68 (95% confidence interval [CI], 0.65-0.71) for the scheme developed by the Atrial Fibrillation Investigators (AFI) and c of 0.74 (95% CI, 0.71-0.76) for the Stroke Prevention in Atrial Fibrillation (SPAF) III scheme. However, with a c statistic of 0.82 (95% CI, 0.80-0.84), the CHADS( 2) index was the most accurate predictor of stroke. The stroke rate per 100 patient-years without antithrombotic therapy increased by a factor of 1.5 (95% CI, 1.3-1.7) for each 1-point increase in the CHADS( 2) score: 1.9 (95% CI, 1.2-3.0) for a score of 0; 2.8 (95% CI, 2.0-3.8) for 1; 4.0 (95% CI, 3.1-5.1) for 2; 5.9 (95% CI, 4.6-7.3) for 3; 8.5 (95% CI, 6.3-11.1) for 4; 12.5 (95% CI, 8.2-17.5) for 5; and 18.2 (95% CI, 10.5-27.4) for 6. CONCLUSION: The 2 existing classification schemes and especially a new stroke risk index, CHADS( 2), can quantify risk of stroke for patients who have AF and may aid in selection of antithrombotic therapy.

We have cloned a novel member of the nuclear receptor superfamily. The cDNA of clone 29 was isolated from a rat prostate cDNA library and it encodes a protein of 485 amino acid residues with a calculated molecular weight of 54.2 kDa. Clone 29 protein is unique in that it is highly homologous to the rat estrogen receptor (ER) protein, particularly in the DNA-binding domain (95%) and in the C-terminal ligand-binding domain (55%). Expression of clone 29 in rat tissues was investigated by in situ hybridization and prominent expression was found in prostate and ovary. In the prostate clone 29 is expressed in the epithelial cells of the secretory alveoli, whereas in the ovary the granuloma cells in primary, secondary, and mature follicles showed expression of clone 29. Saturation ligand-binding analysis of in vitro synthesized clone 29 protein revealed a single binding component for 17beta-estradiol (E2) with high affinity (Kd= 0.6 nM). In ligand-competition experiments the binding affinity decreased in the order E2 > diethylstilbestrol > estriol > estrone > 5alpha-androstane-3beta,17beta-diol >> testosterone = progesterone = corticosterone = 5alpha-androstane-3alpha,17beta-diol. In cotransfection experiments of Chinese hamster ovary cells with a clone 29 expression vector and an estrogen-regulated reporter gene, maximal stimulation (about 3-fold) of reporter gene activity was found during incubation with 10 nM of E2. Neither progesterone, testosterone, dexamethasone, thyroid hormone, all-trans-retinoic acid, nor 5alpha-androstane-3alpha,I7beta-diol could stimulate reporter gene activity, whereas estrone and 5alpha-androstane-3beta,17beta-diol did. We conclude that clone 29 cDNA encodes a novel rat ER, which we suggest be named rat ERbeta to distinguish it from the previously cloned ER (ERalpha) from rat uterus.

The American Society of Echocardiography is accredited by the

In June 2005, a World Health Organization (WHO)-International Programme on Chemical Safety expert meeting was held in Geneva during which the toxic equivalency factors (TEFs) for dioxin-like compounds, including some polychlorinated biphenyls (PCBs), were reevaluated. For this reevaluation process, the refined TEF database recently published by Haws et al. (2006, Toxicol. Sci. 89, 4-30) was used as a starting point. Decisions about a TEF value were made based on a combination of unweighted relative effect potency (REP) distributions from this database, expert judgment, and point estimates. Previous TEFs were assigned in increments of 0.01, 0.05, 0.1, etc., but for this reevaluation, it was decided to use half order of magnitude increments on a logarithmic scale of 0.03, 0.1, 0.3, etc. Changes were decided by the expert panel for 2,3,4,7,8-pentachlorodibenzofuran (PeCDF) (TEF = 0.3), 1,2,3,7,8-pentachlorodibenzofuran (PeCDF) (TEF = 0.03), octachlorodibenzo-p-dioxin and octachlorodibenzofuran (TEFs = 0.0003), 3,4,4',5-tetrachlorbiphenyl (PCB 81) (TEF = 0.0003), 3,3',4,4',5,5'-hexachlorobiphenyl (PCB 169) (TEF = 0.03), and a single TEF value (0.00003) for all relevant mono-ortho-substituted PCBs. Additivity, an important prerequisite of the TEF concept was again confirmed by results from recent in vivo mixture studies. Some experimental evidence shows that non-dioxin-like aryl hydrocarbon receptor agonists/antagonists are able to impact the overall toxic potency of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) and related compounds, and this needs to be investigated further. Certain individual and groups of compounds were identified for possible future inclusion in the TEF concept, including 3,4,4'-TCB (PCB 37), polybrominated dibenzo-p-dioxins and dibenzofurans, mixed polyhalogenated dibenzo-p-dioxins and dibenzofurans, polyhalogenated naphthalenes, and polybrominated biphenyls. Concern was expressed about direct application of the TEF/total toxic equivalency (TEQ) approach to abiotic matrices, such as soil, sediment, etc., for direct application in human risk assessment. This is problematic as the present TEF scheme and TEQ methodology are primarily intended for estimating exposure and risks via oral ingestion (e.g., by dietary intake). A number of future approaches to determine alternative or additional TEFs were also identified. These included the use of a probabilistic methodology to determine TEFs that better describe the associated levels of uncertainty and "systemic" TEFs for blood and adipose tissue and TEQ for body burden.

