Pathology review was required before patient enrolment. The aim of this analysis was to evaluate the role of central pathology review before randomisation.In the PORTEC-3 trial, women with high-risk endometrial cancer (HR-EC) were randomised to receive pelvic radiotherapy (RT) with or without concurrent and adjuvant chemotherapy (two cycles of cisplatin 50 mg/mn = 395) and the UK (n = 900), and for 1226/1295 (95%) matching review and original reports were available. In total, 329 of these patients were enrolled in the PORTEC-3 trial: 145 in the Netherlands and 184 in the UK, comprising 48% of the total PORTEC-3 cohort of 686 participants. Areas of discrepancies were evaluated, and inter-observer agreement between original and review opinion was evaluated by calculating the kappa value (κ).A total of 1295 cases underwent pathology review to confirm HR-EC in the Netherlands (κ = 0.72), lymph-vascular space invasion (κ = 0.72) and histological grade (κ = 0.70).In the 1226 pathology reviews, 6356 selected items were evaluable for both original and review pathology. In 43% of cases at least one pathology item changed after review. For 102 patients (8%), this discrepancy led to ineligibility for the PORTEC-3 trial, most frequently due to differences in the assessment of histological type (34%), endocervical stromal involvement (27%) and histological grade (19%). Lowest inter-observer agreement was found for histological type  and with ClinicalTrials.gov (NCT00411138).This study is registered with ISRCTN (ISRCTN14387080,  Key MessageIn the PORTEC-3 trial, central pathology review before randomisation by expert gynaeco-pathologists changed histological items in 43% of HR-EC patients. This led to ineligibility for the PORTEC-3 trial in 8% of patients. Upfront pathology review is recommended for future trials as well as in daily practice to ensure enrolment of the target trial-population and to avoid over- or undertreatment.Adjuvant treatment of women with endometrial cancer (EC) is based on clinicopathological risk factors, such as histological grade, myometrial invasion, age and lymph-vascular space invasion (LVSI) . A minorAs these high-risk criteria comprise different features of the pathology diagnosis, reproducibility is essential. Studies of pathology review by expert subspecialty pathologists, however, have shown that evaluation of female reproductive tract pathology had the highest rates of discrepancies between original and review pathology assessment including discrepancies with consequences for treatment . ChallenThe PORTEC-3 trial is an international randomised phase III trial of adjuvant therapy in high-risk EC (HR-EC). Women with HR-EC were randomly allocated (1 : 1) to pelvic radiotherapy (RT) alone or RT plus concurrent and adjuvant chemotherapy. Primary end points are overall survival and failure-free survival. To select patients with true HR-EC and avoid unnecessary intensive treatment in lower-risk cases, upfront pathology review was carried out by expert gynaeco-pathologists of the participating groups to confirm HR-EC and eligibility for the study.The current analysis was done to establish the value of upfront pathology review. The aims were to explore the proportion of patients who were ineligible for the PORTEC-3 trial after pathology review, and to evaluate inter-observer variability between original and review pathology assessments.PORTEC-3 is a randomised Intergroup trial led by the Dutch Gynaecological Oncology Group, with participating groups MRC-NCRI (UK), ANZGOG , MaNGO , Fedegyn (France) and CCTG (Canada). Surgery comprised hysterectomy with salpingo-oophorectomy. Lymphadenectomy was at the discretion of the participating centres. For serous or clear cell cancers, surgical staging including omentectomy; peritoneal biopsies and lymphadenectomy was recommended.parametrial or IIIC; or NEEC stage IA–III.Details on patient selection and treatment have been described in a previous publication . Eligibl2 in weeks 1 and 4 of RT, followed by four cycles of carboplatin AUC5 and paclitaxel 175 mg/m2 every 3 weeks).Patients were randomised (1 : 1) to RT (48.6 Gy) or RT plus adjuvant chemotherapy (two cycles of cisplatin 50 mg/mWritten informed consent (IC) was obtained from all patients. The protocol was approved by the Dutch Cancer Society and the Ethics committees. Participating groups obtained their own IRB and ethics approvals and were funded by separate grants.Each participating group had appointed expert gynaeco-pathologists as reviewers for the study. After surgery, the pathology diagnosis was made by the regional pathologist. In case of HR-EC, all histopathology slides and a copy of the pathology report were sent for pathology review as part of patient management, to confirm HR-EC within 1 week, with the aim to ensure that only true HR-EC cases were informed and enrolled in the trial. If IC was given, pathology review for the PORTEC-3 trial was completed with trial-specific items. Upon consent for storage of tumour tissue for translational research a formalin-fixed paraffin-embedded (FFPE)-block was centrally stored. All other blocks and slides were sent back to the referring centre.The items for original and review pathology included WHO histological type, grade, depth of myometrial invasion, distance to serosa or serosal breach, LVSI, cervical stromal involvement, involvement of the tubes and/or ovaries and lymph node involvement. Histological type was evaluated as endometrioid, serous, clear cell, mixed (endometrioid with serous/clear cell components), mucinous, or other histologies according to WHO-classification . Mixed tFor the current analysis, anonymised original and review pathology reports from both randomised and non-randomised patients in the Netherlands (NL) and the UK (UK) were assessed. These two countries were chosen as they had the largest number of patients in the trial (together 48%) and all pathology reviews had been done at two centres in each country. For the UK patients, the review pathologist provided a short confirmation of HR-EC and eligibility. For the randomised patients, the review report was completed after IC was given.Discrepancies between original and central pathology review were assessed as discrepancies with and without change of eligibility for the PORTEC-3 trial. Reasons for non-eligibility were checked by two expert gynaeco-pathologists (TB and NS).κ) was used [κ values the scale proposed by Landis and Koch was used [The data were collected in a SPSS database (version 23.0). For the comparison of the pathology items, Cohen’s kappa value .The PORTEC-3 trial included 686 patients 2006–2013), of whom 145 were recruited in NL and 184 in the UK. Slides from 1295 patients  were sent for pathology review. Fifteen original pathology reports  were not available for analysis. Fifty-four patients  were ineligible based on the original pathology report, which was confirmed by pathology review and they were therefore excluded from the analysis. A total of 1226 patients  were eligible based on local pathology and were included in this analysis  there was a discrepancy between original and review pathology. The highest agreement was found for serosal breach (98%) and cervical stromal involvement (94%), and most disagreement for histological type (15%) and grade , cervical stromal involvement  and change of histological grade in 19% (n = 19), which was similar between the NL and UK cohorts. Eighty-three of these 102 became low risk after central pathology review, while in 19 cases the histological type was reclassified as carcinosarcoma; these were therefore still high risk but were not eligible for the PORTEC-3 trial.In 532 cases (43%) at least one pathology item changed after review, which led to ineligibility for the PORTEC-3 trial in 8% (κ = 0.72), LVSI (κ = 0.72) and histological grade , with overall agreement of 94%. However, a discrepancy here led to ineligibility for the trial in 27/69 (39%) of cases.Highest rates of inter-observer variability were found for histological type κ = 0.7, LVSI , showing that κ values are less reliable for items with few observations.Serosal breach was present in only 5% of cases. Although agreement was high for both countries (97% and 99%), Figure n = 113) were downgraded at review pathology, with most frequent shifts (76 cases) from grade 2 to 1. In 4% (n = 26), the grade was higher at review.The overall agreement for histological grade was 80%; 16% , most frequently due to changes in histological type or cervical stromal involvement. These lower-risk patients did therefore not risk receiving more intensive and potentially toxic treatment. Furthermore, a true HR-EC study population in the PORTEC-3 trial was ensured. For 19 patients the histological type changed to carcinosarcoma and although they were high risk, they were not eligible for the trial.The inter-observer agreement between original and review pathology was highest for cervical stromal invasion. The most frequent discrepancies were found for histological type, histological grade and presence of LVSI. While many of these discrepancies did not affect eligibility for the current study, they were important for prognosis and adjuvant treatment of patients in clinical practice.Discrepancies in gynaeco-pathology diagnosis between original and review pathology have been reported before. A Canadian study reported EC as the tumour site with most frequent differences in pathological assessment . AnotherIn the PORTEC-1 and -2 trials pathology review showed that 24% and 14%, respectively, of patients were in retrospect ineligible, while this was 8% for the PORTEC-3 trial , 17. EliFrequent causes of discrepancies were assessment of histological type and cervical involvement. Several studies have addressed challenges in diagnosing serous, clear cell and mixed cancers, the level of agreement varying from 62% to 83% . In the Variations in defining cervical stromal involvement have also been reported in a study of 76 cases reviewed by 6 expert gynaeco-pathologists with agreement in only 50%. Difficulties comprised the definition of the junction between the lower uterine segment and the endocervix, and the distinction between unattached tumour components or true cervical stromal involvement .A limitation of this study could be that the pathology reviews took place at four university centres, and inter-observer variations between these gynaeco-pathologists were not assessed. The percentages of major discrepancies were, however, quite similar between the two countries. In the PORTEC-2 trial, higher risk of distant metastasis and lower survival were found for patients who were considered ‘high-risk’ after central review pathology, suggesting that the review pathology was more reliable to predict prognosis when compared with the original pathology .Creating a well-defined trial population with confirmed eligibility by upfront pathology review should be considered the standard for future scientific studies. Expert consultation is being increasingly used, but pathology review might not be part of the standard procedure, because it is time consuming and expensive. To this purpose, further standardisation of pathology criteria, expert education and subspecialisation in gynaeco-pathology are essential, as well as rapid access to expert consultation. The transition to digital pathology will greatly facilitate rapid consultation. Introduction of IHC and molecular analysis using the TCGA molecular subgroup classification will further improve risk assignment , 26.Annals of Oncology online). The potential treatment consequences for patients should be the main reason to incorporate pathology review in daily practice. In the current study, most patients with discrepancies were downgraded and were spared unnecessary treatment.A substantial proportion of eligible women declined participation in the trial, mostly because they did not want to receive chemotherapy. Younger patients and those with a more advanced stage of disease more often consented to participate in the trial (In conclusion, upfront pathology review by expert gynaeco-pathologists identified changes in histological type, grade or other items in 43% of patients. Of these, 8% of patients were found ineligible for the trial. This resulted in a true HR-EC population and reliable pathology assessment in the PORTEC-3 trial, which ensures the quality of future translational research. Upfront pathology review is to be preferred in future gynaecological oncology trials and in daily practice. The transition to digital pathology will strongly facilitate rapid expert pathology consultation.Supplementary Figure S1Click here for additional data file.Supplementary Table S1Click here for additional data file.Supplementary Table S2Click here for additional data file.Supplementary DataClick here for additional data file.


