Real-time functional magnetic resonance imaging (rt-fMRI) neurofeedback aids the modulation of neural functions by training self-regulation of brain activity through operant conditioning. This technique has been applied to treat several neurodevelopmental and neuropsychiatric disorders, but its effectiveness for stroke rehabilitation has not been examined yet. Here, we systematically review the effectiveness of rt-fMRI neurofeedback training in modulating motor and cognitive processes that are often impaired after stroke. Based on predefined search criteria, we selected and examined 33 rt-fMRI neurofeedback studies, including 651 healthy individuals and 15 stroke patients in total. The results of our systematic review suggest that rt-fMRI neurofeedback training can lead to a learned modulation of brain signals, with associated changes at both the neural and the behavioural level. However, more research is needed to establish how its use can be optimized in the context of stroke rehabilitation. Behavio1.1Neurofeedback works as a closed loop system that provides real-time information regarding the participant's own brain activity and/or connectivity, which can be used to develop self-learning strategies to modulate these brain signals . It follThe origins of neurofeedback are rooted in electroencephalography (EEG), which measures dynamic changes of electrical potentials over the participant's scalp . This teThe field of neurofeedback has rapidly developed and delved into new avenues by the introduction of real-time functional magnetic resonance imaging (rt-fMRI) technology . Accordi1.2The last two decades have witnessed a proliferation of rehabilitation strategies to promote functional recovery after stroke, such as task-specific exercises, task repetition, mental and motor imagery, imitation and – among technological approaches – robot-assisted training, muscle stimulation, magnetic and electrical stimulation, and the use of virtual environments . However1.3neural and behavioural changes related to motor function or cognition. It thereby evaluates the potential of rt-fMRI neurofeedback-based therapy for stroke rehabilitation. More specifically, we aim to (1) provide an overview of empirical studies investigating the effectiveness of rt-fMRI neurofeedback in modulating brain function and behaviour in healthy individuals and stroke survivors; (2) evaluate the quality of the studies against pre-set methodological and theoretical criteria; (3) provide indications for investigating the use of rt-fMRI neurofeedback in the field of stroke rehabilitation.This systematic review examines whether rt-fMRI neurofeedback can induce 22.1http://www.rtfin.org/literature.html)) from 1970 to July 2017, and screened reference lists. We used the following keywords: FMRI AND  AND (stroke OR cognition OR attention OR memory OR perception OR language OR motor OR behaviour). For the rtFIN database, we searched for relevant studies by selecting the categories fMRI and Multiple modalities.We searched 4 databases  literature database  independently assessed the methodological quality of the studies according to the Joanna Briggs Institute (JBI) critical appraisal tools . We used3N = 17) explicitly examined the effect of rt-fMRI neurofeedback on behavioural outcome measures , degree of processing (presenting raw brain activity or a derived measure), and timing of the presentation (continuous or intermittent). A few studies gave feedback in the auditory modality (modality , whereasmodality . About hmodality .Behavioural outcome measures. The reviewed studies that investigated behaviour included a variety of outcome measures chosen to fit the experimental paradigms of each study. An important factor to consider is the sensitivity of the outcome measures used: if a study does not report significant behavioural changes, it may simply be due to the fact that the outcome measure is not sufficiently sensitive. From this perspective, recent studies have highlighted the importance of using computerized tests for a refined quantification of the participants' performance on a variety of motor and cognitive tasks (ve tasks . Also, tve tasks . Overallve tasks .Follow up/transfer. The current review included only a limited number of long-term follow-up studies in healthy participants, and none in stroke patients (patients . Previoupatients , but thi4.3The findings of this systematic review suggest that rt-fMRI neurofeedback may be effective in ameliorating motor and cognitive deficits in stroke patients. Nonetheless, the limited number of patient studies does not allow to draw conclusions about the efficacy and effectiveness of this technique, which still need to be thoroughly evaluated in future studies. The use of different neurofeedback training approaches and outcome measurements complicates any direct comparison between studies aimed at ameliorating the same function. Although no golden standard exists for the assessment of cognitive and motor impairments in stroke patients, a more consistent selection of methods would ease the comparison of the results obtained across studies. Based on the considerations above, we suggest that future double-blind randomized experiments should include a relatively large number of stroke patients to permit group-level inferences about the efficacy of rt-fMRI neurofeedback. Also, systematic outcome measures on behavioural functions should be used, possibly relying on a standardized battery of clinically-relevant tests . Finally5Effective rehabilitation approaches to improve motor and cognitive function of stroke patients are still lacking. The results emerging from this systematic review suggest that rt-fMRI neurofeedback permits self-regulation of brain activity and can lead to behavioural effects. As such, a more widespread application in the field of stroke rehabilitation is warranted. Neurofeedback may prove particularly useful in early stages after stroke, when physically strenuous interventions are not possible or recommended. In particular, neurofeedback can show the participants that they can take control over seemingly volitionless aspects of their impairment. This feeling of increased control will most likely benefit the individual through the recovery process. Additionally, neurofeedback training in the chronic stage of stroke, where spontaneous recovery has stopped, may trigger functional reorganization in structurally intact parts of the brain, possibly leading to a behavioural recovery that would otherwise not occur.


Pancreatic neuroendocrine neoplasms (PanNENs) are uncommon tumors. Fine needle aspiration (FNA) samples from PanNENs are typically of high cellularity and lack necrosis. In cytology slides from these tumors, dyscohesive cells are usually reported with variably round to oval to plasmacytoid forms exhibiting coarsely granular chromatin and showing immunoreactivity for synaptophysin. We present an unusual, and to our knowledge not previously described, example of an FNA of a PanNEN with large extracellular fibrous spheroids containing intrinsic fibroblasts and rimmed by small to intermediate sized neoplastic epithelial cells with high nuclear cytoplasmic ratios. The cytomorphology of the PanNEN in this case was in some ways reminiscent of that expected in adenoid cystic carcinomas of the salivary glands that most often contain large extracellular globules of basement membrane material and a somewhat biphasic population of lesional cells. The cytomorphology in this case was found to correlate well with the resection specimen histomorphology of an exaggerated gyriform pattern of growth resulting in a unique cobblestone-pavement like microscopic appearance. Knowledge of this potential cytomorphology will aid the cytology community through recognition and reporting of this previously undescribed pattern in an uncommon disease. Pancreatic neuroendocrine neoplasms (PanNENs) are uncommon lesions that occur in approximately 1 out of 100,000 people and constitute 2% of all pancreatic tumors . These lAdvances in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) have been a boon to the detection, diagnosis and staging of PanNENs , 5. EUS-We present the cytology of an EUS-FNA sampled PanNEN with a unique, and to our knowledge, previously unreported cytomorphologic appearance of prominent extracellular spheroids of intrinsic fibrous tissue. The cytology correlates to the histoarchitectural appearance of a gyriform type PanNEN with an unusual and exaggerated fibrous cobblestone-pattern of growth. The final resection specimen and ancillary studies in this case confirm the diagnosis of a PanNEN and exclude the key morphologic differential diagnosis of a pancreatic solid-pseudopapillary neoplasm (PSPPN).The patient was a 41-year-old female with a past medical history significant for an anxiety disorder, clinical depression and obesity. She was a lifelong never smoker and reported occasional use of alcohol. She had no personal or first degree family member history of visceral malignancy. She presented approximately one month prior with complaints of dull, achy, right upper quadrant abdominal pain. This pain worsened after eating. A low fat diet was prescribed with incomplete resolution of symptoms. Esophagogastroduodenoscopy (EGD) was performed and showed no focal findings. Right upper quadrant ultrasonography (US) and magnetic resonance imaging (MRI) studies confirmed a 4.6 × 4.2 × 3.5 cm mass lesion in the distal pancreatic body with no pancreatic duct dilatation . Becauseβ-catenin  as well as 30 ml of blood-tinged CytoLyt (Hologic) fluid containing particles. The fluid portion of the specimen was used to create a ThinPrep (Hologic) liquid based slide, and a Cellient (Hologic) cell block was also created. The modified Giemsa stained slides were used for ROSE with interpretations of adequate cellularity and atypical cells given. The majority of the cellular material in the ROSE slides consisted of three-dimensional microbiopsy tissue particles which were present predominantly in the central areas of the direct smears. These microbiopsy particles contained homogenous magenta spheroids with intimately associated spindled cells and collections of intervening, high nuclear/cytoplasmic ratio, small to intermediated sized cells with crush artifact . Similar-catenin . A diagnβ-catenin and with a low (<3%) proliferation index on Ki-67 testing , grade 1 with negative margins and four uninvolved regional lymph nodes. The majority of the histologic sections showed an exaggerated gyriform pattern of growth resulting in a cobblestone pavement-like architectural pattern with eosinophilic discs of fibrous stroma surrounded by neoplastic cells . The neo testing . Six monGastroenteropancreatic neuroendocrine neoplasms occur infrequently, but their incidence has increased six-fold over the last three decades . ReportePanNETs are known to have varied histo-architectural and cytologic appearances with the histomorphology of well-differentiated PanNETs being similar to that of low grade neuroendocrine tumors at other body sites. PanNETs are often delineated from background pancreatic parenchyma by a pushing border and sometimes a fibrous pseudocapsule. Neoplastic cells can be arranged