BACKGROUND: Transcatheter aortic-valve replacement (TAVR) is an alternative to surgery in patients with severe aortic stenosis who are at increased risk for death from surgery; less is known about TAVR in low-risk patients. METHODS: We performed a randomized noninferiority trial in which TAVR with a self-expanding supraannular bioprosthesis was compared with surgical aortic-valve replacement in patients who had severe aortic stenosis and were at low surgical risk. When 850 patients had reached 12-month follow-up, we analyzed data regarding the primary end point, a composite of death or disabling stroke at 24 months, using Bayesian methods. RESULTS: ). CONCLUSIONS: In patients with severe aortic stenosis who were at low surgical risk, TAVR with a self-expanding supraannular bioprosthesis was noninferior to surgery with respect to the composite end point of death or disabling stroke at 24 months. (Funded by Medtronic; ClinicalTrials.gov number, NCT02701283.).

BACKGROUND: We compared ranibizumab--a recombinant, humanized, monoclonal antibody Fab that neutralizes all active forms of vascular endothelial growth factor A--with photodynamic therapy with verteporfin in the treatment of predominantly classic neovascular age-related macular degeneration. METHODS: During the first year of this 2-year, multicenter, double-blind study, we randomly assigned patients in a 1:1:1 ratio to receive monthly intravitreal injections of ranibizumab (0.3 mg or 0.5 mg) plus sham verteporfin therapy or monthly sham injections plus active verteporfin therapy. The primary end point was the proportion of patients losing fewer than 15 letters from baseline visual acuity at 12 months. RESULTS: Of the 423 patients enrolled, 94.3% of those given 0.3 mg of ranibizumab and 96.4% of those given 0.5 mg lost fewer than 15 letters, as compared with 64.3% of those in the verteporfin group (P<0.001 for each comparison). Visual acuity improved by 15 letters or more in 35.7% of the 0.3-mg group and 40.3% of the 0.5-mg group, as compared with 5.6% of the verteporfin group (P<0.001 for each comparison). Mean visual acuity increased by 8.5 letters in the 0.3-mg group and 11.3 letters in the 0.5-mg group, as compared with a decrease of 9.5 letters in the verteporfin group (P<0.001 for each comparison). Among 140 patients treated with 0.5 mg of ranibizumab, presumed endophthalmitis occurred in 2 patients (1.4%) and serious uveitis in 1 (0.7%). CONCLUSIONS: Ranibizumab was superior to verteporfin as intravitreal treatment of predominantly classic neovascular age-related macular degeneration, with low rates of serious ocular adverse events. Treatment improved visual acuity on average at 1 year. (ClinicalTrials.gov number, NCT00061594 [ClinicalTrials.gov].).