The surgical treatment of bone tumours can result in large peri-operative blood loss, due to their large sizes and hypervascularity. Pre-operative embolisation has been successfully used to downgrade vascularity, thus reducing peri-operative blood loss and its associated complications.Pre-operative embolisation was successfully undertaken on twenty-six patients with a variety of primary and secondary bone tumours.Mean blood loss was 796 mL and we experienced no complications.Pre-operative arterial embolisation of large, richly vascular bone tumours in anatomically difficult positions, is a safe and effective method of downstaging vascularity and reducing blood loss. The resection of primary and secondary bone tumours can be challenging due to their size, anatomical location and richly vascularised nature. This can cause technical difficulties including major peri-operative bleeding and its associated complications. Peri-operative blood loss for large bone tumours treated with surgery alone has had mean losses of 6000 mL, and as much as 18,500 mL [Feldman et al  first deWe presented of our experience with 26 patients, presenting with a variety of bone tumours (average size 10.5 x 7.5 x 5.5 cm), who underwent pre-operative arterial embolisation in our institution. These patients were referred from the regional bone tumour unit due to the nature, size or difficult anatomical location, and embolized aiming to decrease the peri-operative blood loss. The purpose of this study was to evaluate the amount of intraoperative blood loss, transfusion requirements and post-operative functional outcome.Twenty-six patients with a variety of bone tumours, who underwent pre-operative embolisation between 2005 and 2009, were retrospectively studied. The group comprised of 17 females and 9 males. Their mean age was 38 years old.Embolisations were performed in the interventional suite by a senior radiologist (KL) under local anaesthesia only. Very occasionally patients required some sedation or IV analgesia, usually due to the discomfort caused by lying on the tumour for a long period of time. The procedure itself was usually not painful, unless absolute occlusion of the arterial supplied to the tumour occurred. This occurred right at the end of the procedure and was easily controlled with IV analgesia. Most vessels could be catheterized with 4 French glide catheters and occasionally microcatheters. 26 embolisations were performed with a combination of PVA particles 300-500 microns, PVA microspheres 500-700 microns, 700-900 microns, and 900-1200 microns, and Embospheres 500-700 microns, 700-900 microns, and 900-1200 microns and a variety of coils and micro coils, following selective cathererisation of individual vessels deemed to supply the tumour. The embolisation endpoint was deemed to be when all major vessels supplying the tumour had been occluded and there had been a virtual complete obliteration of tumour blush.Surgery was performed within 48 h of embolisation. Peri-operative blood loss was measured from the suction canister, weighing swabs during surgery and from the suction drainage post operatively. Drains were removed when appropriate postoperatively and resection specimens were confirmed histologically.Patients were scored clinically post-procedure (mean 34 months), using the Musculoskeletal Society Tumour Score (MSTS).All 26 embolisation procedures were technically and clinically successful. The mean total blood loss was 796 mL (range 100-1800 mL), and required on average 1.1 units of blood transfusion (range 0-2).The average MSTS functional score was 25/30 (83%).No patient had any surgery or embolisation associated complication, and there were no wound complications, and no tumour recurred within the follow up period. All patients survived at follow up (mean 34 months). Patient demographics, histological diagnosis and anatomical site, size, blood loss, transfusion requirement, functional outcome and follow-up were shown in Our results showed significantly less blood in a variety of surgically resected bone tumours as compared with the pre-embolisation era, and comparable blood loss to other studies -12.The aim of embolisation is to occlude the vascular supply of the tumour. Lackman et al  had someCarpenter et al  successfSalai et al  embolizeBarton et al , reporteThey found that blood loss increased if surgery was not performed soon after embolisation. If surgery occurred within 3 days of embolization, blood loss was 500-1500mL, comparing to 1500-2800 mL at 4-14 days post embolisation, due to re-canalization and angiogenesis.Chatziioannou  and MankApart from reducing blood losses by 50%, Bin Shi et al  found inA known complication of embolization is the possibility of wound healing problems. Wirbel et al  noted thThis study provides further evidence that pre-operative embolisation of tumours in difficult anatomical locations, or in highly vascular tumours keeps blood loss and its associated complications to a minimum. We experienced no complications associated with embolisations and therefore would recommend that pre-operative embolisation should be considered and used as part of the multi-disciplinary approach to the management of bone tumours in difficult anatomical locations or those that are known to be highly vascular, with large extraossesous components as seen on pre-operative imaging, such as renal and thyroid metastases.


