Prognostic value of the myocardial salvage index measured by T2-weighted and T1-weighted late gadolinium enhancement magnetic resonance imaging after ST-segment elevation myocardial infarction: A systematic review and meta-regression analysis

In all patients with ST-segment elevation myocardial infarction, risk stratification should be performed before discharge. The measurement of therapy efficiency with magnetic resonance imaging has been proposed as part of the risk assessment, but it has not been adopted widely. This meta-analysis was conducted to summarize published data on the prognostic value of the proportion of salvaged myocardium inside previously ischemic myocardium (myocardial salvage index) measured by T2-weighted and T1-weighted late gadolinium enhancement magnetic resonance imaging after ST-segment elevation myocardial infarction. Random and mixed effects models were used for analyzing the data of 10 studies with 2,697 patients. The pooled myocardial salvage index, calculated as the proportion of non-necrotic myocardium inside edematous myocardium measured by T2-weighted and T1-weighted late gadolinium enhancement MRI, was 43.0% (95% confidence interval: 37.4, 48.6). The pooled length of follow-up was 12.3 months (95% confidence interval: 7.0, 17.6). The pooled incidence of major cardiac events during follow-up, defined as cardiac death, nonfatal myocardial infarction, or admission for heart failure, was 10.6% (95% confidence interval: 5.7, 15.5). The applied mixed effects model showed an absolute decrease of 1.7% in the incidence of major cardiac events during follow-up (95% confidence interval: 1.6, 1.9) with every 1% of increase in the myocardial salvage index. The heterogeneity between studies was considerable (τ = 21.3). Analysis of aggregated follow-up data after ST-segment elevation myocardial infarction suggests that the myocardial salvage index measured by T2-weighted and T1-weighted late gadolinium enhancement magnetic resonance imaging provides prognostic information on the risk of major cardiac events, but considerable heterogeneity exists between studies

Impact of the COVID ‐19 pandemic on patients with hidradenitis suppurativa

The COVID-19 pandemic caused collateral damage to patients with acute and chronic conditions. In this mono-centre cross-sectional study, we sought to evaluate the impact of the COVID-19 pandemic on patients with hidradenitis suppurativa (HS). In June 2020, we sent an anonymous survey to 109 patients, who were diagnosed with HS in our outpatient clinic from May 2018 to April 2020. Fifty patients (45.9%) completed and returned the survey. Forty-five participants (90.0%) denied any cancellation of hospitalisation due to the COVID-19 pandemic. Hospitalisation was postponed in 8% of cases and cancelled in 2%. Compared to prior to the pandemic, fewer patients consulted their primary physician for changing wound dressings and more changed the dressings themselves or were assisted by their family members. 13% of patients avoided doctor visits due to fear of COVID-19 and 26.1% minimised doctor visits. The Dermatology Life Quality Index showed a moderate to very severe impact on patients' Quality of Life (mean score = 10.06). Only one patient used telemedicine. Due to limited access to primary care and fear of COVID-19, the pandemic had a detectable impact on the hospital management of patients with HS in our facility. Telemedicine still plays a negligible role in primary wound care

Detection of relevant extracardiac findings on coronary computed tomography angiography vs. invasive coronary angiography

Objectives: To compare the detection of relevant extracardiac findings (ECFs) on coronary computed tomography angiography (CTA) and invasive coronary angiography (ICA) and evaluate the potential clinical benefit of their detection. Methods: This is the prespecified subanalysis of ECFs in patients presenting with a clinical indication for ICA based on atypical angina and suspected coronary artery disease (CAD) included in the prospective single-center randomized controlled Coronary Artery Disease Management (CAD-Man) study. ECFs requiring immediate therapy and/or further workup including additional imaging were defined as clinically relevant. We evaluated the scope of ECFs in 329 patients and analyzed the potential clinical benefit of their detection. Results: ECFs were detected in 107 of 329 patients (32.5%; CTA: 101/167, 60.5%; ICA: 6/162, 3.7%; p < .001). Fifty-nine patients had clinically relevant ECFs (17.9%; CTA: 55/167, 32.9%; ICA: 4/162, 2.5%; p < .001). In the CTA group, ECFs potentially explained atypical chest pain in 13 of 101 patients with ECFs (12.9%). After initiation of therapy, chest pain improved in 4 (4.0%) and resolved in 7 patients (6.9%). Follow-up imaging was recommended in 33 (10.0%; CTA: 30/167, 18.0%; ICA: 3/162, 1.9%) and additional clinic consultation in 26 patients (7.9%; CTA: 25/167, 15.0%; ICA: 1/162, 0.6%). Malignancy was newly diagnosed in one patient (0.3%; CTA: 1/167, 0.6%; ICA: 0). Conclusions: In this randomized study, CTA but not ICA detected clinically relevant ECFs that may point to possible other causes of chest pain in patients without CAD. Thus, CTA might preclude the need for ICA in those patients