The assessment of left ventricular (LV) diastolic function should be an integral part of a routine examination, particularly in patients presenting with dyspnea or heart failure. About half of patients with new diagnoses of heart failure have normal or near normal global ejection fractions (EFs). These patients are diagnosed with “diastolic heart failure” or “heart failure with preserved EF.” 1 The assessment of LV diastolic function and filling pressures is of paramount clinical importance to distinguish this syndrome from other diseases such as pulmonary disease resulting in dyspnea, to assess prognosis, and to identify underlying cardiac disease and its best treatment. LV filling pressures as measured invasively include mean pulmonary wedge pressure or mean left atrial (LA) pressure (both in the absence of mitral stenosis), LV end-diastolic pressure (LVEDP; the pressure at the onset of the QRS complex or after A-wave pressure), and pre-A LV diastolic pressure (Figure 1 ).Although these pressures are different in absolute terms, they are closely related, and they change in a predictable progression with myocardial disease, such that LVEDP increases prior to the rise in mean LA pressure. The 4 phases of diastole are marked in relation to high-fidelity pressure recordings from the left atrium (LA) and left ventricle (LV) in anesthetized dogs. The first pressure crossover corresponds to the end of isovolumic relaxation and mitral valve opening. In the first phase, left atrial pressure exceeds left ventricular pressure, accelerating mitral flow. Peak mitral E roughly corresponds to the second crossover. Thereafter, left ventricular pressure exceeds left atrial pressure, decelerating mitral flow. These two phases correspond to rapid filling. This is followed by slow filling, with almost no pressure differences. During atrial contraction, left atrial pressure again exceeds left ventricular pressure. The solid arrow points to left ventricular minimal pressure, the dotted arrow to left ventricular pre-A pressure, and the dashed arrow to left ventricular end-diastolic pressure. The upper panel was recorded at a normal end-diastolic pressure of 8 mm Hg. The lower panel was recorded after volume loading and an end-diastolic pressure of 24 mm Hg. Note the larger pressure differences in both tracings of the lower panel , reflecting decreased operating compliance of the LA and LV. Atrial contraction provokes a sharp rise in left ventricular pressure, and left atrial pressure hardly exceeds this elevated left ventricular pressure. (Courtesy of T. C. Gillebert and A. F. Leite-Moreira.) Echocardiography has played a central role in the evaluation of LV diastolic function over the past two decades. The purposes of this document is to provide a comprehensive review of the techniques and the significance of diastolic parameters, as well as recommendations for nomenclature and reporting of diastolic data in adults. The recommendations are based on a critical review of the literature and the consensus of a panel of experts. The optimal performance of the left ventricle depends on its ability to cycle between two states: (1) a compliant chamber in diastole that allows the left ventricle to fill from low LA pressure and (2) a stiff chamber (rapidly rising pressure) in systole that ejects the stroke volume at arterial pressures. The ventricle has two alternating functions: systolic ejection and diastolic filling. Furthermore, the stroke volume must increase in response to demand, such as exercise, without much increase in LA pressure. 2 The theoretically optimal LV pressure curve is rectangular, with an instantaneous rise to and an instantaneous to low diastolic allows for the for LV filling. This theoretically optimal is by the of and mitral and at valve and LV pressure rapid filling, heart and atrial 2 filling pressures are the of diastolic 2 pressures are elevated the mean pulmonary wedge pressure is mm or the LVEDP is mm Hg. 1 pressures change with in of filling pressures and diastolic LV filling pressures are by filling and of the LV be by myocardial relaxation and in diastolic myocardial the the of to a contraction and relaxation is the the after contraction to its and In normal and with normal myocardial relaxation is at minimal LV pressure. and relaxation to the of of the and are closely is to by and 2 or systolic myocardial with elevated to filling pressures. 4 to the underlying from the and and is by a of that 2 and of the of contraction and relaxation is relaxation in a between in and of other and to global LV relaxation and elevated filling pressures. The of global LV myocardial relaxation is by the of LV pressure a to a pressure is a of the of LV be at a to after is 1 In the of relaxation be in of LV and with the relaxation or the between valve and mitral valve opening. LV filling is by the between LV filling pressures and filling These filling are with or with compliance and to end-diastolic and to the left ventricle these end-diastolic are and ventricular include myocardial and myocardial chamber and the LV diastolic with a of that be The operating at is to the of a to the curve at that and be with two is the is mm the other is to LV chamber over the of diastole by the of the to the diastolic a curve be to the diastolic LV relation of a or to the end-diastolic relation by the lower of at The has the of on myocardial The , is the of the curve and be to chamber of diastolic function is to function and 8 the to be to a at the ventricle the pulmonary valve and a to the left to the This to systolic and diastolic function is to myocardial relaxation and LV and is by myocardial relaxation is by and is by the myocardial and by the diastolic is in patients with normal LV is the for In patients with diastolic heart and or be In LV is in patients with of the of in the LV is and heart disease is the to diastolic heart failure. LV be measured is to in patients the of the of clinical at LV should be measured in to at on LV diastolic function and filling pressures. In LV relaxation is diastolic filling. In the of normal LA pressure, this a of LV filling to diastole after atrial the of filling in these patients the of filling pressures. The of LA volume is and in with the the and This assessment is is a relation between LA and of diastolic and filling pressures at the of LA volume the of filling pressures over patients without of atrial and heart disease have that LA volume 2 is an of heart atrial and must that left be in patients with and and other atrial or and mitral valve disease, in the absence of diastolic is in in the absence of disease (Figure 2 is to LA volume in with a clinical other and of LV LA volume from an with a volume of 2 mitral by from the E was and was This was by the of a larger LA volume normal The atrium ventricular filling its and During ventricular systole and isovolumic the are atrial as from the volume is as LA volume the of in the pulmonary with atrial The atrium is a to LV end-diastolic volume by at stroke volume is as LA volume at the onset of the LA the atrium as a that with valve and atrial contraction and be as LV stroke volume the of LA and The and stroke of the left atrium be and as of LV stroke LV relaxation is with a lower diastolic and a in LA the complex is to optimal LV end-diastolic volume and normal stroke a of diastolic and LA the LA to LV filling from LA stroke LA systolic function be a of and , as the LA ejection as mitral 2 and LA stroke volume 2 In have LA and and clinical in patients with atrial , are to these clinical patients with diastolic have pulmonary pressures. in the absence of pulmonary disease, pressures be to the of elevated LV filling pressures. a was between systolic pressure and LV filling pressures. The of the by with systolic atrial pressure (Figure are to systolic pressure. In patients with and low systolic pressure the of the systolic pressure is on the of systolic pressure. of systolic pressure the In this the was and pressure was at mm Hg. the end-diastolic of the pulmonary (Figure 4 be to diastolic pressure. be or with to by in the The of pressure is for both and be and its change with as well as the of systolic to diastolic in the of diastolic pressure the and by In this the end-diastolic was 2 , and pressure was at to mm for on mean diastolic pressure by well with invasively measured mean pulmonary wedge pressure and be as its The to this are in the lower of particularly in and without In its depends on the of mean pressure, be in The diastolic pressure to LA pressure has in patients without or pulmonary in patients with pulmonary or mean pressures mm diastolic pressure is mm mean wedge pressure. is in the to mitral to assess LV filling. be for optimal of the particularly the left ventricle is to assess E and should be the to that are to volume is between the mitral diastole to a (Figure 2 and is to the onset and of LV mitral be recorded in mitral recordings should be at of to for the evaluation of of as in patients with pulmonary or disease the is the is to at and over cardiac of mitral include the filling and diastolic filling the of filling and the by the of in the LV to the end of ejection and the onset of mitral include mitral A-wave at the of the mitral diastolic filling the A-wave and the mitral integral the atrial filling with the volume at the of the mitral is an to in normal they LV relaxation and elevated filling pressures. is a normal of mitral and the mitral E and and are in 1 24 of other LV diastolic function and filling pressures mitral heart and cardiac mitral and LA in diastolic function a of myocardial to the of diastolic heart failure. for diastolic are as mean Note that for in to with for to This is increases with in and the is in a normal in a normal in a lower to are are these data in the from they for diastolic are as mean Note that for in to with for to This is increases with in and the is in a normal in a normal in a lower to are are these data in the from they are by the mitral and include LV LV filling and LV filling. The of be by mitral the are such as the mitral The diastolic and LV filling are in patients with and or patients with is well that the mitral the pressure (Figure diastole and is by and in LV The mitral A-wave the pressure is by LV compliance and LA is by LV LV diastolic pressures mitral valve and LV compliance the between LV pressure and in LV end-diastolic LV LV diastolic pressures the mitral E and and of the in mitral in response to the pressure In patients with mitral and filling with cardiac filling and LV with LV relaxation filling are the a mitral and diastolic LA pressure, and filling is with a prognosis, after a or filling with myocardial an for heart LV and of In patients with disease or , in LV are mitral with This be to the marked in the of LV relaxation in these pressure for LA pressures. filling and LA in a with a normal are with a to that of a in This is in , and in heart LV filling have a relation with LV diastolic with in normal and patients with cardiac this is an LV systolic function is the of and diastolic heart failure in patients with normal was the for the to assess diastolic function in that mitral to are disease, and and in or of the mitral E and mitral at the of atrial contraction is mitral A-wave be the and A-wave mitral be should be atrial LV filling is by the rapid atrial that no E or is for or is atrial filling are with diastolic mitral between atrial In these pressures from and be the best of LV filling pressures disease is is in the to mitral to assess LV filling. to volume is between the mitral diastole to a include E and and include LV and LV filling. In patients with filling with filling and LV In patients with disease and with in the LV are mitral with The is by mm a and a complex 4 LV is the and in mitral are to distinguish normal from The must a increase in pressure, and the to the volume between the mitral the of in mitral E is an in patients without filling. mitral is by a to increase in LA pressure in the of myocardial the the phase, mitral to a of mitral E with a of the is or such that the the other with a normal mitral both E and with an the with the absolute the of E at the onset of should be In cardiac a of in the is for LV filling a of change normal diastolic Furthermore, the of with is as an that the diastolic filling is of the is that is to this and is clinical in normal from mitral has the of recordings of the mitral to assess the of LV relaxation and filling pressures and In a clinical the be for patients in diastolic function assessment is after mitral and The is by mm a and a complex 4 In cardiac a of in the is for LV filling a of change normal diastolic of pulmonary is in the and