C-MYC, BCL-XL, BCL-6, NF-κβ, PTEN and AKT) in exosomes of plasma as a liquid biopsy method for monitoring and prognostic evolution in B-cell lymphomas.To determine the feasibility of mRNAs (Exosomes were isolated from 98 patients with B-cell Lymphoma and 68 healthy controls. mRNAs were analyzed by quantitative PCR. An additional 31 post-treatment samples were also studied.AKT mRNA was associated with poor response to rituximab-based treatment. Patients with first relapse or disease progression showed a lower percentage of PTEN and BCL-XL mRNA. The presence of BCL-6 mRNA was associated with a high death rate. The absence of PTEN mRNA in the general series, and presence of C-MYC mRNA in follicular lymphomas, were associated with short progression-free survival. BCL-6 and C-MYC mRNA were independent prognostic variables of overall survival. C-MYC mRNA may provide prognostic information with respect to overall survival. BCL-XL mRNA and increase of BCL-6 mRNA in post-treatment samples could serve as molecular monitoring markers.In the general and follicular lymphoma series, the presence of This is the first large study to evaluate the prognostic and predictive values of pretreatment tumor-associated mRNA in exosomes. BCL-6 and C-MYC mRNA positivity in pretreatment samples were predictors of worse PFS compared to patients with mRNA negativity. C-MYC mRNA positivity was also a statistically significant predictor of inability to obtain complete response with first-line therapy. Follicular lymphoma (FL) and Diffuse Large B-Cell Lymphoma (DLBCL) account for over 70% of all non-Hodgkin Lymphomas (NHL) and rituximab is approved for the treatment of these common subtypes . The ideplus rituximab. Currently, we have no molecular prognostic indicators and only known clinical factors are used.The prognosis for patients with primary resistant or relapsed aggressive lymphomas is still poor as over 20% of patients with DLBCL die and 50% relapse within two years of diagnosis. In the case of FL, around 50% will have relapsed at 5 years even when treated with chemotherapy In agreement with Roschewski et al., we believe that assays of circulating tumor RNA/DNA could serve as “liquid biopsies” thereby providing information regarding response or resistance to treatment, in addition, this technique could be of use in both follicular and aggressive lymphomas .in vivo, and ascertain whether current information obtained from in vitro studies can be used to understand the mechanisms developed by exosomes within tumors.Exosomes are nanovesicles not exceeding 100 nanometers protected by a lipid-rich bound membrane. They develop in the cytoplasm, specifically the endoplasmic reticulum, in a variety of normal and pathological cells, including tumor cells. Their differing cells of origin influence their protein content, cytoplasmic or membrane proteins and genetic material. This genetic material can be used to perform liquid biopsies to analyze prognostic and predictive biomarkers. From a functional standpoint, this genetic material, mRNA and miRNA, can epigenetically reprogram recipient cells , in addiC-MYC, BCL-XL, BCL-6, NF-κβ, PTEN and AKT in exosomes is analyzed.The potential use in clinical practice of mRNA presence in exosomes of plasma from patients with B-Cell Lymphoma, which could be taken as liquid biopsies, and their applicability to all NHL subtypes remains to be defined, and especially with respect to predicting prognoses, response to treatment and monitoring during follow-up. In this study, mRNA presence of The six genes evaluated in this study have important roles in the deregulated pathways of many cancers, including lymphoid neoplasms. The PI3K/AKT/mTOR and NF-κβ pathways are involved in several steps of tumorogenesis, such as cell proliferation, survival, angiogenesis and tumor cell drug/radiation resistance –7. AKT rA total of 98 patients with follicular or diffuse large B-cell lymphoma were recruited for this study. Patient characteristics are shown in The overall response rate (ORR) was 93%, complete response (CR) was obtained in 67% patients, and 26% achieved partial remission (PR). After a median follow up of 28 months (range: 19-103 months), 18% of patients relapsed and 15% died.When comparing progression-free survival (PFS) and overall survival (OS) between FL and DLBCL patients, no significant differences were found between these groups . As a reExosomes were quantified by acetylcholinesterase activity, and were detected in plasma from DLBCL and FL patients. No differences in exosome levels were found between the lymphoma groups studied and healthy controls. Levels of acetylcholinesterase activity are show in C-MYC, 16% for BCL-XL, 34% for BCL-6, 8% for NKkB, 25% for PTEN and 3% for AKT. BCL-6 mRNA was detected in more patient plasma samples than in plasma from healthy controls , while presence of PTEN mRNA was detected in more control cases . In addition, the frequency of positivity for BCL-6 mRNA in plasma was higher in DLBCL than in FL patients , and presence of BCL-XL was lower in DLBCL . The frequencies of each mRNA in DLBCL, FL and controls are shown in The studied mRNAs were detected in exosomes in the following proportions: 9% for PTEN and BCL-XL mRNA presence in exosomes at the time of diagnosis . This association with PTEN mRNA was also found in the DLBCL subpopulation . Data of these associations are showed in Table BCL-6 mRNA at the time of diagnosis and a high patient death rate  in patients without. Adjusted analysis showed no associations between the mRNAs analyzed and PFS.In the general series, the Kaplan-Meier test showed a trend to significant association between the absence of BCL-6 and C-MYC mRNA in exosomes: patients with these mRNAs present in plasma at diagnosis had shorter survival than patients without , while patients without had OS of 89.2% and 87.7% . No significant differences in OS were found, including in the two subpopulations, with the other mRNAs analyzed.When the general series were analyzed, a trend toward significant difference was observed in OS for the presence of BCL-6 or C-MYC mRNA in exosomes, together with occurrence of the first relapse/progression . This association was also observed in the follicular lymphoma subpopulation , but not in DLBCL. Additional details are included in Table As stated above, in our general series recruited before receiving rituximab-based treatment, 93% of the lymphoma patients showed complete or partial response to rituximab-based chemotherapy. In this series, the presence of AKT mRNA in exosomes was associated with worse PFS (p=0.038). The Kaplan-Meier analysis also showed that presence of C-MYC and BCL-6 mRNA correlated with worse OS in the responsive patient group  and, when only the FL subpopulation was analyzed, a significant association was observed between the presence of BCL-6 mRNA and progression . More details are shown in Table BCL-6 mRNA in post-treatment samples compared to pre-treatment samples was associated with non-response to treatment  were recruited between January 2005 and January 2011 and followed-up clinically until November 2014. The study was conducted within the GOTEL Group (details can be seen in the Supplementary Methods section). Samples were provided by the 7 participating Spanish hospitals, and molecular analyses were centralized in Puerta de Hierro University Hospital. Written informed consent was obtained from all participants after an explanation of the nature of the study as approved by the research ethics board of the seven hospitals. Histological diagnoses were ascertained by lymph node biopsy. The WHO Classification histological criteria were used for sample diagnosis and classification . ClinicaBlood samples were taken before beginning treatment and, between 4-6 weeks after treatment, blood samples were taken from 16 DLBCL patients and 15 FL. Blood samples were also obtained from 68 healthy blood donors.Prospective follow-up was based on regular clinical, biochemical and radiological examinations, gallium scan and nuclear magnetic resonance or positron emission tomography if recommended by radiologists. In total, 86% of patients received 6 cycles of R-CHOP every 21 days. The remaining patients received rituximab-based treatment with variations of this combination. Response to treatment was assessed on the basis of clinical, radiological and pathologic criteria, according to modified International Workshop Response Criteria Guidelines . DetailsPlasma was prepared by centrifugation of peripheral blood at 2,500 rpm for 25 minutes. Exosomes were isolated from 3 ml of plasma by differential centrifugations. To quantify the amount of exosomes we measured the activity of acetylcholinesterase. Methodological details have been described previously .RNA was extracted using the mirVana™miRNA Isolation Kit  and quantified by NanoDrop ND-1000 . RNA was retro-transcribed with the Gold RNA PCR Core Kit  using random hexamers, in line with the manufacturer's instructions. Real-time PCR was performed in duplicate in a Light-Cycler apparatus using the LightCycler 480 SYBR Green I Master Kit , in line with the manufacturer's instructions. Additional details are shown in Supplementary methods and 2 test. The relationship between the cumulative probability of survival, as well as analyzed predictors, was calculated by the Kaplan-Meier method. Significant differences between curves were evaluated with Mantel's log-rank test. To identify factors that might be of independent significance in influencing survival, the Cox proportional risk regression model was applied. Box plot was performed applying logarithm of data. p values ≤0.05 were considered statistically significant. Statistical analysis was performed using the SPSS software, version 14.0 (SPSS Inc. IL).The clinicopathological parameters were contrasted with the presence of target mRNAs by the χ