Onset of occupational hand eczema among healthcare workers during the SARS‐CoV‐2 pandemic: Comparing a single surgical site with a COVID‐19 intensive care unit

Background As a result of the COVID‐19 outbreak, hygiene regulations have been revised and hand sanitation has been intensified. Objective To investigate the onset of hand eczema during the COVID‐19 pandemic in healthcare workers (HCWs) directly involved in intensive care of COVID‐19 patients and HCWs without direct contact with COVID‐19 patients. Hereby, we aim at increasing awareness about occupational hand eczema and preventive measures that can be adopted. Method A survey was distributed amongst 114 HCWs at a single surgical centre and at a COVID‐19 intensive care unit of the university hospital Ludwig Maximilian University Munich, Germany. Participants were questioned about the daily frequency of hand hygiene prior to and during the pandemic. Participants self‐reported the onset of hand eczema and associated symptoms. Results Our study revealed a significant increase in hand washing, disinfection, and use of hand cream across all participants (P‐value <.001), regardless of having direct contact with COVID‐19 patients. A high prevalence of symptoms associated with acute hand dermatitis of 90.4% was found across all HCWs, whereas hand eczema itself was underreported (14.9%). Conclusion The increase in hand sanitation during the COVID‐19 pandemic impairs the skin of the hands across all HCWs, independent of direct intensive care of affected patients

Efficacy and safety of medications for antihistamine-refractory chronic spontaneous urticaria: a systematic review and network meta-analysis

Purpose Most medications for antihistamine-refractory chronic spontaneous urticaria (CSU) have not been compared head-to-head. This systematic review and network meta-analysis evaluates their relative efficacy and safety. Methods Electronic databases were searched until 05 May 2022 for randomized controlled trials investigating systemic medications for antihistamine-refractory CSU. The change in the urticaria activity score over seven days (UAS7) and occurrence of adverse events were compared between treatments using random-effects network meta-analysis models. Results In all, 32 studies with 3641 patients receiving 31 different systemic medical interventions were included. Among currently available drugs, omalizumab 300 mg injected every 4 weeks and cyclosporine 3–5 mg/kg daily per os were most effective in reducing the UAS7 with a reduction of −10.45 (95% confidence interval [CI]: −12.35, −8.55) and of −10.40 (95% CI: −19.4, −1.4) compared to placebo. Similar efficacies were shown by the nonapproved agents ligelizumab 72 mg injected every 4 weeks (−11.67, 95% CI: −16.80, −7.15) and fenebrutinib 400 mg daily per os (−9.50, 95% CI: −17.56, −1.44). The odds ratio for the occurrence of an adverse event with placebo as comparator was 1.09 for omalizumab (95% CI: 0.83, 1.42), 2.16 for cyclosporine (95% CI: 0.77, 6.07: GRADE; moderate certainty), 0.89 for ligelizumab (95% CI: 0.47, 1.69), and 2.14 for fenebrutinib (95% CI: 0.62, 7.38) in the mentioned dosages. Conclusion Omalizumab 300 mg injected every 4 weeks and cyclosporine 3–5 mg/kg daily per os are the most effective currently available drugs for antihistamine-refractory CSU. Cyclosporine shows a relatively less favorable safety profile

Proposal of 0.5 mg of protein/100 g of processed food as threshold for voluntary declaration of food allergen traces in processed food—A first step in an initiative to better inform patients and avoid fatal allergic reactions: A GA²LEN position paper

Background: Food anaphylaxis is commonly elicited by unintentional ingestion of foods containing the allergen above the tolerance threshold level of the individual. While labeling the 14 main allergens used as ingredients in food products is mandatory in the EU, there is no legal definition of declaring potential contaminants. Precautionary allergen labeling such as "may contain traces of" is often used. However, this is unsatisfactory for consumers as they get no information if the contamination is below their personal threshold. In discussions with the food industry and technologists, it was suggested to use a voluntary declaration indicating that all declared contaminants are below a threshold of 0.5 mg protein per 100 g of food. This concentration is known to be below the threshold of most patients, and it can be technically guaranteed in most food production. However, it was also important to assess that in case of accidental ingestion of contaminants below this threshold by highly allergic patients, no fatal anaphylactic reaction could occur. Therefore, we performed a systematic review to assess whether a fatal reaction to 5mg of protein or less has been reported, assuming that a maximum portion size of 1kg of a processed food exceeds any meal and thus gives a sufficient safety margin. Methods: MEDLINE and EMBASE were searched until 24 January 2021 for provocation studies and case reports in which one of the 14 major food allergens was reported to elicit fatal or life-threatening anaphylactic reactions and assessed if these occurred below the ingestion of 5mg of protein. A Delphi process was performed to obtain an expert consensus on the results. Results: In the 210 studies included, in our search, no reports of fatal anaphylactic reactions reported below 5 mg protein ingested were identified. However, in provocation studies and case reports, severe reactions below 5 mg were reported for the following allergens: eggs, fish, lupin, milk, nuts, peanuts, soy, and sesame seeds. Conclusion: Based on the literature studied for this review, it can be stated that cross-contamination of the 14 major food allergens below 0.5 mg/100 g is likely not to endanger most food allergic patients when a standard portion of food is consumed. We propose to use the statement "this product contains the named allergens in the list of ingredients, it may contain traces of other contaminations (to be named, e.g. nut) at concentrations less than 0.5 mg per 100 g of this product" for a voluntary declaration on processed food packages. This level of avoidance of cross-contaminations can be achieved technically for most processed foods, and the statement would be a clear and helpful message to the consumers. However, it is clearly acknowledged that a voluntary declaration is only a first step to a legally binding solution. For this, further research on threshold levels is encouraged

