X-ray reflection in a sample of X-ray bright Ultraluminous X-ray sources

We apply a reflection-based model to the best available XMM-Newton spectra of X-ray bright UltraLuminous X-ray (ULX) sources (NGC 1313 X-1, NGC 1313 X-2, M 81 X-6, Holmberg IX X-1, NGC 5408 X-1 and Holmberg II X-1). A spectral drop is apparent in the data of all the sources at energies 6-7 keV. The drop is interpreted here in terms of relativistically-blurred ionized reflection from the accretion disk. A soft-excess is also detected from these sources (as usually found in the spectra of AGN), with emission from O K and Fe L, in the case of NGC 5408 X-1 and Holmberg II X-1, which can be understood as features arising from reflection of the disk. Remarkably, ionized disk reflection and the associated powerlaw continuum provide a good description of the broad-band spectrum, including the soft-excess. There is no requirement for thermal emission from the inner disk in the description of the spectra. The black holes of these systems must then be highly spinning, with a spin close to the maximum rate of a maximal spinning black hole. The results require the action of strong light bending in these sources. We suggest that they could be strongly accreting black holes in which most of the energy is extracted from the flow magnetically and released above the disc thereby avoiding the conventional Eddington limit.Comment: Accepted for publication in MNRA

Nottingham prognostic index plus (NPI+) predicts risk of distant metastases in primary breast cancer

The Nottingham prognostic index plus (NPI+) is based on the assessment of biological class combined with established clinicopathologic prognostic variables providing improved patient outcome stratification for breast cancer superior to the traditional NPI. This study aimed to determine prognostic capability of the NPI+ in predicting risk of development of distant disease. A well-characterised series of 1073 primary early-stage BC cases treated in Nottingham and 251 cases from Budapest were immunohistochemically assessed for cytokeratin (Ck)5/6, Ck18, EGFR, oestrogen receptor (ER), progesterone receptor, HER2, HER3, HER4, Mucin 1 and p53 expression. NPI+ biological class and prognostic scores were assigned using individual algorithms for each biological class incorporating clinicopathologic parameters and investigated in terms of prediction of distant metastases-free survival (MFS). The NPI+ identified distinct prognostic groups (PG) within each molecular class which were predictive of MFS providing improved patient outcome stratification superior to the traditional NPI. NPI+ PGs, between series, were comparable in predicting patient outcome between series in luminal A, basal p53 altered and HER2+/ER+ (p > 0.01) tumours. The low-risk groups were similarly validated in luminal B, luminal N, basal p53 normal tumours (p > 0.01). Due to small patient numbers the remaining PGs could not be validated. NPI+ was additionally able to predict a higher risk of metastases at certain distant sites. This study may indicate the NPI+ as a useful tool in predicting the risk of metastases. The NPI+ provides accurate risk stratification allowing improved individualised clinical decision making for breast cancer

Nottingham Prognostic Index Plus (NPI+): a modern clinical decision making tool in breast cancer

Background: Current management of breast cancer (BC) relies on risk stratification based on well-defined clinicopathologic factors. Global gene expression profiling studies have demonstrated that BC comprises distinct molecular classes with clinical relevance. In this study, we hypothesised that molecular features of BC are a key driver of tumour behaviour and when coupled with a novel and bespoke application of established clinicopathologic prognostic variables can predict both clinical outcome and relevant therapeutic options more accurately than existing methods. Methods: In the current study, a comprehensive panel of biomarkers with relevance to BC was applied to a large and well-characterised series of BC, using immunohistochemistry and different multivariate clustering techniques, to identify the key molecular classes. Subsequently, each class was further stratified using a set of well-defined prognostic clinicopathologic variables. These variables were combined in formulae to prognostically stratify different molecular classes, collectively known as the Nottingham Prognostic Index Plus (NPI+). The NPI+ was then used to predict outcome in the different molecular classes. Results: Seven core molecular classes were identified using a selective panel of 10 biomarkers. Incorporation of clinicopathologic variables in a second-stage analysis resulted in identification of distinct prognostic groups within each molecular class (NPI+). Outcome analysis showed that using the bespoke NPI formulae for each biological BC class provides improved patient outcome stratification superior to the traditional NPI. Conclusion: This study provides proof-of-principle evidence for the use of NPI+ in supporting improved individualised clinical decision making

Role of age and comorbidities in mortality of patients with infective endocarditis

Purpose: The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality. Methods: Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015. Patients were stratified into three age groups:<65 years, 65 to 80 years, and = 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk. Results: A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 = 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients =80 years who underwent surgery were significantly lower compared with other age groups (14.3%, 65 years; 20.5%, 65-79 years; 31.3%, =80 years). In-hospital mortality was lower in the <65-year group (20.3%, <65 years;30.1%, 65-79 years;34.7%, =80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%, =80 years; p = 0.003).Independent predictors of mortality were age = 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32–3.34), CCI = 3 (HR:1.62; 95% CI:1.39–1.88), and non-performed surgery (HR:1.64;95% CI:11.16–1.58).When the three age groups were compared, the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality. Conclusion: There were no differences in the clinical presentation of IE between the groups. Age = 80 years, high comorbidity (measured by CCI), and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group