Our goal was to reduce ordering of coagulation studies in the emergency department (ED) that have no added value for patients presenting with chest pain. We hypothesized this could be achieved via implementation of a stopgap measure in the electronic medical record (EMR).We used a pre and post quasi-experimental study design to evaluate the impact of an EMR-based intervention on coagulation study ordering for patients with chest pain. A simple interactive prompt was incorporated into the EMR of our ED that required clinicians to indicate whether patients were on anticoagulation therapy prior to completion of orders for coagulation studies. Coagulation order frequency was measured via detailed review of randomly sampled encounters during two-month periods before and after intervention. We classified existing orders as clinically indicated or non-value added. Order frequencies were calculated as percentages, and we assessed differences between groups by chi-square analysis.Pre-intervention, 73.8% (76/103) of patients with chest pain had coagulation studies ordered, of which 67.1% (51/76) were non-value added. Post-intervention, 38.5% (40/104) of patients with chest pain had coagulation studies ordered, of which 60% (24/40) were non-value added. There was an absolute reduction of 35.3%  in the total ordering of coagulation studies and 26.4%  in non-value added order placement.Simple EMR-based interactive prompts can serve as effective deterrents to indiscriminate ordering of diagnostic studies. Healthcare expenditures have risen sharply in the United States over the past decade and now account for one-fifth of the gross domestic product.Physician decisions drive approximately 80% of healthcare expenditures, and many have suggested targeting clinician behaviors to reduce waste in U.S. healthcare.2More than five million patients undergo emergency department (ED) evaluation for chest pain in the U.S. annually.We conducted a pre and post quasi-experimental study to evaluate the impact of an EMR-based intervention on coagulation study ordering for patients with chest pain. The study was performed in the ED of a 1,059-bed tertiary care hospital with a comprehensive cardiovascular care center. This work was performed as a quality improvement initiative and was granted exempt status by our institutional review board.In August 2014, an electronic interactive prompt was incorporated into the EMR (EPIC) of our ED and set to appear each time a coagulation study (PT or PTT) was ordered. This prompt, which remained in place throughout the remainder of our study period, required ordering clinicians to indicate which anticoagulant therapy, if any, the patient was receiving prior to completion of the order using a series of two mouse clicks.Electronic records were retrieved for all ED patients with a chief complaint of chest pain during a two-month period before (May–June 2014) and after (October–November 2014) the intervention. We excluded a two-month washout period post-intervention to allow for normalization of the effect of the intervention. A systematic random sample of charts was generated for detailed review from each time period by selecting every seventh encounter. Reviewers annotated whether coagulation studies were ordered at time of initial ED evaluation and, if ordered, whether any clinical indication for the order existed. Clinical indications for coagulation study were defined as home vitamin K antagonist therapy, ST-elevation myocardial infarction, history of or suspicion for liver disease, known coagulopathy, initiation of anticoagulant therapy during ED treatment, or strong suspicion for vascular hemorrhage or stroke. We classified orders for patients not meeting these criteria as non-value added.We derived a sample size of at least 98 patients from each study period to detect an absolute 20% reduction in coagulation study order frequency from a baseline frequency of 75% with a confidence interval (CI) of 95% and power of 0.80. We calculated absolute difference and its corresponding 95% CI in the comparison of frequencies of total and non-value added coagulation study orders before and after intervention using chi-square test .There were 727 patient visits with a chief complaint of chest pain during the two-month pre-intervention sampling period and 822 during the post-intervention sampling period. We performed detailed chart review for a randomized selection of 103 visits pre-intervention and 104 visits post-intervention. Demographics were similar between groups with a mean age of 48 years in the pre-intervention group and 44 years in the post-intervention, and 53% male pre-intervention and 58% male post-intervention. Pre-intervention, 73.8% (76/103) of patients with chest pain had coagulation studies ordered, of which 67.1% (51/76) were non-value added with an overall rate of 49.5% (51/103) of patients having coagulation studies that added no value to their care. Post-intervention, only 38.5% (40/104) of patients with chest pain had coagulation studies ordered, of which 60% (24/40) were non-value added. Overall, only 23.1% (24/104) of patients had coagulation study orders that added no value to their care post-intervention. There was an absolute reduction of 35.3%  in the total ordering of coagulation studies and 26.4%  in non-value added order placement. The intervention increased the overall proportion of ordered tests that were value-added.Here, we show that a simple EMR-based intervention served as an effective deterrent to the ordering of non-value added diagnostic studies. While previous studies have shown that EMR-based interventions can lead to changes in clinician behavior, these interventions focused on more robust clinical decision support including display of evidence-based guidelines and individual diagnostic study costs.This intervention led to significant estimated cost savings. Using standard Medicare reimbursement ratesWhile our findings strongly suggest that simple EMR-based interventions can alter clinician behavior and are potentially valuable tools for curtailing waste, there are important limitations to this work. We did not randomize patient encounters to EMR-based intervention, and comparisons were drawn between encounters that occurred before and after intervention. It is possible that other temporally related factors impacted clinician ordering patterns. Similarly, our ability to discern clinician motivation for decreased order frequency was limited to factors recorded in the EMR. For example, it is possible that the effect of our intervention was due to mouse-click fatigue, rather than improved decision-making. Indeed, we observed reductions in overall order frequency, and while our study was not designed to detect this, it is possible that this intervention resulted in decreased orders for coagulation studies that were clinically indicated. However, it is also possible that many of the tests we considered value-added did not provide any clinical contribution to care. For these reasons, EMR-based interventions such as this one are likely best paired with provider education initiatives. Finally, this work was performed at a single site and may not be directly applicable to all ED environments.Simple EMR-based interactive prompts can serve as effective deterrents to indiscriminate ordering of diagnostic studies.


Purpose: Alzheimer’s disease (AD) is pathologically defined by the presence of amyloid plaques and tangles in the brain, therefore, any drug or compound with potential effect on lowering amyloid plaques, could be noticed for AD management especially in the primary phases of the disease. Ectoine constitutes a group of small molecule chaperones (SMCs). SMCs inhibit proteins and other changeable macromolecular structures misfolding from environmental stresses. Ectoine has been reported successfully prohibit insulin amyloid formation in vitro.Methods: We selected eight genes, DAXX, NFκβ, VEGF, PSEN1, MTAP2, SYP, MAPK3 and TNFα genes which had previously showed significant differential expression in Alzheimer human brain and STZ- rat model. We considered the neuroprotective efficacy by comparing the expression of candidate genes levels in the hippocampus of rat model of Sopradic Alzheimer’s disease (SAD), using qPCR in compound-treated and control groups as well as therapeutic effects at learning and memory levels by using Morris Water Maze (MWM) test.Results: Our results showed significant down-regulation of Syp, Mapk3 and Tnfα and up-regulation of Vegf in rat’s hippocampus after treatment with ectoine comparing to the STZ-induced group. In MWM, there was no significant change in swimming distance and time for finding the hidden platform in treated comparing to STZ-induced group. In addition, it wasn’t seen significant change in compound-treated comparing to STZ-induced and control groups in memory level.Conclusion: It seems this compound may have significant effect on expression level of some AD- related genes but not on clinical levels. Acetylcholinesterase suppressors are first-line factors for the remedy of mild to moderate AD.25 Even though small changes in action mechanisms, these inhibitors have different detrimental effects.27 The most accepted adverse effects are nausea, vomiting, and diarrhea; cardiovascular and neurological adverse effects are comparable. The incidence of negative effects is precisely related to the dose administered.27 Therapy with rivastigmine, donepezil or galantamine as Acetylcholinesterase inhibitors for six months to one year resulted in kind of enhanced cognitive function.23 Improvements in daily behavior and activities also were eminent in patients cured with one of these factors; however, none of them has a major therapy efficacy and the clinical importance of these effects is ambiguous. Whenever there is no effective treatment for AD, substances with efficient inhibition of the amyloid formation have been sought as drug candidates for AD management.31A nomination causal event in sporadic Alzheimer’s disease (SAD) is distracted brain insulin metabolism.32 Ectoines are common solutes of aerobic heterotrophic bacteria and compose a class of small molecule chaperones (SMCs). SMCs stack to high intracellular concentrations, inhibiting the misfolding of proteins and other unstable macromolecular structures from environmental stresses.36 SMCs have already known as eminently effective in maintaining enzymatic activities against heating, freezing and drying.37 Regarding to a reporting, SMCs like ectoine, betaine, trehalose, citrulline could successfully constrain insulin amyloid formation in vitro .38 All findings propose the effect of SMCs against amyloid formation, which may make them permanent drug candidates for medicating neurodegenerative diseases in the future. Ectoine maintains proteins and enzymes from proteolysis, thermal stress and change of the pH or the salt concentration. Studies showed its potency to maintain various proteins, nucleic acids, membranes and whole cells.42 Many genes have been reported to be related with AD which they have shown expression changes in Alzheimer model and human brain comparing to normal group.44 Among them DAXX, NFκβ, VEGF genes with the role in apoptosis, inflammation and angiogenesis showed significant statistical diversity in Alzheimer human brain.43 Furthermore, Psen1, Mtap2, Syp, Mapk3 and Tnf α genes with the role in γ-secretase, cytoskeleton, synapses, kinase and inflammation showed significant statistical diversity in STZ rat model.44Ectoine is a heterocyclic amino acid or a partially hydrogenated pyrimidine