in many patterns with pseudoglandular, trabecular, organoidal, festooned, ribbon-like, angiomatoid, nested, rosette-like, and sheet-like patterns reported . Gyrifor9–β-catenin immunoreactivity in PSPPNs have been touted as sensitive and specific markers for the two tumors [Differential diagnostic considerations in both histopathologic and cytopathologic specimens may include adenocarcinomas, pancreatic solid pseudopapillary neoplasms (PSPPNs), acinar cell tumors, hematolymphoid neoplasia, chronic pancreatitis, metastatic neoplasms from distant body sites, and others. Cytologic overlap between cases of PanNETs and PSPPNs can lead to difficulty and challenge in accurately separating these entities. Some authors have emphasized morphologic nuances that may be of value in distinguishing PanNETs from a PSPPN. With clear cells, nuclear folds/grooves and small, intracellular hyaline globules favoring PSPPN , 14. Theo tumors , 16. In o tumors .Ki-67 labeling has emerged as a cornerstone for histologic grading of PanNETs and is now incorporated into the WHO classification scheme . In our β-catenin immunoreactivity may be rarely encountered in PanNETs. A recent error reduction focused study of the cytologic criteria for the diagnosis of PSPPNs by EUS-FNA emphasized the presence of fine (and not coarsely granular) chromatin, nuclear grooves, pseudo papillae, pink stroma and small intracellular cytoplasmic hyaline globules as being statistically significantly associated with PSPPNs [Overlap of cytomorphologic features between PanNETs and PSPPNs can result in difficulty when attempting to accurately classify EUS FNA samples, and in some instances ancillary IHC studies may not allow for exact classification, as the synaptophysin immunoreactivity expected in PanNETs may on occasion be present in PSPPNs, and spurious h PSPPNs . In our


Hereditary amyloidosis refers to a wide spectrum of rare diseases with different causative mutations in the genes of various proteins including transthyretin, apolipoprotein AI and AII, gelsolin, lysozyme, cystatin C, fibrinogen Aα-chain, β2-microglobulin, apolipoprotein CII and CIII.Among hereditary amyloidosis subtypes, we describe here a specific case of Apolipoprotein AI amyloidosis (AApoAI), where the diagnosis began from an almost asymptomatic hepatomegaly followed by the development of primary hypogonadism. Baseline laboratory tests showed increased liver enzymes, while imaging tests revealed a suspected infiltrative liver disease. Patient underwent into liver biopsy and histological examination detected the presence of periodic acid-Schiff (−) and Congo-red (+) amorphous eosinophilic material within normal liver tissue. In the typing of amyloid by immunoelectron microscopy, the liver appeared heavily infiltrated by anti-apoAI (+) amyloid fibrils. Gene sequencing and mutational analysis revealed a single-base mutation at position c.251 T > C resulting in an amino acid substitution from leucine to proline in the mature ApoAI protein. This amino acid change led to lower cleavage and ApoAI deposition into the involved organs. Few years later, our patient remaining without treatment, came with symptoms consistent with primary hypogonadism but testicular involvement with ApoAI deposits could not be proven since the patient refused testicular biopsy. Based on this case, we recap the diagnostic challenges, the clinical manifestations, and the potential treatment options for this indolent hereditary amyloidosis subtype.This case-report enlarges the clinical picture of ApoAI-driven disease and its complex genetic background and in parallel suggests for a more systematic approach in any case with strong suspicion of hereditary amyloidosis. Hereditary amyloidosis includes a group of rare diseases, usually inherited in an autosomal dominant manner and characterized by extracellular deposition of insoluble fibril proteins in target organs, causing disruption of their structure and function , 2. TherAPOA1 gene, located on chromosome 11q23-q24, encodes the primary form of apolipoprotein AI (ApoAI). ApoAI is synthesized as a pre-protein by the liver and the intestine, is cleaved by plasma protease, providing the long mature form and degraded mainly in kidney [APOA1 gene are known, of which more than 20 have been associated with hereditary ApoAI amyloidosis (AApoAI) [APOA1 gene results in the deposition of ApoAI in various tissues causing distinct clinical syndromes with different age of onset, pattern of organ involvement, progression rate, and prognosis [The n kidney , 6. ApoAn kidney . More thrognosis –10.In this report, we present the case of a middle-aged male patient with a rare presentation of ApoAI amyloidosis, describing the indolent course of his disease, and discussing the diagnostic challenges and the possible treatment options.A 48-year-old man  with a past medical history of vitiligo, was admitted to our center  due to bloating and sense of “fullness” in the right upper quadrant of his abdomen, worsening gradually during the past few weeks before his presentation. No fever or dyspnea was reported and the patient had no signs of chronic liver disease. On physical examination, palpable hepatomegaly was detected but without splenomegaly. The patient reported no symptoms of peripheral or autonomic neuropathy and the neurologic exam was unremarkable.Liver function tests showed increased alkaline phosphatase  and gamma-glutaminotransferase levels (~ 8 times UNL) while both alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were only slightly increased (<2xUNL). Serum bilirubin, creatinine and albumin levels were in normal range, no prolongation of clotting time or proteinuria was observed. Following imaging tests, abdominal ultrasound showed a liver span in the mid-clavicular line of 21.5 cm, and in consistence, computed tomography (CT) showed diffuse liver enlargement and a reduction in portal vein diameter. An infiltrative liver disease was suspected.After the baseline work-up and within the first week of patient admission, liver biopsy was performed and histologic examination revealed the presence of periodic acid-Schiff (PAS) negative amorphous eosinophilic material within normal liver tissue and portal areas. Initial Congo red staining was negative but due to high clinical suspicion for amyloidosis, a second tissue evaluation was performed and was positive for Congo red. However, immunohistochemistry was unclear, since both anti-kappa and anti-lambda as well as anti-AA staining were positive, probably due to absorption. Serum and urine immunofixation were negative and serum free light chains were normal. Cardiac biomarkers (NTproBNP and hsTnT) were within normal range. No evidence of heart involvement was found in cardiac echocardiography.CTG to CCG. This change resulted in a amino acid substitution, from leucine to proline in the peptidic residue 60 of the mature ApoAI.protein. Sanger sequencing was used for subsequent screening of the proband family members; his siblings (two brothers) and his mother lacked the mutation, but paternal DNA was unavailable.Liver tissue sample was sent for typing of amyloid to Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo and University of Pavia, Italy. By immunoelectron microscopy performed according to the standard already published methodology , 12, theThe patient received no treatment and remained in 6-months follow-up. Two years later he came for his scheduled visit complaining for erectile dysfunction. No other signs or symptoms of autonomic neuropathy were present. Further testing revealed low testosterone levels with concomitant high levels of gonadotrophins, consistent with primary hypogonadism while subsequent semen analysis showed azoospermia. Scrotal ultrasound showed normal size of the testicles. Primary hypogonadism was attributed to testicular involvement, but this hypothesis could not be proven since the patient refused testicular biopsy.The patient remains in stable very good clinical status for the past 4 years in regular follow-up visits, without evidence of deterioration of his liver or other organ function. His symptoms due to hypogonadism have resolved with testosterone-replacing therapy. The CARE guidelines were followed in reporting this case .In this report, we recognized a case of hereditary AApoAI caused by a novel single nucleotide mutation c.251 T > C in the APOA1 gene, described for the first time in a patient of Greek ancestry. This single-base mutation resulted in an amino acid substitution from leucine to proline in the mature ApoAI.protein, leading to lower cleavage and increased deposition of ApoAI into the involved organs. In our case, the ApoAI-driven disease presented initially with liver involvement followed by the development of primary hypogonadism most probably due to the deposition of ApoAI in extracellular testicular tissue. Hypogonadism as a clinical presentation has also been reported in other cases of AApoAI –9 and thhttps://www.uniprot.org/uniprot/P02647) and pinpoints on this pattern the exact sites of identified mutations (http://www.amyloidosismutations.com/cdna-aapoai.html). For example, another already described mutation in the same genetic locus of APOA1 leads to Leu60Arg amino-acid substitution and has a totally different phenotype [In general, each specific mutation results in a syndrome with different clinical manifestations and organ involvements . Figure henotype . Leu60Prhenotype . This ishenotype . Among khenotype  and onlyhenotype , 19, theThe absence of thorough family history, the lack of recorded symptomatology and of DNA sampling from the paternal side may not allow us to depict the comprehensive inherited figure of the disease but this missing information reflects also the high likehood of loosing such a diagnosis due to relatively indolent disease course with no clear organ dysfunction. The use of immunoelectron microscopy allowed the precise diagnosis and typing of amyloid in this patient. Using as an example our case, the role of amyloid typing with immunoelectron microscopy and mass spectrometry, should be acknowledged and emphasized as critical components of the diagnostic approach , 12.In contrast to AL amyloidosis, in hereditary forms of amyloidosis the elimination of the production of the precursor protein is not usually a realistic target and their management focuses on addressing symptoms in target organs. Some patients with AApoAI amyloidosis may require cardiac, liver or renal transplantation due to severe organ insufficiency over the course of the disease. Liver transplantation (orthotopic transplantation) has been suggested as a therapeutic option, for familial AApoAI  when theIn conclusion, this is a case report presenting a previously unknown amyloidogenic single point mutation in APOA1 gene associated with hereditary ApoAI amyloidosis with liver and gonadal involvement. Amyloidosis should be timely considered in individuals presenting with chronic elevation of cholestatic enzymes especially when no other alternative explanation exist. The suspicion of amyloidosis is the most important step in the diagnostic approach; however, advanced technology may be required for the accurate diagnosis and the correct typing of amyloid.