in the assessment of LV diastolic is for the of the volume in the upper pulmonary In the best recordings are by the such that the valve is to volume is the pulmonary for optimal of the must be low to the onset and of the atrial be in of the is much lower in the The is LA by atrial contraction, with the of is that recordings be at a of to at and that include the of cardiac of pulmonary include systolic diastolic the systolic filling integral integral integral and the in are the of the the between and mitral A-wave and are two systolic and is a is to atrial should be to the of systolic to diastolic is by in LA pressure and LA contraction and , is to stroke volume and in the , is by in LV filling and compliance and in with mitral E and are by LV diastolic atrial and LA in LA compliance and an increase in LA pressure the and increase the resulting in an a systolic filling and a of the of and increase (Figure as well as the between and mitral A-wave , , Atrial in a and the absence of of mitral at the of the and pulmonary from a with the pulmonary at and its at in with mitral is best recorded at the of the are by 1 have reflecting mitral E the In normal increase with In patients with a systolic of is to decreased LA compliance and mean LA pressure. This has in patients with atrial mitral valve disease, and the other the is particularly is the of LV A-wave pressure increase and patients with LV relaxation with normal filling pressures and with elevated normal mean LA pressures. This increase in LVEDP is the first with diastolic such as LA mitral and filling, an increase in mean LA pressure and a of diastolic In the in patients with normal mitral valve disease, and In an an elevated mitral have the role of pulmonary flow. of the in pulmonary is the in recordings for This is for for atrial contraction that the pulmonary and in the of atrial contraction diastolic mitral and pulmonary has to the This increases the of the mitral A-wave and that of the in the pulmonary the to for LV A-wave pressure atrial the of atrial contraction and relaxation pulmonary systolic of filling pressures. a of the left atrium with its relaxation be from systolic or in of pulmonary is in the and in the assessment of LV diastolic to volume is the pulmonary for optimal of the include and the systolic filling and in is the between and mitral A-wave and as well as the In patients with systolic filling fractions are to decreased LA compliance and mean LA pressure. The for is the , The (Figure to have the is in the with a and is to The is the of the LV from the mitral valve to the the is to lower the that the central is is measured as the of the first filling, measured from the mitral valve to 4 the LV the of the from no to is is , is to the pressure by by , this is and for routine clinical from a with and LV The was to filling, normal LV filling is by an and an filling of the has on the diastolic filling relaxation with myocardial and LV failure. In the normal the filling the and is by a pressure between the LV and the This a and has to LV and LV During heart failure and myocardial is of with a of , , evaluation and of filling in clinical is by the of that flow. pressure, and systolic and , Furthermore, in and complex The slow in a ventricle is in part to that the In these the between and the pressure is The of and the of techniques to to LV myocardial function in a is a that has to be a of LV diastolic that the of measured by In is to in with mitral E to LV filling pressures. in patients have that the of E to is to LA pressure, and be to LV filling pressures by and in with In patients with of LV diastolic function are and is as a to identify diastolic in this should other provide for the of LV filling and mm with should be the for the of LV filling pressures in patients with normal In patients with normal LV and filling pressures have a normal , , In are a of on in patients with normal as well as with is in the The is the of the LV from the mitral valve to the with to lower the that the central is is measured as the of the first filling, measured from the mitral valve to 4 the LV or the of the from no to is In patients with is and should other an mm with with normal LV and elevated filling pressures have normal is in the to mitral be by this is the The volume should be at or 1 the and of the mitral and as to the of the mitral in both systole and should be to have have for the and to the In the should be at and the lower be is LV and are to should be between the and the of cardiac be in patients of is that recordings be at a of to at and that should the of cardiac include the systolic and diastolic The diastolic has as or and the diastolic as The the of and is to to arterial The of and as well as and to to and be the other the between the QRS complex and onset is with LV relaxation and provide in the the assessment of global LV diastolic is to and at at the and of the mitral and the of function on these and , mitral and are is to and The include and the mitral E to The an role in the of LV filling pressures. the between the QRS complex and the onset of mitral E is from the between the QRS complex and onset to provide to in as in the is to the for both to E and to and to and and the of the onset of The of include LV relaxation (Figure 8 systolic and LV minimal pressure. between and LV relaxation was in , and LV filling pressures have a minimal on in the of LV , , the other with normal or LV , , , in patients with cardiac disease, be to for the of LV relaxation on mitral E and the be for the of LV filling pressures (Figure The of include LA systolic function and such that an increase in LA to an increase in LVEDP to a from the mitral from a normal and a with LV and LV relaxation 8 , , and from a with heart failure and normal The was from of the In the of LV relaxation and of LA pressure, the is and such that at the pressure crossover , the other mitral E with or LV filling. the between the onset of E and is with diastolic , and have that is on the of LV relaxation and LV minimal pressure. 1 of are by to other of LV diastolic and the be to LV relaxation and with mitral E be to LV filling pressures. , , , at is to the of a the or absence of disease, and other in the and the are should be as the data in LV diastolic is to the from the and of the mitral for the of LV filling pressures. is lower the is the by and different should be on the of LV as well as are in patients with normal or LV systolic is to the and (Figure in the of is to the in the the a is with normal LV filling a is with filling pressures. the is between 8 and other should be of have that in patients with normal and have the best with LV filling pressures and of LV , These the of in this and recordings from a with an myocardial the between and is to the of and in such patients to at of LV relaxation and filling pressures. is particularly in in the has its and the of 4 is a for this The clinical in to include with normal cardiac function or with mitral valve disease and the is 8 to In an has in patients with LV filling pressures. are both and clinical to the of the as well as and minimal with is for these are with low are from different cardiac is This to clinical in other are are a of clinical in and the should be In normal is to and the provide a of filling pressures. These be by normal cardiac and and the onset of in with mitral E is in patients with mitral and mitral is in patients with to and normal LV relaxation to the In these the should be the be with have to preserved LV for the and diastolic be in this and the was to to LV filling pressures or is in the to mitral The volume should be at or 1 the and of the mitral is that recordings be at a of to at and that should the of cardiac include the systolic and and diastolic the assessment of global LV diastolic is to and at at the and of the mitral and In patients with cardiac disease, be to for the of LV relaxation on mitral E and the be for the of LV filling pressures. The is as an of filling pressures in normal or in patients with mitral valve disease, and and be different In clinical is as a or are in the and in the the or of myocardial or and are for the of and provide in the evaluation of diastolic During the heart the LV a complex that to is to this comprehensive assessment is by and are and and the clinical to myocardial has with and this to myocardial has as a clinical and has comprehensive evaluation for the assessment of systolic , be measured by an that by in , The function as that be from to and and are by of between The is be from an This is in to is to between the cardiac and the with include and is by lower of that myocardial and provide diastolic This the of myocardial as a of in and diastolic be to diastolic and , is in an that diastolic with the of differences in the of from myocardial contraction to relaxation with identify have a relation between and global diastolic and the of LV Furthermore, a that global myocardial the relaxation and that the mitral E myocardial LV filling pressure in patients in the was and was in patients with normal and with the evaluation of diastolic function by is of its clinical and myocardial are the for LV diastolic LV is to contraction of in the the in a The of the over the a in from the the LV systolic and the LV a in systole the relaxation and is at the of mitral valve opening. to the of that have the The of is to as the LV to an role for normal systolic and diastolic to LV filling , has that the in LV with or of diastolic to diastolic in with normal to be to a in diastolic the of LV has with and other complex is the of LV and be in clinical the of is to LV , LV is as the between and measured in LV the is to the mitral and for to the with at The clinical of LV is LV and in patients with diastolic or diastolic heart both and , and no relation was with the of LV the other in patients with these In an and in both of heart the was with LV volume and that LV best the between systolic and diastolic In of LV and for routine clinical and are to clinical an of diastolic function evaluation in the The of is a and clinical of in patients is to be from with different be at the LV in the myocardial relaxation is LV pressure the isovolumic relaxation in a LA pressure. mitral valve is and is is measured by as in by has the of on the of LV is to with of LV pressure and LA pressure to LV pressure LA This has and be to provide a of in of a assessment of LV The instantaneous pressure between the and the left ventricle diastole be from the the of pressure is and LV minimal pressure is LV pressure the be from the of the The be from the mean and LVEDP between the and the left is in second at after the onset of and between the onset of and the to of the was in an clinical is to a the the and mean pressure between the left ventricle and the left atrium be by in patients with well with measured pressures by The to is 2 2 and are to from the is between the of to the at the of the at the of the of to assess myocardial both the and are in clinical from the is of to the of the by an rise followed by a after are with a pressure and elevated mean LA pressure. the other a with slow and the of LV systolic and in the absence of valve disease patients with a rapid of of and a pressure half are of a rapid rise in LV diastolic pressure to LV myocardial relaxation is is a in the and a of In in the of a low mitral be to a in LV diastolic pressure to slow LV filling pressure these in mitral an and have for LV relaxation be with normal or filling on LV relaxation relaxation is the in cardiac is in patients with diastolic is a for myocardial relaxation mitral in and between and patients with or have myocardial for the is to is the mean 2 of the to the 1 In the of myocardial the and well with and LV minimal pressure. this has a and is in clinical is and with the of myocardial be in patients with normal LV and is as an of LV relaxation in patients with and left In the other is to other by has the of on the of LV patients with or have myocardial is as an of LV relaxation in patients with and left In the other is to other mitral and by be to be from high-fidelity pressure recordings and mitral filling on a the curve by the diastolic mitral are to filling and to stroke volume by , this the LV chamber be The of end-diastolic compliance of LV from a of pressure and volume is at to LV end-diastolic volume and to this be in patients with diastolic with with LV have rapid of of LV filling and that with a LA pressure LV filling, is to the of LV This is by that LA change the of of LV filling. and data in have the of as LV 2 , for and LV relaxation is In mitral is an that should be in LV particularly in patients without marked of LV LA contraction