derivative  received no medication and surgery; the sham group (Eight rats) had bilateral intracerebroventricular (ICV) injection of aCSF as the vehicle of STZ; the Alzheimer group (Seven rats) which received bilateral ICV infusion of STZ, and the treated STZ group (Eight rats) which received the compound for fifteen days after modeling as intrapritoneal injection (6 mg/day).38 All groups except the control one had five recovery days after surgery and before treatment with aCSF, STZ and compound- treated. All procedures were shown in details in Thirty one mature male 46 The maze was a round black pool with 150 cm diameter, 60 cm height. Maze was filled with water to a depth of 40 cm with temperature of about 23°C. Four identical spaced places at the circumference of the pool divided the pool into four quadrants, and were used as beginning parts. An escape platform of 10 cm diameter was located 2 cm beneath the surface of the water at a fixed position in the center of one of the quadrants. All rats were participated to a daily session of four training trials for five consecutive days. Each rat was permitted to find the latent platform within sixty seconds. The time spent to detect the platform (Escape latency), the distance each rat swam to find the platform (Path Length) and the swimming speed (Velocity) were recorded. One day after acquisition, a probe test was performed to evaluate memory level by removing platform.47Learning and memory examined for all group of rats using Morris Water Maze (MWM) test after treatment.48All processes were performed according to the National Institute of Health Guide for the care and use of laboratory animals.49After MWM test, they were immolated and all hippocampi were dissected and reserved in RNA protector solution at -20°C.TM First Strand cDNA Synthesis Kit  according to the manufacturer's protocol.Total RNAs were extracted from hippocampus tissues using UP100H ultrasonic processor (Germany) and RNeasy Plus Mini Kit  conferring to the manufacturer's protocol. Purity and integrity of RNAs were specified using Nano-drop spectrophotometer and gel electrophoresis. cDNA synthesis was performed using RevertAidDaxx, Nfkb, Vegf, Psen1, Mtap2, Syp, Mapk3 and Tnf α in rat hippocampus of each group were detected using SYBR green Real Time PCR  in ABI 7500 Real-time PCR system  and). All genes expression normalizations were done by Actb endogenous control.51 Cycle threshold (Ct) values were used to calculate fold changes in gene expression between groups using REST 2009 software. P-values less than 0.0125 for analysis by REST and in other analysis less than 0.05 were considered statistically significant. MWM test data were analyzed by GraphPad Prism 6 software; Kruskal Wallis (Dunn’s multiple comparisons test) test was used for three recorded factors  in all treated and untreated groups separately during five days.The relative expression levels of the eight genes After evaluating the learning and memory level changes using MWM test, our results represented a remarkable gradual decrease in swimming distance and time for finding the hidden platform during five days in all groups, despite of no significant change in these two criteria in -treated comparing to the STZ-induced group during five days, Syp, Mapk3 and Tnf α genes were down-regulated and Vegf gene was upregulated in rat’s hippocampus after two weeks treatment with comparing to STZ-induced group . Also in Mapk3 gene was observed in the STZ-induced comparing to the control group, whereas significant 4.5-fold down-regulation was seen in the -treated comparing to the STZ-induced group . As it is obvious in Tnfα showed significant down-regulation in STZ-induced comparing to control group  the same in -treated versus STZ-induced group with about 2- fold reduction . Vegf which was remarkably decreased in the STZ-induced comparing with the control group , but its expression showed about 2-fold significant up-regulation in the -treated comparing to the STZ-induced group .ed group . Statist in Vegf . As it iDaxx, Nfkb, Vegf Psen1, Mtap2, Syp, Mapk3 and Tnf α) for Alzheimr’s disease in RNA level in AD rat model. Our results showed that three genes, Syp, Mapk3 and Tnf α were significantly down-regulated in the treated compared to the STZ-induced group as same as up-regulation of Vegf.In this study, we evaluated expression of eight candidate genes  reported their finding as notably reduced expression of synaptophysin (Syp) in the hippocampus of icv-STZ mice. Also other Synapse-related genes were found not to be significantly reduced in STZ- induced model even some of them were up-regulated.44 In the present study, as it is obvious in  Syp showed no significant up-regulation in the STZ-induced comparing to the control group also, in the -treated comparing to the STZ- induced group there was a significant down-regulation.Synaptic loss and dysfunction are reported to be the molecular basis of cognitive defect in AD.Mapk3) is an anti- apoptosis gene which is also involved in neuron plasticity .44 Protein phosphorylation regulates neuronal plasticity, APP processing and tau aggregation.54 Regarding studies, several protein kinases disorder in AD brain or play many roles in the disease. In the study by chen et al. (2012), gene expressions of some AD-related protein kinases showed down-regulation in STZ-induced mice, but only Mapk3 expression change was significant. In our study no significant down-regulation of this gene was observed in the STZ-induced comparing to the control group, whereas significant 4.5-fold down-regulation was seen in the -treated comparing to the STZ-induced group.Mitogen-activated protein kinase 3  instead of intraperitoneal could be resulted in better management of Alzheimer’s disease.We would like to thank all colleagues specially Dr. Saeed Talebi who helped us in gene expression analysis and Dr. Parvaneh Daneshmand for useful comments. The study was supported by the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.Not applicable.Authors declare no conflict of interest in this study.


Mycobacterium bovis bacillus Calmette-Guérin (BCG) vaccine in a lipid matrix has been shown to confer protection against M. bovis infection and reduce the severity of tuberculosis (TB) when fed to brushtail possums (Trichosurus vulpecula), the major wildlife vector of bovine TB in New Zealand. Here we demonstrate the feasibility of aerial delivery of this live vaccine in bait form to an M. bovis-infected wild possum population, and subsequently assess vaccine uptake and field efficacy. Pre-trial studies indicated a resident possum population at very low density (<0.6 possums/ha) at the field site, with a 5.1% prevalence of macroscopic TB lesions. Pilot studies indicated that flavoured lipid matrix baits in weather-proof sachets could be successfully sown aerially via helicopter and were palatable to, and likely to be consumed by, a majority of wild possums under free-choice conditions. Subsequently, sachet-held lipid baits containing live BCG vaccine were sown at 3 baits/ha over a 1360 ha area, equating to >5 baits available per possum. Blood sampling conducted two months later provided some evidence of vaccine uptake. A necropsy survey conducted one year later identified a lower prevalence of culture-confirmed M. bovis infection and/or gross TB lesions among adult possums in vaccinated areas  than in unvaccinated areas ; P = 0.098. Although not statistically different, the 81% efficacy in protecting possums against natural infection calculated from these data is within the range of previous estimates of vaccine efficacy in trials where BCG vaccine was delivered manually. We conclude that, with further straightforward refinement to improve free-choice uptake, aerial delivery of oral BCG vaccine is likely to be effective in controlling TB in wild possums. We briefly discuss contexts in which this could potentially become an important complementary tool in achieving national eradication of TB from New Zealand wildlife.Oral-delivery  Mycobacterium bovis bacillus Calmette-Guerin; BCG) aimed at helping control bovine tuberculosis (TB) caused by virulent strains of M. bovis among wildlife in New Zealand. Bovine TB is a zoonotic disease that affects cattle world-wide. In developed countries, the risk to human health is diminished by pasteurisation of milk and slaughterhouse inspection to prevent affected meat from entering the food chain, combined with efforts to eliminate the disease from livestock  fate-of-bait data from the comparative choice baiting trial, 2] CC and fate-of-bait data from the single-choice baiting trial, 3] immunological data (as stimulation indices in response to PPD-B) from the 2-month post-vaccination study, 4] necropsy and culture data from wildlife caught or shot in the area prior to vaccine deployment, 5] necropsy data from the 13-month post-vaccination study .Data presented in this study are publicly accessible at In October 2010, a trap-catch index of 3.3% (n = 368 trap nights) was recorded in the pilot trial area, indicating that possum density over the whole area was very low (< 0.6 possums/ha). At such low densities, estimates are imprecise  in similM. bovis infection detected among 51 of the 93 possums that had no visible lesions .Surveys conducted 6–24 months before the main vaccine field trial confirmed substantial TB presence in wildlife in the study area, with culture-confirmed TB lesions recorded in 67.0%  of a total of 91 pigs . Of 98 pIn the first assessment of free-choice uptake of sachet-held bait, possums were confirmed as having visited bait sites (by bite marks on CCs) on 12 separate occasions over three nights at 8 of the 33 sites where rhodamine-dyed baits had been set. Eight adult possums  were then trapped in the vicinity over the next two nights, all of which had been marked by rhodamine-B. Two of the female possums that were trapped were carrying dependent juveniles, neither of which bore rhodamine marking.In the pilot sowing trial, 186 baits were successfully deployed from the helicopter, equating to a delivery density to 3.7 baits/ha. Ground searches along the flight paths located 101 sachets within line-of-sight of the paths—98 were still intact, one was torn but still contained the bait, and two were torn with the bait removed. Fourteen sachets were found trapped in thorny shrub vegetation 0.3–2.0m off the ground. The number of intact sachets found equates to a confirmed presence of least 2.02 visually-locatable baits/ha for the second night after aerial sowing. The difference between the density of baits sown and the number we found after the first night is possibly not only because some baits were simply not found, but because some may have been moved away