Chyle leaks may occur as a result of surgical intervention. Chyloperitoneum, or chylous ascites after liver transplantation, is rare and the development of chylothorax after abdominal surgery is even more rare. With increasingly aggressive surgical resections, particularly in the retroperitoneum, the incidence of chyle leaks is expected to increase in the future. Here we present a unique case of a combined chylothorax and chyloperitoneum following liver transplantation successfully managed conservatively. Risk factors for chylous ascites include para-aortic manipulation, extensive retroperitoneal dissection, use of a Ligasure device, and early enteral feeding as well as early enteral feeding. The clinical presentation is typically insidious and may include painless abdominal distension. Diagnosis can be made by noting characteristic milky white drainage which on laboratory examination has a total fluid triglyceride level >110 mg/dl, an ascites/serum triglyceride ratio of >1 and a leukocyte count in fluid >1000/uL with a lymphocyte predominance. Chyle leaks may lead to significant morbidity and mortality. Numerous management options exist, with conservative nonoperative measurements leading to the most consistent and successful outcomes. This includes a step-up approach beginning with dietary modifications to a low-fat or medium chain triglyceride diet followed by nil per os with addition of total parenteral nutrition and somatostatin analogues such as octreotide. Rarely do patients require more invasive treatment. Early recognition and appropriate management are imperative to mitigate this complication. Chyle leaks, manifesting as chylothorax or chyloperitoneum/chylous ascites, can be broadly categorized into non-traumatic and traumatic etiologies. The latter can occur as a result of surgery. Chylous ascites is a rare complication after liver transplantation with reported incidences of 0.6-7% –7. ChyloWe herein present a unique case of combined chylothorax and chyloperitoneum following liver transplantation successfully managed conservatively.The patient is a 56-year-old female with end-stage liver disease  secondary to chronic hepatitis C genotype 1 likely contracted secondary to blood transfusion after a motor vehicle accident 40 years prior who presented for a deceased donor Liver transplantation. She had a 35-pack year smoking history. Preoperative morbidities included grade 2 esophageal varices, portal hypertensive gastropathy, encephalopathy and fluid overload as manifested by ascites and hydrothorax. She required regular therapeutic paracenteses every 3 weeks and weekly thoracenteses prior to her transplant.The liver donor was positive for the hepatitis C virus and deemed high risk according to the Center for disease control and prevention (CDC) criteria. The cause of death was determined to be due to heroin overdose.She underwent an orthotopic Piggy-back liver transplant with a duct-to-duct biliary reconstruction with stent and cholecystectomy. Additionally, an abdominal transdiaphragmatic thoracentesis was performed for drainage of a right-sided hydrothorax. Ultimately, a right-sided chest tube was placed due to significant persistent right-sided hepatic hydrothorax. Two 19F blake drains were placed in the perihepatic space. Cold ischemia time was 6h 44min. Warm time was 33 min. Total operative time was 7h 13min.Her early postoperative course was unremarkable and she progressed appropriately. She was extubated shortly after surgery and her liver function tests (LFTs) trended down. Postoperative day (POD) 1 a liver ultrasound was obtained and demonstrated patent vasculature with normal directional flow with resistive indices of 0.72-0.77. The chest tube was placed to water seal on POD3 and subsequently removed along with the abdominal drains. She developed an acute kidney injury and a hypotonic, hypovolemic hyponatremia which was attributed to intravascular volume depletion which improved with sodium bicarbonate and fluid restriction. She was discharged home with home physical therapy on POD11. Her immunosuppressive therapy included thymoglobulin induction . Steroid taper began on POD1. Tacrolimus was initiated on POD3. She received perioperative antibiotic prophylaxis.Two days after discharge she was seen in clinic at which time a chest x-ray demonstrated presence of a large right hydrothorax/pleural effusion . She undChyle leaks can occur through various mechanisms, one of them due through direct leakage (such as lymphatic disruption after trauma or surgery) . They caThe clinical presentation of chyle leak is typically insidious and related to the anatomic location with painless abdominal distension and dyspnea as presenting symptoms in chylous ascites and chylothorax, respectively. The diagnosis is made by a combination of drainage of milky white fluid which may have a temporal relation with initiation of enteral feeds, total fluid triglyceride (TG) level >110 mg/dL, ascites/serum TG ratio of >1, leukocyte count in fluid >1000/uL with a lymphocyte predominance , 17. AddRisk factors for chylous ascites after Hepatobiliary surgery and liver transplantation include para-aortic manipulation, retroperitoneal invasion, early enteral feeding , presence of pretransplant ascites and use of LigaSure vessel sealing system (LVSS) for perihepatic dissection.. In our The management options are numerous, with conservative enteral management resulting in the most consistent and successful outcomes with resolution of up to 100% of cases with multimodal therapy. This entails typically a step-up approach beginning with a low-fat or medium chain triglyceride (MCT) diet, as these are not absorbed through the lymphatics, and dietary cessation of long chain triglycerides (LCT) leads to a significant decrease in the rate of lymphatic flow promoting closure of any leak. The next step is making the patient nil per os (NPO) with the addition of total parenteral nutrition (TPN) followed by octreotide, a somatostatin analogue , 4, 19. Chyle leak is a rare complication of surgical interventions which is expected to increase with expansion expanded indications for neoadjuvant therapy and retroperitoneal and transplant surgery. Additionally, increased use of diagnostic imaging may also contribute to rise in the rate of diagnosis of chyle leaks. Consequences of chyle leaks may be major and lead to significant prolongation in length of hospital stay, morbidity, and mortality especially with delays in recognition and management. There is significant overlap in the treatment of various anatomic locations of chyle leaks and prior surgery in one anatomic compartment does not preclude a chyle leak in another. The majority of patients see improvements with a step-up approach of conservative therapy and infrequently require invasive treatment.


Sporadic Creutzfeldt-Jakob disease (CJD) is the most common prion disease, resulting in rapid neurocognitive decline, and is universally lethal. CJD has a confounding clinical presentation with similarities which overlap with many other neurodegenerative disorders. Brain biopsy is the current gold standard; however, less-invasive initial screening tests are also utilized. These include brain magnetic resonance imaging (MRI), electroencephalography (EEG), and cerebrospinal fluid (CSF) laboratory studies.Five patients presented to our facility with varying levels of nonspecific cognitive impairment and movement disorders. CJD was initially suggested after review of each patient’s brain MRI. The T2-weighted fluid attenuation inversion recovery and diffusion-weighted images in each case demonstrated varied classic patterns of signal abnormality involving the cortex, basal ganglia, thalami, and brainstem. EEG and CSF studies were confirmatory in three and four patients, respectively (EEG not performed in one patient). One death occurred two months after initial presentation, and the other four patients were transferred to hospice three, four, nine, and 20 months after initial presentation.Radiological evaluation is an invaluable component of the workup for nonspecific neurodegenerative disorders because brain MRI may suggest the initial diagnosis of CJD, as demonstrated in our presented cases. Familiarity with the spectrum of classic MRI findings suggestive of sporadic CJD can improve radiologists’ role in early detection of the most common prion disease. Clinicians may benefit from understanding the utility of the newer CSF laboratory studies , which are far less invasive than the gold standard of brain biopsy. Early diagnosis can help save medical resources and guide clinicians to form appropriate plans of care with the patient and family. Creutzfeldt-Jakob disease (CJD) is an uncommon cause of dementia, but must be considered as a differential diagnosis when suggested by a rapid onset, suggestive electroencephalography (EEG), or imaging findings. CJD has a global incidence of approximately 0.5 to one cases per million . There aCJD is a prion disease, which demonstrates unique findings on pathologic analysis. Gray matter undergoes neuronal loss and vacuoles form in the neuropil creating a “sponge-like” appearance . Newer cFive cases of CJD at our institution are discussed below with a review of clinical, imaging, and laboratory findings. Based on MRI findings, the diagnosis of CJD can be suggested by University of California-San Francisco (UCSF) revised criteria proposed in 2011, summarized in Table Case 1A 67-year-old female initially presented with cognitive decline over two weeks, accompanied by vomiting, hallucinations, and blurred vision. She had a history of breast cancer and a recent cruise to the Bahamas, during which she remained on the boat due to inclement weather. She was admitted at an outside hospital and became progressively less responsive. She then became unresponsive and was transferred to our facility for critical care and video EEG monitoring.An MRI demonstrated asymmetric, diffuse hyperintensity of the cortex and striatum on T2-FLAIR and DWI sequences Figure . Using tCase 2A 61-year-old female with history of type 2 diabetes mellitus, hypertension, and hypothyroidism, presented with persistent dizziness. A brain MRI demonstrated an acute right middle cerebral artery infarct affecting the right insular cortex and right corona radiata without any evidence of CJD (“MRI definitely not CJD”). The patient was discharged after appropriate treatment for stroke. Six weeks later she presented from home with increasing confusion, weakness, difficulty ambulating, and hallucinations. A brain MRI demonstrated very subtle restricted diffusion in the bilateral frontal cortices, basal ganglia and thalami, greater on the left . Six months after the initial diagnosis, the patient was reported to have intermittent confusion, gait disturbance, and occasional bladder and bowel incontinence. At this time he began receiving home hospice services . One year after the initial presentation, the patient had lost 40 lbs in the last six months, was nearly unresponsive, and unable to ambulate.Case 4A 72-year-old female presented with rapidly increasing dementia for the past two months, aphasia, hallucinations, and oculomotor and facial apraxia. Twenty months prior, the patient presented to an outside facility with dementia and gait disturbance and was diagnosed with Parkinson’s dementia. She demonstrated some initial improvement with carbidopa/levodopa, but the effect was only temporary. Eleven months prior to presentation at our institution, she underwent nasal surgery and afterward developed increasing confusion and hallucinations. Nine months prior to presentation, she had a fall and developed epidural and subdural hematomas, which confounded the clinical and imaging findings.The brain MRI demonstrated asymmetric restricted diffusion involving the striatum and frontal/temporal/insular cortex with notable involvement of the cingulate gyrus Figure . Using tCase 5A 60-year-old male with a history of hemochromatosis, type 2 diabetes mellitus, and hypothyroidism presented to an outside hospital with word finding difficulty and blood glucose level of approximately 400 mg/dL (with HbA1c 13.1%). An MRI performed at the outside hospital was interpreted as only demonstrating age-related white matter changes. The patient experienced declining mental status with unintelligible speech two weeks after presentation and intermittent jerking and weakness of the right upper extremity. With continuing decline, the patient was transferred to our facility three weeks after initial presentation. A new MRI was performed at our facility, which demonstrated asymmetric (left greater than right), diffuse DWI hyperintensity of the bilateral cortex and striatum Figure .Using the 2011 UCSF modified grading system, the imaging met criteria for “MRI definitely CJD.” Results for CSF studies returned two weeks later and were negative for RT-QuIC, positive for T-tau, and inconclusive for 14-3-3 protein due to blood in the sample. An EEG showed generalized rhythmic delta activity with delta brush. Neonates normally may demonstrate a delta brush, which abates within the first month of life. Pathologically, the delta brush is a nonspecific sign of metabolic or structural abnormalities and often portends a worse prognosis in adult patients . At thisCJD is classically described as a rapidly progressive dementia. Nonspecific symptoms cause difficulty in diagnosing CJD with top differential diagnoses including Alzheimer disease and dementia with Lewy bodies . In addiCJD continues to present a diagnostic challenge with brain biopsy still considered the gold standard for diagnosis but carries the risk of contamination of the surgical suite and pathology lab. As demonstrated by the review of these five patients, clinical presentation, MRI, EEG, and CSF lab testing cannot always provide a definitive diagnosis. Table Imaging plays a vital role in the diagnosis of CJD. Computed tomography (CT) scans of the brain typically have little to no diagnostic value in the evaluation of rapidly progressive dementia, often demonstrating nonspecific atrophy or otherwise normal findings. MRI is the superior imaging test; specifically, DWI and T2-FLAIR. Spongiform changes propagate early in the disease process causing vacuole formation in the gray matter, which restricts diffusion with hyperintense signal greater on DWI than T2-FLAIR. Later in the disease process, gliosis predominates, and hyperintense signal on T2-FLAIR will typically be greater than on DWI .Several guidelines have been created over the years to assist in diagnosing CJD including the World Health Organization, MRI-CJD consortium, and most recently the proposed UCSF revised criteria in 2011 . PositivThe five cases demonstrate the spectrum of typical MRI findings in CJD patients. Of patients with MRI findings consistent with CJD, only one-third have initial involvement of the basal ganglia . It is sOn EEG, sharp-wave complexes are the characteristic finding in CJD with a sensitivity and specificity of 66% and 74%, respectively . The genCSF testing allows for a less-invasive option to perform laboratory testing when compared to brain biopsy and pathologic analysis. RT-QuIC is a direct test for prion disease from CSF samples. RT-QuiC has demonstrated a sensitivity of 87-91% and specificity of 98-100% [Radiological evaluation is a critical component of the initial workup for nonspecific neurodegenerative disorders because brain MRI may suggest the initial diagnosis of CJD, as demonstrated in our presented cases. Radiologist’s familiarity with the spectrum of classic MRI findings suggestive of sporadic CJD can facilitate early detection of this most common prion disease. Clinicians may also benefit from understanding the utility of the newer CSF laboratory studies , which are far less invasive than the gold standard of brain biopsy. Early diagnosis can help save medical resources, avoid unnecessary procedures, and guide clinicians to form appropriate plans of care with the patient and family.