BACKGROUND: Patients with elevated triglyceride levels are at increased risk for ischemic events. Icosapent ethyl, a highly purified eicosapentaenoic acid ethyl ester, lowers triglyceride levels, but data are needed to determine its effects on ischemic events. METHODS: We performed a multicenter, randomized, double-blind, placebo-controlled trial involving patients with established cardiovascular disease or with diabetes and other risk factors, who had been receiving statin therapy and who had a fasting triglyceride level of 135 to 499 mg per deciliter (1.52 to 5.63 mmol per liter) and a low-density lipoprotein cholesterol level of 41 to 100 mg per deciliter (1.06 to 2.59 mmol per liter). The patients were randomly assigned to receive 2 g of icosapent ethyl twice daily (total daily dose, 4 g) or placebo. The primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina. The key secondary end point was a composite of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke. RESULTS: A total of 8179 patients were enrolled (70.7% for secondary prevention of cardiovascular events) and were followed for a median of 4.9 years. A primary end-point event occurred in 17.2% of the patients in the icosapent ethyl group, as compared with 22.0% of the patients in the placebo group (hazard ratio, 0.75; 95% confidence interval [CI], 0.68 to 0.83; P<0.001); the corresponding rates of the key secondary end point were 11.2% and 14.8% (hazard ratio, 0.74; 95% CI, 0.65 to 0.83; P<0.001). The rates of additional ischemic end points, as assessed according to a prespecified hierarchical schema, were significantly lower in the icosapent ethyl group than in the placebo group, including the rate of cardiovascular death (4.3% vs. 5.2%; hazard ratio, 0.80; 95% CI, 0.66 to 0.98; P=0.03). A larger percentage of patients in the icosapent ethyl group than in the placebo group were hospitalized for atrial fibrillation or flutter (3.1% vs. 2.1%, P=0.004). Serious bleeding events occurred in 2.7% of the patients in the icosapent ethyl group and in 2.1% in the placebo group (P=0.06). CONCLUSIONS: Among patients with elevated triglyceride levels despite the use of statins, the risk of ischemic events, including cardiovascular death, was significantly lower among those who received 2 g of icosapent ethyl twice daily than among those who received placebo. (Funded by Amarin Pharma; REDUCE-IT ClinicalTrials.gov number, NCT01492361 .).