Sex- and age-related differences in the management and outcomes of chronic heart failure: an analysis of patients from the ESC HFA EORP Heart Failure Long-Term Registry

Aims: This study aimed to assess age- and sex-related differences in management and 1-year risk for all-cause mortality and hospitalization in chronic heart failure (HF) patients. Methods and results: Of 16 354 patients included in the European Society of Cardiology Heart Failure Long-Term Registry, 9428 chronic HF patients were analysed [median age: 66 years; 28.5% women; mean left ventricular ejection fraction (LVEF) 37%]. Rates of use of guideline-directed medical therapy (GDMT) were high (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists: 85.7%, 88.7% and 58.8%, respectively). Crude GDMT utilization rates were lower in women than in men (all differences: P\ua0 64 0.001), and GDMT use became lower with ageing in both sexes, at baseline and at 1-year follow-up. Sex was not an independent predictor of GDMT prescription; however, age >75 years was a significant predictor of GDMT underutilization. Rates of all-cause mortality were lower in women than in men (7.1% vs. 8.7%; P\ua0=\ua00.015), as were rates of all-cause hospitalization (21.9% vs. 27.3%; P\ua075 years. Conclusions: There was a decline in GDMT use with advanced age in both sexes. Sex was not an independent predictor of GDMT or adverse outcomes. However, age >75 years independently predicted lower GDMT use and higher all-cause mortality in patients with LVEF 6445%

Clonal chromosomal mosaicism and loss of chromosome Y in elderly men increase vulnerability for SARS-CoV-2

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) had an estimated overall case fatality ratio of 1.38% (pre-vaccination), being 53% higher in males and increasing exponentially with age. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, we found 133 cases (1.42%) with detectable clonal mosaicism for chromosome alterations (mCA) and 226 males (5.08%) with acquired loss of chromosome Y (LOY). Individuals with clonal mosaic events (mCA and/or LOY) showed a 54% increase in the risk of COVID-19 lethality. LOY is associated with transcriptomic biomarkers of immune dysfunction, pro-coagulation activity and cardiovascular risk. Interferon-induced genes involved in the initial immune response to SARS-CoV-2 are also down-regulated in LOY. Thus, mCA and LOY underlie at least part of the sex-biased severity and mortality of COVID-19 in aging patients. Given its potential therapeutic and prognostic relevance, evaluation of clonal mosaicism should be implemented as biomarker of COVID-19 severity in elderly people. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, individuals with clonal mosaic events (clonal mosaicism for chromosome alterations and/or loss of chromosome Y) showed an increased risk of COVID-19 lethality

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

Active faults sources for the Pátzcuaro–Acambay fault system (Mexico): fractal analysis of slip rates and magnitudes <i>M</i>_w estimated from fault length

The Pátzcuaro–Acambay fault system (PAFS), located in the central part of the Trans-Mexican Volcanic Belt (TMVB), is delimited by an active transtensive deformation area associated with the oblique subduction zone between the Cocos and North American plates, with a convergence speed of 55&thinsp;mm yr−1 at the latitude of the state of Michoacán, Mexico. Part of the oblique convergence is transferred to this fault system, where the slip rates range from 0.009 to 2.78&thinsp;mm yr−1. This has caused historic earthquakes in Central Mexico, such as the Acambay quake (Ms = 6.9) on 19 November 1912 with surface rupture, and another in Maravatío in 1979 with Ms = 5.6. Also, paleoseismic analyses are showing Quaternary movements in some faults, with moderate to large magnitudes. Notably, this zone is seismically active, but lacks a dense local seismic network, and more importantly, its neotectonic movements have received very little attention. The present research encompasses three investigations carried out in the PAFS. First, the estimation of the maximum possible earthquake magnitudes, based on 316 fault lengths mapped on a 15&thinsp;m digital elevation model, by means of three empirical relationships. In addition, the Hurst exponent Hw and its persistence, estimated for magnitudes Mw (spatial domain) and for 32 slip-rate data (time domain) by the wavelet variance analysis. Finally, the validity of the intrinsic definition of active fault proposed here. The average results for the estimation of the maximum and minimum magnitudes expected for this fault population are 5.5 ≤ Mw ≤ 7. Also, supported by the results of H at the spatial domain, this paper strongly suggests that the PAFS is classified in three different zones (western PAFS, central PAFS, and eastern PAFS) in terms of their roughness (Hw = 0.7, Hw = 0.5, Hw = 0.8 respectively), showing different dynamics in seismotectonic activity and; the time domain, with a strong persistence Hw = 0.949, suggests that the periodicities of slip rates are close in time (process with memory). The fractal capacity dimension (Db) is also estimated for the slip-rate series using the box-counting method. Inverse correlation between Db and low slip-rate concentration was observed. The resulting Db = 1.86 is related to a lesser concentration of low slip-rates in the PAFS, suggesting that larger faults accommodate the strain more efficiently (length  ≥ 3&thinsp;km). Thus, in terms of fractal analysis, we can conclude that these 316 faults are seismically active, because they fulfill the intrinsic definition of active faults for the PAFS.</p