Preparation of organic–inorganic hybrids with conventional conjugated polymers such as polyfluorene (PF) and poly(3-hexylthiophene) (P3HT) were demonstrated via the facile blending in solution by employing polyhedral oligomeric silsesquioxane (POSS) having heterogeneous alkyl substituents. From the optical measurements, it was shown that the modified POSS derivatives played a critical role in facilitating amorphous state of polymer matrices. Interestingly, although inter-strand interaction decreased after POSS addition in the hybrid films, thermal stability can be enhanced in the presence of the modified POSS with long alkyl chains. Furthermore, it was demonstrated that carrier mobilities through the hybrid film was minimally reduced by POSS. These results suggest that POSS should be a versatile building block to form hybrid with various types of polymers for enhancing durability without loss of electronic properties of organic components. By mixing organic molecules and inorganics at the nano level, robust materials, called organic–inorganic hybrids, are created, which have multiple functions originating from both components . BecausePolyhedral oligomeric silsesquioxane (POSS) has attracted attention for preparing functional hybrids ,8,9,10 aHerein, we report the influence on electronic properties and enhanced thermal stability of hybrids composed of conjugated polymers by loading POSS derivatives having dual types of alkyl substituents. Three types of heterogeneous POSS derivatives with two kinds of alkyl substituents were synthesized, and. from the solution method, polymer hybrids with conventional conjugated polymers such as polyfluorene (PF) and poly(3-hexylthiophene) (P3HT) were prepared by loading octa-substituted alkyl POSS. The series of measurements for optical and thermal properties and carrier-transport ability revealed that the heterogeneous POSS derivatives can improve thermal stability without critical losses of other properties. This is the first example, to the best of our knowledge, demonstrating the applicability of POSS “element-block” for fabricating hybrids with conjugated materials without losses of optoelectronic properties of conjugated polymers.iso-butyl (iC4) and cyclopentyl (CP) groups on POSS have relatively lower affinity toward conjugated polymers and induced loss of thermal stability, while the octadecyl (C18) group can enhance thermal stability of the matrices . It. It34]. Luminescent properties were also examined with the hybrid films . In the Next, thermal stability of the hybrid films was evaluated with thermogravimetric analysis TGA, . Degrada−3 cm2 V−1 s−1. Compared to each pristine polymer, significant changes in the mobility were not observed. Furthermore, the carrier mobilities decreased with an increasing external electrical field with similar extents  experiment in which the transient photocurrent generated with a laser pulse was monitored by an oscilloscope  40,41,4,441,42.  extents . TypicalIt was demonstrated that POSS “element-blocks” enable transformation of conjugated polymers into thermally-stable hybrid materials without critical losses of optical and electronic properties provided by the organic components. This was accomplished by POSS cages controlling the solid-state packing within the hybrid composition. Moreover, by selecting the type of substituents as the longer alkyl chain on POSS, miscibility was enhanced, indicating that hybrid formation based on POSS “element-blocks” possess a wide applicability to various polymer matrices. This information on property–structure relationships would be helpful for designing further effective fillers for modulating optoelectronic functions as well as thermal properties of conjugated polymers. In the development of organic opto-electronic devices, reinforcement of durability is still one of big issues to be overcome. Our concept and materials could be valid to satisfy these demands.


Bone sialoprotein (BSP), a member of the SIBLINGs  family, has recently be associated to inflammatory and infectious diseases. We therefore measured BSP concentrations in 136 patients at admission to the intensive care unit (ICU) and 3 days of ICU. BSP levels were compared to 36 healthy blood donors and correlated to clinical data. In these analysis, BSP serum levels were strongly elevated at the time point of admission to the ICU when compared to healthy controls. Moreover BSP concentrations were significantly elevated after 3 days of treatment on the intensive care unit. A further increase in BSP levels was detected in patients with higher APACHE-II-scores and in patients with septic disease. While in most patients, BSP levels decreased during the first three days of treatment on a medical ICU, patients with persistently elevated BSP levels displayed an unfavorable outcome. In these patients, persistently elevated BSP concentrations were a superior predictor of mortality than established indicators of patient´ prognosis such as the SAPS2 or the APACHE-II score. In summary, our data argue for a novel utility for BSP as a biomarker in patients treated on a medical ICU. Serum based markers allowing the early diagnosis of septic disease or predicting the clinical fate of critically ill patients would be of high relevance for guiding patients’ treatment, highlighting the persistent demand for new biomarkers in the context of critical illness and sepsis2, multiple sclerosis3, lupus erythematosus4 and Crohn’s disease5, highlighting the role of this protein family in inflammatory and infectious diseases. We have recently reported that serum levels of Osteopontin, another SIBLING protein, were significantly elevated in critically ill patients. Of note, elevated OPN levels were strong predictor for an unfavourable patients’ outcome6. Moreover, we demonstrated that in patients with cholangiocellur carcinoma, display higher serum Osteopontin concentrations when compared to controls. In these patients, elevated serum levels of Osteopontin indicated a poor patients’ outcome and more postoperative complications7.The so called Small integrin-binding ligand N-linked glycoproteins (SIBLINGs)- family consists of five integrin-binding glycophosphoproteins, namely the bone sialoprotein (BSP), dentin matrix protein 1 (DMP1), dentin sialophosphoprotein (DSPP), matrix extracellular phosphoglycoprotein (MEPE) and osteopontin (OPN). SIBLINGs are soluble, secreted proteins which are involved in the regulation of different biological processes such as cell proliferation, apoptosis, angiogenesis, wound repair, and regulation of ECM remodeling. On a molecular level, SIBLINGs have been shown to modulate various signalling pathways with a critical role in inflammation and infection, including PI3K/Akt-, the Ras/Raf- and NF-κB- pathway. SIBLINGs have been suggested to be involved in the pathophysiology of various benign and malignant diseases. Elevated expression and serum concentrations of Osteopontin, the most widely studied member of the SIBLINGs family, were shown in samples from patients sufferering from systemic or focal inflammation, occurring e.g. during tuberculosisRecently, a function of members of the SIBLINGs family was suggested in the regulation of inflammation and immunity, it is presently unknown if bone sialoprotein plays a functional role in systemic infections in ICU patients or if BSP might have a function as a biomarker in critically ill patients. To address this question we measured BSP concentrations in the serum of critically ill patients that were treated on a large medical ICU within a tertiary referral center. We specifically analyzed whether BSP levels were elevated in patients treated on the ICU and subsequently might have a diagnostic value in the context of sepsis or multi-organ failure. Finally, we analyzed whether BSP measurements might serve marker indicating short- and long-term outcome in critical illness and sepsis.9. Obesity was assumed in patients with a body mass index of >30 kg/m² at ICU admission (prior to any treatment such as fluid resuscitation), type 2 diabetes in patients with a respective medical history and a concomitant intake of diabetes related medication.We enrolled 136 patients that were admitted our intensive care unit at the University Hospital (RWTH) Aachen (Table 16. Glomerular filtration rates (GFR) were calculated on basis of serum cystatin C levels. ICU mortality was defined as death on ICU; overall mortality included death at the ICU or during the observation period .Interleukin-6 (IL-6), Interleukin-10 (IL-10), TNF, procalcitonin (PCT), soluble urokinase plasminogen activator receptor (suPAR), NTproCNP, Ghrelin, Hyaluronic acid and A proliferation inducing ligand (APRIL) were measured as described previouslyBSP serum concentrations were analyzed using a commercial enzyme immunoassay according to the manufacturers’ instructions .17. Optimal cut off points to differentiate between two groups were calculated using the Youden Index, as described elsewhere18.All statistical analyses were performed with SPSS  or GraphPad Prism 5.0 as previously describedTo examine a potential role of BSP serum concentrations as a biomarker in patients treated on a medical intensive care unit, we analyzed BSP serum concentrations critically ill patients at admission to the ICU. In this analysis, BSP levels were significantly higher in patients, when compared to healthy blood donors. We next analyzed the impact of disease severity on BSP levels in patients with critical illness. Therefore patients were subdivided into those with low APACHE-II-scores and those with high APACHE-II-scores, respectively. Of note, patients with high APACHE-II-scores >15) revealed higher BSP serum levels, when compared to patients less severe disease states Fig.  and this5 revealeDifferent metabolic diseases including type 2 diabetes, hyperinsulinemia and obesity were recently linked with elevaed serum levels of osteoblast related proteins including BSP. To analyze the impact of metabolic diseases on BSP serum levels in critically ill patients, we analyzed BSP levels with respect to the presence of type 2 diabetes and. In these analysis BSP levels at admission to the intensive care unit were almost identical in patients with or without preexisting diabetes or obesity Fig. . Moreove6. Based on these recent data we examined the impact of sepsis on serum BSP levels in our cohort of patients. Interestingly, patients with septic etiology of critical illness demonstrated significantly higher BSP serum levels compared to patients with other disease etiology  displayed a significantly higher mortality compared to the other patients Fig. . We dete22. Moreover, brain natriuretic peptide (BNP) and Osteopontin concentrations were found to be directly correlated in critical illness6. Notably levels of BSP, another member of the SIBLINGS family, also correlated to BNP  in this cohort of ICU-patients.We next performed correlation analysis with a broad panel of laboratory parameters. These analyses demonstrated that BSP levels were strongly correlated with markers indicating the presence of systemic infection and bacterial infection. As such high BSP levels were correlated to CRP , PCT  family of genetically related proteins that are clustered on human chromosome 428. Other members of this family are dentin matrix protein 1 (DMP1), osteopontin, dentin-sialophosphoprotein (DSPP), statherin and Matrix Extracellular PhosphogloprotEin (MEPE)29. A unifying feature of the SIBLING proteins is an Acidic Serine Aspartate Rich MEPE associated motif (ASARM). This motif and the released ASARM peptide unfold their action regulating the activity of two proteins: FGF 23 and PHEX, playing important roles in mineralization, bone turnover, mechanotransduction, phosphate regulation and energy metabolism30. Besides these physiological functions, it has also been demonstrated, that BSP play an important role in bone