from the flight path by possums.By re-searching over the flight deployment area along transects set at 90 degrees to the original flight paths, 57 aerially-delivered sachet baits were located and marked by waypoints for the next pilot trial. Over 3 subsequent nights of exposure, 40% of these sites in total had the bait either confirmed eaten (14%) or the sachet and bait removed from the site (26%) . This waIn the pilot ground-based deployment trial conducted in the main trial blocks, examination of CCs after 7 days indicated animal bite marks at 143 (45%) of the 316 sites where CCs had been placed next to sachet baits . OverallSachets baits were successfully deployed by aerial delivery from a helicopter, as judged by a ground-based observer (GN) positioned under the flightpaths who was readily able to visually track samples of baits (15–20) as they fell. The day of deployment was clear and still with ground frost, and shady south-facing slopes remained frosty throughout the day, so the lipid remained solid except that for a few of the baits which landed on ground in full sun on north-facing slopes, where the lipid matrix had begun to melt by late afternoon.M. bovis infection [Blood samples were collected for LPA from 9 possums trapped from one non-vaccinated block, and 52 possums trapped from the two vaccine-treatment blocks. The majority of blood samples (59/61) had SI values between 0.1 and 17.1; however, two animals (one from the non-vaccinated block and one from the treatment blocks) had extremely high SI values of 124 and 327. Given such values most likely reflect responses to virulent nfection , these iM. bovis infection in unvaccinated areas was 5.8%  among a total of 104 adult and juvenile possums captured and euthanized.At trial completion, the overall prevalence of M. bovis , comprising five from the non-vaccinated blocks and one from the vaccine blocks  was thus over five times higher than in the vaccinated blocks . Pooled by treatment, the difference is marginally significant .In total, 181 adult possums (89 from non-vaccinated blocks and 92 from vaccine blocks) were killed and necropsied in October 2012, 13 months after vaccine deployment, with this sample including no artificially infected animals. Of these, six had culture-confirmed e blocks . The estM. bovis infection among free-ranging (but hand-vaccinated) possums [a priori indication that the vaccine would work in the field, if it could be effectively delivered to (and freely consumed by) wild possums. This would avoid the impractical requirement of having to catch wild animals first to vaccinate them by hand [We sought to develop a practical tool for reducing or eliminating TB from a wildlife host living within remote areas of difficult terrain where the usual approach  is not feasible or not socially-acceptable. We considered that the successful development and laboratory testing of the lipid matrix as an effective carrier for live BCG , its abi possums , togethe by hand , 46–50. M. bovis infection prevalence 13 months after vaccine deployment was markedly lower in the vaccinated blocks. Our sample sizes were too small to confirm the significance of protection with high statistical power, but, if not a chance effect, our result suggests a vaccine protective efficacy of 81%.In North America and in Western Europe, aerial distribution of free-choice oral vaccines has been used to vaccinate mesocarnivores against sylvatic rabies and to vaccinate wild boar against classical swine fever (CSF) virus . In lineRetrospective power-based sample size estimates have indicated that—with the low endemic prevalence of TB among possums in the NSIHC—further or repeat vaccine trials in this area would require greater effort if they are to stand a chance of achieving a result with strong statistical validity, involving in excess of 350 adult possums . That was not achievable with the trapping resources available to our studies largely because, with hindsight, the density of possums in this area was far lower than anticipated, although we cannot state with precision how low. At the time the study was instigated, the 3.3% trap-catch rate in the pilot trial area, along with previous survey data , was assM. bovis infection, are not yet available or reliable for use in free-ranging wildlife [et al. [M. bovis infection. The disparity between the 16% LPA positives in our trial and the 35% recorded in confirmed vaccinated possums by Tompkins et al. [Nevertheless, the statistically weak evidence of a vaccine effect that we recorded here is supported by the blood-testing results. Definitive blood tests to detect positive BCG vaccine responses, and to distinguish these from responses observed to virulent wildlife , howeverwildlife , it is k [et al.  reporteds et al.  suggestss et al.  has sugg2) was substantially higher than maximum deployment rates of up to 150 baits/km2 used in aerial rabies vaccination campaigns [First, the baiting rate could simply have been too low for all possums to encounter vaccine. That is unlikely because our deployment rate , furthendicated  so such S1 File(DOCX)Click here for additional data file.


In this work, we investigated the possibility of using the freeze-drying process in order to retain the native low impedance state and, thereby, improve the shelf-life of conductive polymer poly (PEDOT)-PSS modified neural electrodes. Control PEDOT-PSS coated microelectrodes demonstrated a significant increase in impedance at 1 kHz after 41–50 days of room temperature storage. Based on equivalent circuit modeling derived from electrochemical impedance spectroscopy, this increase in impedance could be largely attributed to a decrease in the interfacial capacitance consistent with a collapse and closing of the porous structure of the polymeric coating. Time-dependent electrochemical impedance measurements revealed higher stability of the freeze-dried coated microelectrodes compared to the controls, such that impedance values after 41–50 days appeared to be indistinguishable from the initial levels. This suggests that freeze drying PEDOT-PSS coated microelectrodes correlates with enhanced electrochemical stability during shelf storage.Coating microelectrodes with conductive polymer is widely recognized to decrease impedance and improve performance of implantable neural devices during recording and stimulation. A concern for wide-spread use of this approach is shelf-life,  Conductive polymer (CP) modified microelectrodes are promising for developing small but sensitive and powerful neural interfaces for recording and stimulation ,5,6,7,8.In general, the PEDOT modification of neural microelectrodes is very straightforward and involves electrochemical deposition ,12,13,14In our previous reports ,8 on theFreeze-drying, also known as lyophilization, involves the removal of the solvent directly from the solid phase to the vapor phase and has been reported to keep the native structure intact in porous nano-materials ,20. Insp3,4-Ethylenedioxylthiophene (EDOT) and Poly(sodium 4-styrenesulfonate) (PSS) were purchased from Sigma-Aldrich . Phosphate-buffered saline (PBS) was from Mediatech Inc. . Pt/Ir implantable microwires (PI20030.1A5) were obtained from MicroProbes for Life Sciences .vs. Ag/AgCl reference electrode .Cyclic voltammetry (CV) was used to dynamically eletrodeposit  the polyAfter the PEDOT modification, the microwire electrodes were rinsed with PBS, EIS was recorded and quickly freeze-dried using a Virtis Advantage  lyophilizer. The lyophilization protocol was immediate shelf freezing to −40 °C, followed by 12 h of primary drying, with subsequent temperature ramping to 20 °C and 8 additional hours for secondary drying. The freeze-dried microwires were placed in individual vials, flushed with high purity Nitrogen gas, sealed and stored. The control non-freeze-dried PEDOT: PSS modified microwires were similarly flushed with Nitrogen and stored.vs. Ag/AgCl reference electrode (scan rate was 1 V/s). The impedance was measured at the open circuit potential from 0.1 Hz to 1 MHz, with a peak-to-peak amplitude of the sinusoidal voltage of 20 mV. ZsimpWin  was used to fit the EIS data.CV and EIS of the modified Pt/Ir microwires were recorded using a potentiostat  in PBS at 22 °C. The potential range in CV was 0–0.5 V 2 in individual vials. The control group of 25 non-freeze-dried PEDOT-PSS modified microwires were similarly flushed with N2 and stored.A total of 50 commercially available implantable Pt/Ir microwire electrodes were electrochemically modified with PEDOT-PSS. Every 10 days, 5 freeze-dried PEDOT modified microwires and 5 controls were taken out from sealed vials, placed in PBS, and EIS was recorded. Any electrode showing 10% increase in the impedance at 1 kHz compared to that immediately after electrochemical deposition was considered to be failed. The impedance magnitude at 1 kHz was chosen because of its correspondence to the bandwidth of common electrophysiologic signals associated with neural recording ,12,22. Fpoly and Qpoly are the charge transfer resistance and the constant phase element or CPE of the associated non-ideal double layer capacitor across the polymeric interface, respectively. RS is the solution resistance and Cd is the double layer capacitance due to the pores and/or defect sites that directly expose the metallic electrode surface to the solution. Rpoly remains similar  using a previously published  electric similar  indicatiic aging ,8. Howev process ,8 and moThe most likely explanation for the higher stability of the freeze-dried PEDOT modified electrodes is that the freeze-drying process involves a quick initial transition to a frozen solid state and then evaporation of the solvent molecules directly from the solid to a vapor state. This process could essentially bypass the liquid phase related capillary-driven collapse of the porous PEDOT structure. In other words, freeze-drying locks the native structure of the polymer with the high electrochemically active surface area.In conclusion, we showed that freeze drying could be a useful method to increase the stability of PEDOT modified neural electrodes. We also demonstrated that the probable mechanism for the failure mode is related to the collapse of the porous polymeric structure, closing of the small pores first and consequent reduction in the electrochemically active surface area. We believe that these findings will facilitate a wider use of CP modified neural electrodes by improving the shelf-life for storage and transportation, and potentially reducing the cost through repeated and long term multiple use. Besides, this may also help other fields where conductive PEDOT films are extensively used, for example, in organic electronics.