BACKGROUND: Patients with advanced heart failure have improved survival rates and quality of life when treated with implanted pulsatile-flow left ventricular assist devices as compared with medical therapy. New continuous-flow devices are smaller and may be more durable than the pulsatile-flow devices. METHODS: In this randomized trial, we enrolled patients with advanced heart failure who were ineligible for transplantation, in a 2:1 ratio, to undergo implantation of a continuous-flow device (134 patients) or the currently approved pulsatile-flow device (66 patients). The primary composite end point was, at 2 years, survival free from disabling stroke and reoperation to repair or replace the device. Secondary end points included survival, frequency of adverse events, the quality of life, and functional capacity. RESULTS: Preoperative characteristics were similar in the two treatment groups, with a median age of 64 years (range, 26 to 81), a mean left ventricular ejection fraction of 17%, and nearly 80% of patients receiving intravenous inotropic agents. The primary composite end point was achieved in more patients with continuous-flow devices than with pulsatile-flow devices (62 of 134 [46%] vs. 7 of 66 [11%]; P<0.001; hazard ratio, 0.38; 95% confidence interval, 0.27 to 0.54; P<0.001), and patients with continuous-flow devices had superior actuarial survival rates at 2 years (58% vs. 24%, P=0.008). Adverse events and device replacements were less frequent in patients with the continuous-flow device. The quality of life and functional capacity improved significantly in both groups. CONCLUSIONS: Treatment with a continuous-flow left ventricular assist device in patients with advanced heart failure significantly improved the probability of survival free from stroke and device failure at 2 years as compared with a pulsatile device. Both devices significantly improved the quality of life and functional capacity. (ClinicalTrials.gov number, NCT00121485.)