mineralization and the development of bone cancer31. Moreover, BSP is involved into breast cancer cell adhesion to the bone32 and is also a predictive marker of bone metastases in resectable non-small-cell lung cancer33. While a functional importance of BSP in cancer development has been extensively demonstrated, the role of BSP in critical illness and sepsis has previously not been elucidated. In contrast, we and others have previously shown an important role of another SIBLING protein, osteopontin (OPN), in critical illness34, sepsis36, renal37 and heart failure38. Like osteopontin, BSP has been shown to be upregulated in renal failure39. In contrast, an impaired liver function does not affect BSP serum levels39. Interestingly, in our analysis osteopontin and BSP displayed similar effects40: Serum levels of both proteins are elevated in patients with critical illness. Moreover, serum levels of both proteins are correlated to markers of organ function, inflammation and prognosis scores and correlate with an unfavorable prognosis, especially, when elevated at day three after admission to ICU6. Thus, it is conceivable that both molecules have a similar functional role in critical disease, which may be most likely be executed via shared functional groups, like the ASARM motif. As stated above, the fibroblast growth factor-23 (FGF23) is regulated by the ASARM motif of SIBLING proteins30. FGF23 is a circulating phosphaturic protein that decreases the expression of NPT2, a sodium-phosphate cotransporter in the proximal tubule41. Cleavage of intact FGF23 has been demonstrated to be enhanced during inflammation and sepsis in patients with chronic kidney disease42. This effect resolves after resolution of infection. It is suggested that this effect might participate into the counter-regulatory response to severe inflammation in critical disease42. This effect is likely executed by the shared ASARM motif of SIBLING proteins like osteopontin or BSP30. In line with this suggestion, negative regulators of FGF23 like PHEX, which also binds to the ASARM motif, are induced by inflammatory molecules like TNF, which may contribute to hypophosphataemia during sepsis and other inflammatory conditions43 causing critical disease. Of note, we could demonstrate a close correlation of BSP serum levels and proinflammatory biomarkers like TNF in our study. BSP serum levels also correlated with the heart failure marker BNP in our collective of critically ill patients. In line, the BSP target FGF2344 and the SIBLING protein osteopontin38 have been shown to be associated with a poor prognosis of heart failure patients.BSP is a major structural protein of the bone matrix. It constitutes approximately 12% of the non-collagenous proteins in human bone and is synthesized by skeletal-associated cell types, including hypertrophic chondrocytes, osteoblasts, osteocytes, and osteoclasts. The only extraskeletal site of its synthesis is the trophoblast45. Signaling pathways that are involved in bone mineralization seem to be involved into the complex sequence of inflammatory and immunosuppressive stimuli during sepsis and critical disease47. Further molecular studies are needed to elucidate these complex mechanisms. In addition to the functional importance of the ASARM-PHEX-FGF23 axis, other potential mechanism of action of BSP in sepsis are conceivable: e.g. a direct interaction of BSP with Staphylococcus aureus microbial surface components via Bone Sialoprotein-binding Protein (Bbp)48, which may facilitate adherence of the microbes to components of the extracellular matrix of the host.Suggesting a role of the BSP/ASARM- PHEX- FGF23 signaling pathway in inflammatory-related hypophosphatemia, our data point to an important issue: The important functional and prognostic role of phosphate imbalance and bone mineralization homeostasis in sepsis and critical disease due to e.g. heart failure or renal failureIn summary, our data highlight a potential function of bone sialoprotein in the prognostic judgment of patients during the first days of ICU treatment. Of course, these data need to be confirmed in further longitudinal clinical trials using independent cohorts of before a clinical use can be considered. Finally, our results suggest a previously unrecognized function of BSP in the pathophysiology of critical illness and should trigger further mechanistic research on the role of BSP and SIBLING proteins in general in the regulation of inflammation in this clinical setting.Supplementary information


LMNA genotype–phenotype cardiac correlations are reported: first, that cardiac involvement in multisystem laminopathies prevails with mutations upstream of the nuclear localisation signal (NLS); second, that worse outcomes occur with non-missense (compared with missense) mutations. We tested whether LMNA mutation DNA location and mutation subtype can predict phenotype severity in patients with lamin heart disease.Two LMNA mutations with cardiac-predominant phenotype. Hierarchical cluster analysis (HCA) assembled lamin heart disease into classes based on phenotype severity. 176 reported causative mutations were classified and any relationships to mutation location/subtype assessed by contingency analysis.We used a semantic workflow platform and manual electronic literature search to identify published More adverse phenotype was associated with mutation location upstream of the NLS  but not with non-missense mutations , although an association with non-missense mutations was identified in a subcluster with malignant ventricular arrhythmia . HCA limited to the 65 mutations described on ClinVar as pathogenic/likely pathogenic showed similar findings  as did analysis limited to pathogenic/likely pathogenic variants according to the American College of Medical Genetics and Genomics standards.LMNA mutation located upstream versus downstream of the NLS have a more adverse cardiac phenotype, and some missense mutations can be as harmful as non-missense ones.Cardiac patients with an  LMNA genotype–phenotype cardiac correlations are currently reported: that cardiac involvement in multisystem laminopathies prevails with mutations upstream of the nuclear localisation signal (NLS), and that worse outcomes occur with non-missense (compared with missense) mutations.Two More adverse phenotype was associated with mutation location upstream of the NLS but not with non-missense mutations, although an association with non-missense mutations was identified in a subcluster with malignant ventricular arrhythmia.LMNA mutation located upstream versus downstream of the NLS may have a more adverse cardiac phenotype, and some missense mutations can be as harmful as non-missense ones.Cardiac patients with an LMNA gene (1q22). They are implicated in DNA replication, cell cycle regulation, chromatin organisation, differentiation maintenance, nuclear stability, pore positioning, gene expression and signal transduction. LMNA mutations cause laminopathies, a spectrum of multisystem diseases, including some types of muscular dystrophy, lipodystrophy and acrogeria syndromes.Lamins A and C are nuclear envelope proteins encoded by the MNA gene q22. TheyLMNA mutation position relative to the NLS predicts organ system involvement, with cardiac involvement prevailing with upstream mutations .LMNA mutation , except in cases indicated, for which the original publication used the reference sequence for the lamin C transcript (NM_005572.3). Assertions of clinical significance per mutation were sought from the ClinVar archivewww.acmg.net),http://www.hgmd.cf.ac.uk). Each reported mutation was examined by the following in silico predictive algorithms: MutationTaster, PolyPhen-2, SIFT, PROVEAN and Condel (see The nomenclature found in ndel see .Mutation subtype was classified as non-missense (ins-del/truncating or mutations affecting splicing) or missense (single nucleotide substitutions) as previously describedMutation location was classified as upstream or downstream of the NLS with amino acid (a.a.) 417 as cut-off. For mutation location we also separately considered whether they occurred in the tail domain or upstream of the tail  as outlined above. Each subphenotypic attribute was scored as present (1)/absent (0), except for MVA and aHF which were scored as present (2)/absent (0) in proportion with their greater clinical importance. We provisioned for 0–0 match to be a ground of similarity across all categories.Phenotypic information per mutation was collected from the published literature to permit a MOGE(S) nosology classification.LMNA gene mutations in the general population, we mined data on the Genome Aggregation Database . For each variant identified the allele frequency was recorded.To explore the prevalence of identified 10.1136/openhrt-2018-000915.supp2Supplementary dataLMNA mutations with published and available phenotypic data was performed in RUnsupervised hierarchical cluster analysis (HCA) of the 2 or Fisher’s exact test as appropriate) to assess the relationship between HCA phenotype severity class, and (1) LMNA mutation subtype  and (2) LMNA mutation location (relative to the NLS and relative to the tail).We used a 2×2 contingency analysis  were missense. Considering the refined classification, 111 mutations were in the missense/inframe ins/del group (63%). One hundred and seventy-six mutations  NLS (a.a. 417–422); (2) Ser 625 potential phosphorylation site; or (3) the lamin A specific –CaaX motif . HCA repeated for mutations relative to the tail domain similarly showed an association of more adverse cardiac phenotype with mutations upstream of the tail  compared with those in the tail.There was an association between more adverse cardiac phenotype and LMNA mutations with pathogenic/likely pathogenic assertions listed in ClinVar showed a similar association between more adverse cardiac phenotype and mutation location upstream of the NLS  and upstream of the tail , but not with non-missense mutation subtype , except again in the MVA subcluster (11 mutations), where non-missense mutations prevailed . Repeating the HCA limited to the 145 LMNA mutations with pathogenic/likely pathogenic assertions according to the ACMG standards confirmed an association between more adverse cardiac phenotype and mutation location upstream of the NLS  and upstream of the tail , but not with non-missense mutation subtype  except in the MVA subcluster (26 mutations), where non-missense mutations prevailed . Repeating the HCA considering the 176 mutations reclassified into missense/inframe ins/del versus others showed no association between mutation subtype and cardiac phenotype severity .There was no association between non-missense mutation and more adverse cardiac phenotype  except in the MVA subcluster, where non-missense mutations prevailed . Repeating the HCA limited to the 65 LMNA unique mutations presented in LMNA mutations across the 138 632 gnomAD participants (0.51%). Eleven of these 26 mutations (42%) carried a pathogenic/likely pathogenic assertion on ClinVar. The majority (82%) of LMNA mutations identified in gnomAD were missense and located downstream of the NLS (83%). We did not count the intronic c.1158–44C>T mutation as it has only been described in one paper  scheme, we identified 199 published cardiac LMNA mutations upstream of the NLS (exons 1–6) were shown to have more cardiac organ involvement compared with other systems.LMNA mutations identified in the apparently healthy gnomAD population were rarely upstream of the NLS—eight times more likely to be located downstream . HCA data suggest that mutations upstream of the NLS, irrespective of mutation subtype, may be having a greater impact on protein structure and function relevant to the heart, and consequently on phenotypic expression, compared with mutations in and around the tail. One reason for this is that the region upstream of the NLS harbours the highly conserved rod