The year 2015 was once more filled with exciting and important novel developments inthe field of invasive electrophysiology and implantable cardiac devices. Theseinclude technical innovation, novel molecular and cellular insights, andpresentation of large randomized clinical trials as well as important 'real-world'registries. In addition, several new guidelines surfaced in 2015, including thosefor the treatment of ventricular arrhythmias and prevention of sudden cardiac death.It is virtually impossible to cover all novel developments that would meritdiscussion in this type of overview; as a result, the authors had to make aselection, focusing on several important developments with direct implications fordaily clinical practice.1 This technology will become standard for AFcatheter ablation in the future. A word of caution: there is growing evidencethat more extensive ablation in the atria does not per seimprove the rhythm outcome after AF catheter ablation. The Minimax Trialcompared two ablation strategies for pulmonary vein isolation (PVI) in 234patients who underwent catheter ablation of paroxysmal AF: circumferentialantral PVI alone  vs. PVI with intravenous ridge ablation to achieveindividual PVI . After a mean follow-up of 17 ± 8 months,freedom from AF after limited 'minimal' ablation was not worse compared withmore extensive 'maximal' ablation .2 Previous data indicated thatadenosine-guided detection of dormant pulmonary vein re-conduction andsubsequent re-isolation of the veins can be successfully applied to improveoutcome of AF catheter ablation.3 However, a much bigger randomized trial published inEuropean Heart Journal now questioned the usefulness ofadenosine testing: in the Japanese UNDER anti-tachycardia pacing (ATP) Trial,2113 patients were randomized to either adenosine challenge or control and nodifference in AF recurrence rate was shown at 1 year.4 The reasons for the contradictory resultsreported from these two multi-centre, randomized trials are unclear at presentand deserve further investigation. Treatment with anti-arrhythmic drugs aftercatheter ablation was shown to reduce the AF recurrence 90 days after catheterablation in the EAST AF trial, however, at 1 year there was no difference inarrhythmia recurrence between treatment and control group.5 These results are quite in linewith the data of the AmioCat Trial.6 In AmioCat patients were randomized to amiodarone or placebofor 8 weeks after AF catheter ablation. While amiodarone treatment reducedhospitalizations and cardioversions in the 3-month post-ablation blankingperiod, there was no difference in AF recurrence rate at 6-month follow-up . Thus, anti-arrhythmic drugs may prevent early AFrecurrences after ablation but may not promote a better atrial re-modellingresulting in a higher sinus rhythm rate during follow-up. The 5-year follow-updata of the MANTRA-PAF Trial were reported during the ESC Congress in London:MANTRA-PAF evaluated the comparative effects of first-line radiofrequencycatheter ablation of AF with anti-arrhythmic drug therapy. At 2-year follow-up,there was no difference in cumulative AF burden between the ablation andanti-arrhythmic drug group, while the burden of AF was significantly lower inthe ablation group .9 Persistent AF ablation strategyhas never been mature enough for a consensus to emerge, neither in the past norin 2015. Rotor ablation using contact phase mapping has beenquestioned,10 andCAFÉ ablation is not specific enough to be convincing as demonstrated bya large meta-analysis.11 Incontrast, lifestyle modification such as weight loss is remarkably effective inreducing AF burden (10% loss translates into a six-fold AF burden reduction) andin inducing reverse remodelling on left atrial size and left ventricular septalthickness.12Catheter ablation of atrial fibrillation (AF) remained in focus of clinicalstudies and large-scale trials. The use of force-sensing ablation cathetertechnologies seems to improve the induction of durable atrial lesions and wasshown to significantly reduce AF recurrence rate after catheter ablation in ameta-analysis mainly made of non-randomized trials.13 Asthe fourth NOAC, edoxaban has been approved in 2015 in many countriesincluding the USA, Switzerland, and Europe based on the results of theENGAGE AF-TIMI 48 trial.15 the management ofrivaroxaban around catheter ablation for AF (VENTURE-AF),16 and the outcome ofamiodarone co-medication in patients receiving edoxaban,17 to name just a few.Virtually, all subgroups of the large NOAC trials indicate a consistentbenefit and safety of these drugs compared with warfarin, furtherunderlining their overall superiority. This is supported by importantreal-world data 18indicating efficacy and safety, which is in line with that observed in therandomized clinical trials.Due to the results from large-scale clinical trials, the non-vitamin Kantagonist oral anticoagulants (NOACs) are the preferred treatment forstroke prevention in non-valvular AF, as reflected in current ESCguidelines.19 Moreover, in a Phase 3 study, idarucizumabwas demonstrated to effectively and immediately reverse the anticoagulanteffect of dabigatran in patients presenting with serious bleeding orrequiring an urgent procedure.20 As a result, the US Food and Drug Administration hasapproved the drug in October 2015; the Committee for Medicinal Products forHuman Use of the European Medicines Agency has also recently issued apositive opinion, and approval is expected by the end of this year or early2016. Importantly, idarucizumab is ineffective against Xa-inhibitors;instead, different directly acting antidotes are being developed, includingandexanet alfa and PER977. First results are also positive with theseagents, and larger-scale clinical trials are anticipated within the year2016. While these drugs clearly represent an important addition to ourportfolio, many aspects in the practical use remain to be determined,including the type of patients and conditions requiring reversal and thetime of reinstitution of anticoagulation. These and other issues areelegantly described in the 2015 updated version of the European Heart RhythmAssociation practical guide,21 following the great success of its first versionpublished in 2013.22Arguably, the most exciting novelty in the field of NOACs comes from thedevelopment of specific reversal agents ('antidotes'). In a Phase 1 study inhealthy men, the monoclonal antibody idarucizumab (specific for dabigatran)was well tolerated with no unexpected or clinically relevant safetyconcerns, and was associated with immediate, complete, and sustainedreversal of dabigatran-induced anticoagulation.23However, these data do require validation in a prospective randomized trialbefore clinical practice for oral anticoagulation after catheter ablationmay be changed.24Will catheter ablation of AF have an impact on stroke risk? Novel data from alarge Danish registry suggest a very low risk of stroke for patients aftercatheter ablation.25; the importance of diagnosing andcorrectly triaging VTs, particularly those easily amenable to catheterablation  and/or riskof sudden cardiac death. The new ESC Guidelines for the treatment ofventricular arrhythmias and prevention of sudden cardiac death werepresented during the ESC congress in London.35 These guidelines provide up-to-datestate-of-the-art summary of current knowledge and best practice treatment inthis field.Catheter ablation of ventricular tachycardia (VT) is one of the fastestgrowing fields in interventional electrophysiologyablation , is a ch36During a mean follow-up of 1.9 ± 1.8 months (i.e. covering primarilythe perioperative and early postoperative period), no unanticipated seriousadverse device events were observed, including no device dislodgement andonly one pericardial effusion without tamponade . Of note, the latter occurred in a patient in whom thedevice needed to be repeatedly repositioned (18×). In the majority ofpatients (81%), however, the device was properly placed with no or only onerepositioning. During follow-up, electrical values including pacingthresholds, impedance, and sensing remained stable and favourable, resultingin an anticipated battery longevity of 12.6 years (range8.6-14.4).36 As aresult of these findings, the MICRA system received CE mark in the summer of2015, followed by careful rollout to selected centres and operators afterundergoing comprehensive in vivo and ex vivo training. These positiveinitial