BACKGROUND: Although transcatheter aortic-valve replacement (TAVR) is an accepted alternative to surgery in patients with severe aortic stenosis who are at high surgical risk, less is known about comparative outcomes among patients with aortic stenosis who are at intermediate surgical risk. METHODS: We evaluated the clinical outcomes in intermediate-risk patients with severe, symptomatic aortic stenosis in a randomized trial comparing TAVR (performed with the use of a self-expanding prosthesis) with surgical aortic-valve replacement. The primary end point was a composite of death from any cause or disabling stroke at 24 months in patients undergoing attempted aortic-valve replacement. We used Bayesian analytical methods (with a margin of 0.07) to evaluate the noninferiority of TAVR as compared with surgical valve replacement. RESULTS: A total of 1746 patients underwent randomization at 87 centers. Of these patients, 1660 underwent an attempted TAVR or surgical procedure. The mean (±SD) age of the patients was 79.8±6.2 years, and all were at intermediate risk for surgery (Society of Thoracic Surgeons Predicted Risk of Mortality, 4.5±1.6%). At 24 months, the estimated incidence of the primary end point was 12.6% in the TAVR group and 14.0% in the surgery group (95% credible interval [Bayesian analysis] for difference, -5.2 to 2.3%; posterior probability of noninferiority, >0.999). Surgery was associated with higher rates of acute kidney injury, atrial fibrillation, and transfusion requirements, whereas TAVR had higher rates of residual aortic regurgitation and need for pacemaker implantation. TAVR resulted in lower mean gradients and larger aortic-valve areas than surgery. Structural valve deterioration at 24 months did not occur in either group. CONCLUSIONS: TAVR was a noninferior alternative to surgery in patients with severe aortic stenosis at intermediate surgical risk, with a different pattern of adverse events associated with each procedure. (Funded by Medtronic; SURTAVI ClinicalTrials.gov number, NCT01586910 .).