domain, which is key to lamin protein assembly into mechanostructurally robust dimers . Another hypothesis is that while upstream mutations will invariably corrupt both isoforms, the lamin C isoform may be unscathed with more downstream mutations, thus potentially compensating for the mutant/deficient lamin A, mitigating phenotypic expression. The HCA data also show that while non-missense mutation subtype alone was insufficient to explain worse phenotype overall, it associated with MVA, as per the published literature and existing guideline. We go on to show that non-missense mutations are rare in the gnomAD population (12%) when compared with missense ones. Indeed, missense LMNA mutations distal to the NLS were the most common variants to be encountered in the gnomAD database search.Previously LMNA literature. We chose to employ hierarchical cluster agglomeration as this method is well suited for the interrogation of nominal data such as ours, by permitting a great many distance functions invented for nominal data, and theoretically more sound in this context than simply Euclidean distance. By combining a manual literature search with a transparent and reproducibleetal,et alet alLMNA mutations used in our analysis were not yet available to investigators listed in This work is the first time the MOGE(S) system was used to systematically classify mutation-specific morphofunctional subphenotypes across the published LMNA mutations are known to be sequence-level alterations and predominantly missense. Frameshift, nonsense, abnormal splicing and intragenic deletions and duplications, capable of resulting in a loss-of-function (haploinsufficiency), would be expected to have greater clinical impact when compared with single nucleotide substitutions. Data from three retrospective studies suggested thisLMNA missense mutations have unequivocally been linked to highly adverse phenotypes  are known to be age-dependent, their individual age dependency was not scrutinised here on account of the heterogeneity of reported data in the published literature. Juvenile onset was therefore systematically captured instead. Future work should seek to rigorously investigate the relationship between the more adverse cardiac phenotype and gender.Limitations of our work include the reliance on reported mutations and clinical details from the literature, and possibly therefore inconsistent and incomplete data sets from different centres. While the genetic data published may have been precise, the scope and quality of the phenotype data and clinical investigations may not have been rigorous and occasionally incomplete, explaining our inability to include 12% of the 199 originally identified. Here we have focused on Lamin mutations upstream of the NLS or C-terminal tail domain associate with an overall more severe cardiac phenotype than those downstream, and some missense mutations can be as harmful as non-missense ones. Replication of findings in a larger prospective lamin heart disease cohort is needed to understand whether future cardiac guidelines should consider incorporating some of the more adverse missense mutations and mutation location  for patient risk stratification.


The worldwide obesity epidemic continues unabated, adversely impacting upon global health and economies. People with severe obesity suffer the greatest adverse health consequences with reduced life expectancy. Currently, bariatric surgery is the most effective treatment for people with severe obesity, resulting in marked sustained weight loss, improved obesity-associated comorbidities and reduced mortality. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), the most common bariatric procedures undertaken globally, engender weight loss and metabolic improvements by mechanisms other than restriction and malabsorption. It is now clear that a plethora of gastrointestinal (GI) tract-derived signals plays a critical role in energy and glucose regulation. SG and RYGB, which alter GI anatomy and nutrient flow, impact upon these GI signals ultimately leading to weight loss and metabolic improvements. However, whilst highly effective overall, at individual level, post-operative outcomes are highly variable, with a proportion of patients experiencing poor long-term weight loss outcome and gaining little health benefit. RYGB and SG are markedly different anatomically and thus differentially impact upon GI signalling and bodyweight regulation. Here, we review the mechanisms proposed to cause weight loss following RYGB and SG. We highlight similarities and differences between these two procedures with a focus on gut hormones, bile acids and gut microbiota. A greater understanding of these procedure-related mechanisms will allow surgical procedure choice to be tailored to the individual to maximise post-surgery health outcomes and will facilitate the discovery of non-surgical treatments for people with obesity. The prevalence of obesity continues to increase unabated. Globally in 2014, approximately 52% of the adult population were overweight (1.9 billion) or obese (> 600 million) [2, or greater than 35 kg/m2 in the presence of obesity-related complications [Bariatric surgery is recognised as the most effective treatment for people with severe obesity, defined by a body mass index (BMI) equal to or greater than 40 kg/mications .The concept of bariatric surgery emerged during the 1950s when procedures that involved small intestine resection were noted to result in weight loss –9. The fOver the past decade, the effectiveness of bariatric surgery has resulted in a marked increase in the number of procedures undertaken worldwide, with approximately 580,000 operations performed in 2014 . The surDespite the increasing use of bariatric surgeries, the underlying mechanisms remain incompletely understood. Post-operative weight loss is highly variable  and manyIn RYGB, the stomach is divided generating a small gastric pouch (20–30 mL), which is then anastomosed with the mid-jejunum, creating the Roux or alimentary limb. Ingested nutrients thus bypass most of the stomach, duodenum, and the proximal jejunum. Anastomosis of the biliopancreatic limb with the jejunum allows drainage of bile acids (BA) and pancreatic secretions, which mix with the nutrients in the jejunum (common limb)  Fig. 1)1). A tec2 and was intended as a purely restrictive procedure. However, the significant sustained weight loss and metabolic benefits obtained by SG led to its adoption as a standalone procedure. SG involves transection along the greater curvature creating a tube-like new stomach removing the fundus and body [Sleeve gastrectomy (SG), was initially performed as a first-stage procedure to reduce weight in patients with a BMI of greater than 50 kg/mand body  Fig. 1)2 and wasand body .It has been clearly demonstrated that bariatric surgery is an effective treatment for severe obesity engendering marked weight loss, sustained in the long term when compared to calorie-restricted dieting. The 20-year outcome data from the Swedish Obese Subjects (SOS) study showed that patients who received bariatric surgery achieved a significantly greater mean body weight reduction of approximately 18% compared with approximately 1% in patients who received standard medical treatment through their local health centres . RYGB paA limited number of RCTs have compared the efficacy of RYGB against SG with regards to weight loss outcomes and resolution of obesity-related comorbidities, especially T2D. The STAMPEDE trial, which was not powered to detect differences between procedures, reported that RYGB was associated with greater weight loss and a need for fewer T2D medications after 5 years compared with SG. This is interesting considering that 3-year results from the same authors and from other short-term studies showed similar results for the two procedures –19. The Feeding behaviour is determined by homeostatic and reward-related brain centres that continually integrate peripheral signals relating to energy stores and nutrient availability  Fig. 2)2). ObesiIn contrast to the anorectic actions of PYY and GLP-1, ghrelin, produced primarily by P/D1 cells in oxyntic glands in the gastric fundus, stimulates appetite and energy intake. Circulating ghrelin levels increase in the fasted state and decrease post-prandially proportionally to the amount of ingested food . GhrelinBA are produced in the liver, stored in the gallbladder and secreted into the duodenum upon nutrient ingestion. Their main role is the facilitation of micelle formation promoting the digestion of dietary fat and fat-soluble vitamins. More recently, BA have also been shown to play a role in regulating glucose and energy homeostasis . BA actiThe human gut hosts trillions of microorganisms . Gut micTaste and olfactory signals can impact on energy intake by influencing food selection . There iObesity is the result of a chronic positive energy balance . Once thA dysbiotic relationship between host and microbiome has been suggested to contribute to the development of obesity , with prThe neural response to food cues is altered in people with obesity compared to people with normal weight. This has been confirmed by brain-imaging studies showing an increased stimulation of central reward pathways in response to eating or food cues . In addiLifestyle interventions lead to weight loss. However, people with overweight and obesity find it very hard to maintain this weight loss in the long term. In response to weight loss, which throughout evolution would have been a threat to survival, multiple powerful biological changes occur that lead to increased hunger, enhanced neural responses to food cues and heightened drive to consume energy-dense foods. Compensatory changes include decreased energy expenditure, due to reduced lean muscle mass and reduced sympathetic activity , reducedThe multifactorial mechanisms promoting weight loss following RYGB/SG remain incompletely understood. However, it is clear that the beneficial effects are not achieved through malabsorption and restriction alone , 59. RedIn contrast to the unfavourable gut hormone changes that accompany weight loss induced by lifestyle intervention, RYGB and SG are associated with reduced ghrelin levels and increased circulating meal-stimulated PYY and GLP-1 levels. These gut hormone changes precede and are independent from weight loss and are sustained up to 10 years post-operatively , 62.Since the landmark publication by Cummings et al.  showing Following RYGB, nutrient-stimulated circulating levels of PYY and GLP-1 are markedly elevated, most likely as a result of increased nutrient stimulation of L cells as a consequence of anatomical rearrangement. SG leads to rapid gastric emptying and enhanced exposure of L cells to nutrients with increased nutrient-stimulated PYY and GLP-1 levels, but to a lesser extent than following RYGB.Patients with poor post-operative weight loss reported increased subjective hunger and lower satiety levels coupled with lower circulating PYY, GLP-1 and higher ghrelin, when compared with people with good weight loss . These fOther gut hormones with effects on feeding behaviour have also been studied. However, the extent of their role in mediating the beneficial effects of RYGB and SG are unclear. For completeness, we have summarised these below:Glucose-dependent insulinotropic polypeptide (GIP) is an incretin peptide hormone secreted by K-cells in the proximal small intestine. GIP increases postprandial glucagon secretion, intestinal glucose absorption and storage of fatty acids in adipose tissue . PreviouOxyntomodulin, a pro-glucagon-derived peptide with anorectic effects, is increased early after RYGB . This efCholecystokinin (CCK), another anorexigenic hormone, has been suggested to act synergistically with leptin, and amylin, a pancreatic hormone co-secreted with insulin . IncreasGastrin is a peptide hormone that