results were mirrored in a larger group of 725 patients, of whom 719(99.2%) underwent successful implantation.37 Electrical values  were favourable in 292 of 297 patients with paired 6-month data.There were 28 major complications in 25 of 725 patients . Thesenumbers compared favourably with historic controls undergoing transvenouspacemaker implantation. Importantly, no device dislodgements wereobserved.37Results of the second available single-chamber transcatheter pacing system,the Nanostim , were equally presented and published thisyear.38 In thefirst 526 patients undergoing implantation, the system was successfullyimplanted in 504 (95.8%). Of the 300 patients who completed 6-monthfollow-up, the primary efficacy outcome  wasreached in 90%. Of the total cohort of 526 patients, serious device-relatedadverse events occurred in 6.5% of patients, including cardiac tamponade in5 (1.0%), device dislodgement in 6 (in 1.5%), and device migration duringimplantation owing to inadequate fixation in 2 patients (0.4%). Furtherexperience with both leadless pacing systems will show how they compare ineven larger populations and in daily clinical practice.One of the main trends for cardiac devices in the year 2015 was the continuedmovement towards the abandonment of intravascular leads. After an initiallytedious start, leadless single-chamber pacemakers have finally arrived indaily clinical practice. Early results from the 140 patients receiving theMedtronic MICRA leadless pacemaker system demonstrated a favourable efficacyand safety profile.Patients with a typical single-chamber pacemaker indication currentlyrepresent the primary population for leadless pacers, i.e. permanent AF withsymptomatic bradycardia and/or AV block. Future studies and real-worldexperience will show how these device behave long term (including the novelrate-adaptive sensor system); first personal experiences are encouraging.The development for more advanced systems is ongoing, including dual-chamberpacemakers, cardiac resynchronization therapy, and communication with thesubcutaneous implantable cardioverter defibrillator (ICD).39 Defibrillation efficacywas not different between both groups during follow-up. Similarly, in theSIMPLE trial of 2500 patients, routine defibrillation testing did not resultin a reduction in arrhythmic deaths during a mean follow-up of 3.1years.40Implantable cardioverter defibrillator testing is no longer necessary duringroutine and uncomplicated ICD implantation: in the Nordic ICD Trial, 1077patients were randomly assigned to first time ICD implantation with (n =540) or without (n = 537) testing of defibrillation threshold.41 Previous results from randomized clinicaltrials and analysis from big data sets indicated that these technologies mayhave beneficial effects when applied appropriately.42 However, recent data fromthe Optilink HF Trial reported at the ESC Congress in London showeddisappointing results: the trial randomized 1002 patients with heart failureand an indication for ICD implantation to remote automated pulmonarycongestion alert 'on' (n = 505) or 'off' (n = 497). After 18 months offollow-up, there was no significant difference between groups in primaryendpoint, which was a composite of all-cause death and cardiovascularhospitalizations. More promising data are derived from the follow-up reportof the CHAMPION Trial that assessed the efficacy of automatic pulmonarypressure measurement in heart failure patients to guide and optimize heartfailure therapy.43 Thesuperiority of the treatment group over the control group previouslyreported was maintained for an additional 13 months to the end of theRandomized Access Period with a significant reduction of heartfailure-related hospitalizations by 33% and of all-cause hospitalizations by16%. Second, the good results in the treatment group were maintained duringan Open Access Period of another 12 months, during which no increase inhospitalizations was observed. Most importantly, heart failure-relatedhospitalizations and all-cause hospitalizations in the former control groupwere reduced significantly by 48 and 21%, respectively, after pulmonaryartery pressure information became available to guide therapy during theOpen Access Period. Thus, implant-based remote telemonitoring seems highlypromising to support heart failure therapy and it will be just a matter oftime when haemodynamic sensors will be combined with pacemakers,defibrillators, and cardiac resynchronization devices.Almost all pacemakers and defibrillators that are currently available havethe technical option for remote monitoring.45 Recently publishedregistry results have indicated a decreasing risk of complications,suboptimal programming, and (to a lesser degree) inadequate shock deliverieswith increasing experience and volume.46 In addition, the same registries demonstrated ahigh efficacy for the termination of VT and VF, with 90.1% of events(100/111) terminated with one shock and 98.5% (109/111) terminated withinthe available five shocks.35 Also, the S-ICD may beconsidered  in patients with difficult venous access, after thetransvenous ICD removal for infections or in young patients with a long-termindication for ICD therapy.35 Indeed, the lack of possibility to deliver ATP orbradycardia pacing remains the most important shortcoming of current S-ICDdevices. Combination of the S-ICD with leadless pacers clearly would be oneof the most obvious possible solution to this problem. However, withevidence-based programming (high-rate or long-duration detection zones), theoverall amount of delivered ATP will likely be decreasing as a result ofboth spontaneous VT termination and VTs occurring below the detection limit.A prospective, randomized trial (PRAETORIAN) comparing currently availabletransvenous and subcutaneous ICDs (i.e. without the possibility of ATP) hasbeen initiated and is currently ongoing.Ever since its approval in 2009, the subcutaneous ICD (S-ICD) system hasincreasingly gained attention and attraction. Indeed, its complete lack ofintravascularly placed electrodes is potentially associated with asubstantial reduction in morbidity  due to lead complicationsassociated with currently used 'classical' transvenous ICD systems. In 2015,the new generation EMBLEM S-ICD System was approved, the main feature ofwhich is its 20% thinner size combined with a 40% longer life expectancywhen compared with the previous S-ICD system. At the same time, novelalgorithms are being developed to overcome the risk of inadequate shockdeliveries.35 In the absence of arandomized clinical trial, this recommendation was based mainly on largeregistries such as the recently published prospective registry of patientsusing the wearable defibrillator (WEARIT-II), which followed 2000 recipientsof the WCD with a median wear time for 90 days.48 In this registry, a total of 120 sustainedventricular tachyarrhythmias (VT/VF) were observed in 41 patients. Of thesepatients, 54% received appropriate WCD shocks, while only 10 patients (0.5%)received inappropriate WCD therapy.Also for the first time, the new 2015 guidelines for the prevention of suddencardiac death give recommendations for the use of the wearable cardioverterdefibrillator WCD; . With aImportantly, at the end of the individual time frame of WCD use, an ICD wasimplanted in only 840 patients (42%), with an improvement in EF being themost frequent reason for withholding ICD implantation. Given the potentialcost saved for de novo ICD implantation as well as  associatedfollow-up cost and cost of complications, this strategy may in addition alsoturn out cost-effective, but comprehensive analyses in this regard arecurrently lacking.In the year 2015, many interesting studies have surfaced in the field of invasiveelectrophysiology and cardiac devices, most of which may have  important implications for daily clinical practice. Ongoing confirmationand expansion of these data with experience from the real world will be crucialto substantiate their efficacy and safety in the 'real world'. Coverage of allof the exciting developments in one concise review is impossible; as such,various methods and technologies had to be omitted for the time being, includingsome preliminary results on the use of multi-site pacing and comparisons ofpoint-by-point vs. single shot ablation. If the rate and quality of innovationpersists, undoubtedly the year 2016 will equally be a successful one in thefield of arrhythmias.