We demonstrate that a monolayer graphene membrane is impermeable to standard gases including helium. By applying a pressure difference across the membrane, we measure both the elastic constants and the mass of a single layer of graphene. This pressurized graphene membrane is the world's thinnest balloon and provides a unique separation barrier between 2 distinct regions that is only one atom thick.

BACKGROUND: We compared transcatheter aortic-valve replacement (TAVR), using a self-expanding transcatheter aortic-valve bioprosthesis, with surgical aortic-valve replacement in patients with severe aortic stenosis and an increased risk of death during surgery. METHODS: We recruited patients with severe aortic stenosis who were at increased surgical risk as determined by the heart team at each study center. Risk assessment included the Society of Thoracic Surgeons Predictor Risk of Mortality estimate and consideration of other key risk factors. Eligible patients were randomly assigned in a 1:1 ratio to TAVR with the self-expanding transcatheter valve (TAVR group) or to surgical aortic-valve replacement (surgical group). The primary end point was the rate of death from any cause at 1 year, evaluated with the use of both noninferiority and superiority testing. RESULTS: A total of 795 patients underwent randomization at 45 centers in the United States. In the as-treated analysis, the rate of death from any cause at 1 year was significantly lower in the TAVR group than in the surgical group (14.2% vs. 19.1%), with an absolute reduction in risk of 4.9 percentage points (upper boundary of the 95% confidence interval, -0.4; P<0.001 for noninferiority; P = 0.04 for superiority). The results were similar in the intention-to-treat analysis. In a hierarchical testing procedure, TAVR was noninferior with respect to echocardiographic indexes of valve stenosis, functional status, and quality of life. Exploratory analyses suggested a reduction in the rate of major adverse cardiovascular and cerebrovascular events and no increase in the risk of stroke. CONCLUSIONS: In patients with severe aortic stenosis who are at increased surgical risk, TAVR with a self-expanding transcatheter aortic-valve bioprosthesis was associated with a significantly higher rate of survival at 1 year than surgical aortic-valve replacement. (Funded by Medtronic; U.S. CoreValve High Risk Study ClinicalTrials.gov number, NCT01240902.).

BACKGROUND: Student mental health in higher education has been an increasing concern. The COVID-19 pandemic situation has brought this vulnerable population into renewed focus. OBJECTIVE: Our study aims to conduct a timely assessment of the effects of the COVID-19 pandemic on the mental health of college students. METHODS: We conducted interview surveys with 195 students at a large public university in the United States to understand the effects of the pandemic on their mental health and well-being. The data were analyzed through quantitative and qualitative methods. RESULTS: Of the 195 students, 138 (71%) indicated increased stress and anxiety due to the COVID-19 outbreak. Multiple stressors were identified that contributed to the increased levels of stress, anxiety, and depressive thoughts among students. These included fear and worry about their own health and of their loved ones (177/195, 91% reported negative impacts of the pandemic), difficulty in concentrating (173/195, 89%), disruptions to sleeping patterns (168/195, 86%), decreased social interactions due to physical distancing (167/195, 86%), and increased concerns on academic performance (159/195, 82%). To cope with stress and anxiety, participants have sought support from others and helped themselves by adopting either negative or positive coping mechanisms. CONCLUSIONS: Due to the long-lasting pandemic situation and onerous measures such as lockdown and stay-at-home orders, the COVID-19 pandemic brings negative impacts on higher education. The findings of our study highlight the urgent need to develop interventions and preventive strategies to address the mental health of college students.

autophagic responses. Here, we critically discuss current methods of assessing autophagy and the information they can, or cannot, provide. Our ultimate goal is to encourage intellectual and technical innovation in the field.

COVID-19 can involve persistence, sequelae, and other medical complications that last weeks to months after initial recovery. This systematic review and meta-analysis aims to identify studies assessing the long-term effects of COVID-19. LitCOVID and Embase were searched to identify articles with original data published before the 1st of January 2021, with a minimum of 100 patients. For effects reported in two or more studies, meta-analyses using a random-effects model were performed using the MetaXL software to estimate the pooled prevalence with 95% CI. PRISMA guidelines were followed. A total of 18,251 publications were identified, of which 15 met the inclusion criteria. The prevalence of 55 long-term effects was estimated, 21 meta-analyses were performed, and 47,910 patients were included (age 17-87 years). The included studies defined long-COVID as ranging from 14 to 110 days post-viral infection. It was estimated that 80% of the infected patients with SARS-CoV-2 developed one or more long-term symptoms. The five most common symptoms were fatigue (58%), headache (44%), attention disorder (27%), hair loss (25%), and dyspnea (24%). Multi-disciplinary teams are crucial to developing preventive measures, rehabilitation techniques, and clinical management strategies with whole-patient perspectives designed to address long COVID-19 care.

peer reviewed

Efforts to extend nanoparticle residence time in vivo have inspired many strategies in particle surface modifications to bypass macrophage uptake and systemic clearance. Here we report a top-down biomimetic approach in particle functionalization by coating biodegradable polymeric nanoparticles with natural erythrocyte membranes, including both membrane lipids and associated membrane proteins for long-circulating cargo delivery. The structure, size and surface zeta potential, and protein contents of the erythrocyte membrane-coated nanoparticles were verified using transmission electron microscopy, dynamic light scattering, and gel electrophoresis, respectively. Mice injections with fluorophore-loaded nanoparticles revealed superior circulation half-life by the erythrocyte-mimicking nanoparticles as compared to control particles coated with the state-of-the-art synthetic stealth materials. Biodistribution study revealed significant particle retention in the blood 72 h following the particle injection. The translocation of natural cellular membranes, their associated proteins, and the corresponding functionalities to the surface of synthetic particles represents a unique approach in nanoparticle functionalization.