stimulates the secretion of gastric acid from the parietal cells of the stomach, aids in gastric motility and reduces appetite. There is some evidence suggesting that postprandial gastrin levels fall after RYGB  while SGNeurotensin is co-expressed in enteroendocrine cells with GLP-1 and PYY. Circulating neurotensin levels increase after RYGB and have also been proposed to contribute to eating behaviour changes post-RYGB .Additional gut hormones, such as ileal-derived FGF-19, (discussed below) may also contribute to weight loss and metabolic changes following bariatric surgery.Following RYGB and SG, changes in circulating BA levels and composition are reported and these changes are suggested to contribute to weight loss and improved glucose metabolism. Indeed, in animal models, rerouting bile to the distal small bowel by transposing the common bile duct results in improved body weight, glucose metabolism, and hepatic steatosis, and increases in plasma BA similar to those seen after RYGB. Despite their anatomical differences, RYGB and SG exert similar effects on BA, altering both their composition and circulating concentrations; however, the changes observed following SG are more modest , 77. TheFollowing RYGB and SG, the intestinal microbiome is altered. Animal studies with faecal transplant from RYGB-treated to germ-free mice resulted in significantly greater weight loss suggests that the altered microbiome per se contributes to weight loss . SignifiEnteroplasticity refers to the post-surgical adaptations, including remodelling of the intestinal mucosa, morphologic changes, and altered innervation . There iRYGB was recently reported to enhance SGLT1-dependent intestinal glucose uptake in the common limb and utilisation, leading to overall improvements in systemic glucose control . WhetherPost-surgery change in appetite, taste and smell may contribute to food preference changes following RYGB and SG. Interestingly, early data suggest that RYGB and SG may differentially impact upon subjective changes in appetite, taste, olfaction and food aversion post-operatively. Large longitudinal studies combining subjective and objective measures of taste and olfaction are warranted to detect possible procedures-related effects .Afferent vagal nerve fibres in the stomach are sensitive to mechanical stretch related to food ingestion and signal to the brain . FollowiBariatric surgery is the most effective weight loss strategy for people with severe obesity leading to reduced mortality and improvement in obesity-associated comorbidities. However, although bariatric surgery is highly effective, at the individual level, clinical response is highly variable. There are profound anatomical differences between RYGB and SG which in turn impact upon the mechanisms underlying the weight-reducing effects of these two procedures. Gut hormones, BA, gut microbiota and other mechanisms, many of them to be identified yet, contribute to the durability of decreased appetite and the sustainable weight loss following both RYGB and SG. Studies comparing weight loss suggest that after 3 years, a subtle weight loss difference may exist in favour of RYGB. Recent data suggest that longer-term health improvements are related to the degree of sustained weight loss achieved, thus highlighting the need to maximise post-surgery weight loss. A greater understanding of the procedure-related mechanisms and interaction with a person’s genetics and pre-surgery phenotype will allow surgical procedure choice to be tailored to the individual to maximise the weight loss and metabolic outcomes, and will facilitate the discovery of novel non-surgical treatments for people with obesity.


Primary graft dysfunction (PGD) remains the leading cause of early mortality post-heart transplantation. Despite improvements in mechanical circulatory support and critical care measures, the rate of PGD remains significant. A recent consensus statement by the International Society of Heart and Lung Transplantation (ISHLT) has formulated a definition for PGD. Five years on, we look at current concepts and future directions of PGD in the current era of transplantation. Heart transplantation remains the closest resemblance to a ‘cure’ for end-stage heart failure. Worldwide, more than 4000 adults undergo heart transplantation annually . Whilst PGD presents as severe ventricular dysfunction of the donor graft which fails to meet the circulatory requirements of the recipient in the immediate post-transplant period. It may manifest as either single or biventricular dysfunction with low cardiac output and hypotension despite adequate filling pressures –5. In 202) lasting at least 1 h. The requirement of an intra-aortic balloon pump signifies moderate PGD-LV, whereas requirement of extracorporeal short-term mechanical circulatory support in the form of extracorporeal membrane oxygenation (ECMO) or ventricular assist devices (VADs) in any form  is diagnostic of severe PGD-LV [PGD is defined as being a separate entity from secondary graft dysfunction, which is when a discernible cause for allograft dysfunction is identified. Such causes can include hyperacute rejection, graft dysfunction secondary to pulmonary hypertension or a recognised intraoperative complication. The diagnosis of PGD is made within 24 h post-transplantation and is separated into PGD-LV, for PGD affecting the left ventricle or biventricular failure; and PGD-RV for isolated right ventricular involvement . A severe PGD-LV .2, TPG < 15 mmHg and/or pulmonary artery systolic pressure < 50 mmHg) [PGD-RV does not have a severity scale and is diagnosed based on the requirement of a right-sided short-term VAD (RVAD) or right heart catheter measured haemodynamics in keeping with isolated right-sided dysfunction  .Previous studies had used the need for mechanical circulatory support as a criterion for diagnosis of primary graft dysfunction; however, the timing of initiation of therapy and endpoints differs from these studies, leading to significant variation in incidence reporting 2.3–32.4%) [% 4, 8–1–18–11. WThe donor heart is exposed to a multitude of physiological insults at four specific time points: brainstem death, hypothermic ischaemia, warm ischaemia and ischaemia-reperfusion injury.The first insult occurs during declaration of brainstem death in donation after brainstem death (DBD). Raised intracranial pressure (ICP) invariably is the final pathway in DBD donors in which case the aetiology of death is usually a result of an intracerebral haemorrhage, hypoxia leading to oedema, inflammation or a space occupying lesion in the cranium. The cerebral perfusion pressure is usually maintained by homeostatic mechanisms which result in an increased arterial pressure. Due to the limited plasticity of the brain within the confines of the cranium, brain herniation ensues resulting in pontine ischaemia . This caVasomotor tone is reduced to the loss of spinal cord sympathetic activity resulting in unopposed vasodilatation, further reducing preload and indirectly afterload, affecting coronary blood flow and reducing myocardial perfusion. As a response, there is an intense release of myocardial noradrenaline immediately after brain death that results in mitochondrial and cytosolic calcium overload to increase contractility to counteract this unopposed vasodilatation . PituitaThese patients are also prone to metabolic disturbances due to acidosis, hypomagnesaemia or hypokalemia secondary to mannitol initiation to reduce ICP, catecholamine administration, all of which contribute to increased myocardial oxygen demand or reduced myocardial perfusion . This in3) administration only in depleted donors [Early donor management may reduce the deleterious effects of the abovementioned phenomenon. Early administration of vasopressors is aimed at reducing the unopposed vasodilatation . Methylpd donors , 21, 22.Despite advancements in normothermic ex vivo perfusion devices, cold storage remains the mainstay of transportation after organ retrieval. Organ retrieval often has two distinct phases, a warm phase and a cold phase. The warm phase involves dissection of the heart and exposure of the innominate artery and the two cavae with variations in the degree of dissection depending on whether the lungs are to be retrieved as well. The retrieval surgeon also palpates the coronary arteries for potential disease. The aorta is prepared for administration of cold cardioplegia for commencement of the cold phase.+ ions [+/H+ exchanger is activated resulting in an increase in intracellular Na+ which activates the Na+/Ca2+ exchanger [2+. This will play a major role in the pathogenesis of ischaemic-reperfusion injury.Depending on the size of the patient and type of cardioplegic solution administered, the volume of administration may differ. The retrieval surgeon then performs a left atriotomy by lifting the heart. Once the aortic cross-clamp is applied, cold cardioplegia is infused via the aortic root at approximately 4 °C. The retrieval process is completed with the heart placed in a cold storage container. Cold storage induces hypothermic arrest of metabolism and maintains viability during this reduced metabolic state, therefore abating cellular swelling and minimalizing reperfusion injury . At thes+ ions . The Na+xchanger , 28. TheOn arrival at the recipient centre, the heart is removed from cold storage and inspected. The period in which the heart is removed from cold storage or from ex vivo normothermic perfusion to the final release of the recipient aortic cross-clamp is termed warm ischaemic time. The heart is exposed to warmer temperatures which slowly increases its metabolic rate resulting in increased formation of oxygen free radicals. In a study by Marasco et al., warm ischaemic time and increasing donor age were independent predictors of early survival, suggesting an acceleration of the deleterious effects described during the cold ischaemic phase . SimilarIschaemia-reperfusion injury (IRI) is defined as cardiomyocyte damage secondary to myocardial restoration of blood flow . On releAnimal studies do however highlight attenuation of IRI using preconditioning in diabetics –48, femaAnother mechanism of IRI is hypercontracture-mediated sarcolemmal rupture (HMSR). During the ischaemic phase, the low cytosolic ATP concentrations are quickly exhausted resulting in myofibrillar shortening that remains fixed as all cross-bridges between actin and myosin remain in an attached state . This ca2+ overload which develops during ischaemia and is rapidly re-energised, as it would on release of the cross-clamp [+/Ca2+ exchanger pumps. Sarcolemmal rupture also results in increasing Na+ influx into cardiomyocytes via gap junctions and may propagate to adjacent cells [Reperfusion-induced hypercontracture occurs after prolonged ischaemia. There is greater myofibrillar shortening and cytoskeletal damage when compared to the ischaemic phase alone. It causes a marked rise in end-diastolic pressure with increased ventricular wall stiffness. It is shown to be due to Cass-clamp . In cellss-clamp . Sarcoless-clamp  and ankyss-clamp , impairint cells .Donation after circulatory death (DCD) provides a different set of insults to the donor heart. The heart is placed in a hypoxemic and hypercarbic environment following withdrawal of life support . This ca+/H+ exchanger in a pathway similar to the warm ischaemic period described above, with a net result of an accumulation of intracellular Ca2+ and follows the ischaemic-reperfusion pathway on reperfusion.This prolonged ischaemic period causes intracellular acidosis which causes activation of the NaATP channels). Endogenous nitric oxide, a potent vasodilator, is also implicated in the pathogenesis alongside vasopressin deficiency [Some recipient factors may also predispose a patient to PGD. Recipients, especially patients who have been on inotropic support and mechanical devices, have activation of their systemic inflammatory response, which causes intense vasodilation and therefore lowering of the systemic vascular resistance. The net result is a hypotensive state despite adequate filling and a high cardiac output that is refractory to vasopressor support . The exaficiency .Prolonged ischaemic time has been shown in previous studies to correlate with complications occurring after cardiopulmonary bypass . This asAnother pathogenic mechanism that has been suggested in the past is recipient pulmonary hypertension. The donor heart in its ischaemic state is exposed to a relatively high pulmonary vascular resistance, giving rise to right-sided heart failure. Due to the poor adaptability of the right ventricle to a sudden change in vascular resistance, biventricular dysfunction ensues due to a reduced left-sided preload, thereby reducing coronary perfusion and end organ perfusion in the systemic circulation . This hoThere are several risk factors that have been suggested that may contribute to PGD. These include donor factors, recipient factors and procedural factors.Avtaar Singh et al. (2018) highlighted donor age to be a significant risk factor on multivariate analysis. This may have been due to the poorer tolerance for long ischaemic times in hearts from older donors. They highlighted an odds risk of 20% for each decade increment in donor age. A similar finding was noted by Russo and colleagues . They noFemale-donor to male-recipient gender mismatch is a risk factor for PGD. The exact mechanism is poorly understood as this persisted despite organ size matching. Male-donor to female-recipients did not result in an increased PGD rate. Gender-mismatched organs also had a poorer survival at up to 5 years. In liver transplantation, recipients had poorer graft survival in female-donor/male-recipient cohorts compared with other donor-recipient gender groups despite adjustment for donor risk factors and recipient variables . The rolIntracranial haemorrhage is the most common cause of death for DBD donors in the UK. One study showed increased PGD rates in organs retrieved from donors with intracranial haemorrhage compared to donors with traumatic cause of death . The exaDonors with hypertension often have a degree of left ventricular hypertrophy (LVH). This is more apparent across Europe where the average age of the donor is older compared to North America . The useInotropic support is sometimes needed during the donor organ retrieval process due to the depletion of catecholamine and/or a systemic inflammatory phenomenon as described above. Noradrenaline use can cause left ventricular dysfunction in the absence of brain death . It alsoPre-operative recipient ECMO/VAD usage has also been linked to PGD post-operatively , 96, 97.A recent study by Truby and colleagues highlighted the role of continuous flow LVAD (CF-LVAD) in recipients as a risk factor for severe PGD . This isThe role of recipient diabetes as a predictor of PGD is evident in multiple studies . The resSeveral studies have associated advancing recipient age with PGD and mortality , 92. A rA recipient re-sternotomy indicates previous surgery, most commonly for durable ventricular assist device implantation, previous congenital cardiac surgery or previous coronary bypass or valvular surgery . The disAmiodarone is a class III antiarrhythmic used for a variety of arrhythmias including both ventricular, supraventricular and atrial tachyarrhythmias. Its mechanism of action is primarily by prolonging the refractory period myocardium. Arrhythmias are highly prevalent in advanced heart failure patients . The eviIn DBD donations, the ischaemic time consists of the placement of the donor aortic cross-clamp till the release of the recipient aortic cross-clamp . For DCDCold ischaemic time consists of the time spent in cold storage and warm ischaemia ensues once the heart is removed from cold storage or the OCS rig till release of the aortic cross-clamp. Prolonged ischaemic time is associated with an increased rate of PGD , 92, 119Prolonged cardiopulmonary bypass (CPB) duration independently predicts post-operative morbidity and mortality after general cardiac surgery . KirklinThe size of the donor graft has many implications on the recipient. It is a powerful predictor of survival recipients receiving undersized grafts having an increased 1-year mortality, and a 36% increased mortality within the first 30 days . Smits sThe current definition for PGD is based on the treatment options utilised. Several biomarkers have been suggested as potential predictors of PGD, although to date none are used in routine care.The pro-inflammatory state accompanying PGD supports the use of inflammatory markers as potential predictive biomarkers. Tumour necrosis factor-α (TNF-α), interleukin-6 (IL-6), neutrophils and procalcitonin (PCT) have all been suggested as potential biomarkers.Tumour necrosis factors are produced by lymphocytes and macrophages that cause cell lysis . TNF-α hBirks and colleagues noted an increased expression of TNF-α in unused donor hearts due to poor function and compared them with donors with good ventricular function (used donors) and patients with advanced heart failure (HF) . In lungA Brazilian group showed recipients receiving grafts from donors expressing lower concentrations of plasma soluble tumour necrosis factor receptors 2 (sTNFR2) and IL-6, required more inotropic support post-transplantation .Interleukin 6 (IL-6) is produced in response to infections and tissue injuries by stimulation of acute phase responses. It bridges the adaptive and innate immune responses and plays a major role in autoimmune conditions , 147. BiIL-6 was also shown to be associated with PGD post-lung transplantation. The serum and bronchioalveolar lavage concentrations of IL-6 were higher in transplant recipients with PGD than those without .Animal models have shown that ischaemic cardiac myocytes in watershed viable zones of a myocardial infarction exhibited reperfusion-dependent expression of IL-6 mRNA after reperfusion , 151.Procalcitonin (PCT) is a 116-amino acid peptide that has an approximate molecular weight of 14.5 kDa and belongs to the calcitonin (CT) superfamily of peptides . It is a−1 was a potentially useful tool in predicting the end-management heart usability for transplantation. Similar findings were noted by Wagner and colleagues with increased 30-day mortality and early graft dysfunction in hearts utilised from donors with elevated PCT levels [In transplantation, PCT was used to differentiate bacterial infection from organ rejection. PCT levels are elevated in both conditions but significantly higher in the presence of infections , 154. ItT levels . The incT levels , but notT levels  or lung T levels .Both NLR and platelet to lymphocyte ratio (PLR) have been used as markers of inflammation with prognostic value in coronary artery disease , 161 andn = 111). A Polish single-centre study noted similar findings in their renal transplant cohort, with NLR showing good predictive value of early graft dysfunction [A group in Argentina studied the relationship between the two ratios and survival after heart transplantation . They nofunction . Anotherfunction . HoweverCardiac troponins are regulatory proteins that control the calcium-mediated interaction between actin and myosin. The measurements of serum cardiac troponin I (cTnI) and cardiac troponin T (cTnT) have shown to be sensitive and specific markers of myocardial damage .The pathophysiology of brainstem death results in a catecholamine storm that is believed to cause transient myocardial ischaemia and injury . CirculaP = 0.28). Vijay et al. conducted a similar study, using endomyocardial biopsy proven rejection at 1 year as the primary endpoint. They noted a linear correlation between grade of rejection at 1-year and donor cTnT levels [Several studies however have shown that elevated serum troponin levels in donors may predict adverse outcomes post-transplantation. Increasing cTnT levels have been shown to be associated with a reduction in left ventricular ejection fraction in the donor . PotapovT levels . AnotherT levels .In donors with subarachnoid haemorrhages, cTnI was a good indicator for left ventricular dysfunction, however this was reversible, and did not affect outcomes post-transplant , 174. BoA recent study of cTnI in the preservation solution (University of Wisconsin solution and Custodiol) during transportation of heart grafts however showed that elevated cTnI  was predictive of post-transplant PGD . They al2). The authors however could not show a correlation between post-operative inotropic support and BNP levels.Brain natriuretic peptide (BNP) and its amino-terminal pro-fragment, N-terminal pro–B-type natriuretic peptide (NT-proBNP) are commonly used for diagnosis and prognostication in heart failure , 180. ThSWItch/sucrose non-fermentable, a matrix-associated, actin-dependent regulator of chromatin subfamily a-like 1 (SMARCAL1) is an intracellular protein that acts as a DNA-dependent ATPase involved in transcription, DNA repair and chromatin dynamics . AharineHypoxia-inducible factor (HIF)-1 is a heterodimeric α, β transcription factor that mediates tissue responses to hypoxia . AharineSeveral published abstracts have highlighted the role of serum exosome proteomic analysis in the recipient as a potential biomarkers for PGD , 192. GiA single administration of cold flush preservation fluid remains the gold standard for myocardial protection during transplantation. It confers reliable protection for a limited amount of ischaemic time in young donor hearts . The incTreatment of PGD thus far is still primarily supportive care. In a consensus statement by Kobashigawa et al., the treatment and management of PGD across five high volume transplant centres were evaluated. PGD is initially managed by using inotropic support using catecholamines and phosphodiesterase inhibitors. The most common escalation therapy follow inotropic use is using an intra-aortic balloon pump. Following this, advanced mechanical support is initiated which is usually directed by the expertise of the transplant units themselves. The most common mode of support is extracorporeal membranous oxygenation with both central and peripheral cannulation strategies utilised. The heart should be allowed to eject to prevent stasis and thromboembolic complications.For primary RV-PGD, nitric oxide may be used to reduce the pulmonary vascular resistance. Following a period of support on ECMO, a short-term ventricular assist device is then implanted depending on the level of support needed . Where possible, the patient is then re-evaluated for a redo-orthotopic heart transplantation.Levosimendan is a calcium sensitising agent and inodilator which increases cardiac contractility. Its primary mode of action is by increasing the sensitivity of troponin-C to calcium during systole thereby increasing cardiac performance without increasing myocardial oxygen consumption. It also reduces peripheral vascular resistances by opening of adenosine triphosphate–dependent K+ channels . It was The inotropic effects of levosimendan may often take hours to develop, which may be offset by its potent vasodilation capacity . It may Plasmapheresis is a process by which whole blood is passed through a filter to separate the plasma components from the larger cellular components of red blood cells, white blood cells and platelets . Its usePGD is the leading cause of early morbidity and mortality following heart transplantation. It is thought to be multifactorial in origin and several risk factors implicated. The search for an accurate biomarker however remains elusive. Treatment options to date remain supportive with no definitive pharmacological agents identified as of yet. Plasmapheresis may have a role in depletion of inflammatory chemokines and cytokines for treatment of PGD.