Proposal of 0.5 mg of protein/100 g of processed food as threshold for voluntary declaration of food allergen traces in processed food-A first step in an initiative to better inform patients and avoid fatal allergic reactions : A GA(2)LEN position paper

Background Food anaphylaxis is commonly elicited by unintentional ingestion of foods containing the allergen above the tolerance threshold level of the individual. While labeling the 14 main allergens used as ingredients in food products is mandatory in the EU, there is no legal definition of declaring potential contaminants. Precautionary allergen labeling such as "may contain traces of" is often used. However, this is unsatisfactory for consumers as they get no information if the contamination is below their personal threshold. In discussions with the food industry and technologists, it was suggested to use a voluntary declaration indicating that all declared contaminants are below a threshold of 0.5 mg protein per 100 g of food. This concentration is known to be below the threshold of most patients, and it can be technically guaranteed in most food production. However, it was also important to assess that in case of accidental ingestion of contaminants below this threshold by highly allergic patients, no fatal anaphylactic reaction could occur. Therefore, we performed a systematic review to assess whether a fatal reaction to 5mg of protein or less has been reported, assuming that a maximum portion size of 1kg of a processed food exceeds any meal and thus gives a sufficient safety margin. Methods MEDLINE and EMBASE were searched until 24 January 2021 for provocation studies and case reports in which one of the 14 major food allergens was reported to elicit fatal or life-threatening anaphylactic reactions and assessed if these occurred below the ingestion of 5mg of protein. A Delphi process was performed to obtain an expert consensus on the results. Results In the 210 studies included, in our search, no reports of fatal anaphylactic reactions reported below 5 mg protein ingested were identified. However, in provocation studies and case reports, severe reactions below 5 mg were reported for the following allergens: eggs, fish, lupin, milk, nuts, peanuts, soy, and sesame seeds. Conclusion Based on the literature studied for this review, it can be stated that cross-contamination of the 14 major food allergens below 0.5 mg/100 g is likely not to endanger most food allergic patients when a standard portion of food is consumed. We propose to use the statement "this product contains the named allergens in the list of ingredients, it may contain traces of other contaminations (to be named, e.g. nut) at concentrations less than 0.5 mg per 100 g of this product" for a voluntary declaration on processed food packages. This level of avoidance of cross-contaminations can be achieved technically for most processed foods, and the statement would be a clear and helpful message to the consumers. However, it is clearly acknowledged that a voluntary declaration is only a first step to a legally binding solution. For this, further research on threshold levels is encouraged.Peer reviewe

Proposal of 0.5 mg of protein/100 g of processed food as threshold for voluntary declaration of food allergen traces in processed food-A first step in an initiative to better inform patients and avoid fatal allergic reactions: A GA(2)LEN position paper

BackgroundFood anaphylaxis is commonly elicited by unintentional ingestion of foods containing the allergen above the tolerance threshold level of the individual. While labeling the 14 main allergens used as ingredients in food products is mandatory in the EU, there is no legal definition of declaring potential contaminants. Precautionary allergen labeling such as “may contain traces of” is often used. However, this is unsatisfactory for consumers as they get no information if the contamination is below their personal threshold. In discussions with the food industry and technologists, it was suggested to use a voluntary declaration indicating that all declared contaminants are below a threshold of 0.5 mg protein per 100 g of food. This concentration is known to be below the threshold of most patients, and it can be technically guaranteed in most food production. However, it was also important to assess that in case of accidental ingestion of contaminants below this threshold by highly allergic patients, no fatal anaphylactic reaction could occur. Therefore, we performed a systematic review to assess whether a fatal reaction to 5mg of protein or less has been reported, assuming that a maximum portion size of 1kg of a processed food exceeds any meal and thus gives a sufficient safety margin.MethodsMEDLINE and EMBASE were searched until 24 January 2021 for provocation studies and case reports in which one of the 14 major food allergens was reported to elicit fatal or life-threatening anaphylactic reactions and assessed if these occurred below the ingestion of 5mg of protein. A Delphi process was performed to obtain an expert consensus on the results.ResultsIn the 210 studies included, in our search, no reports of fatal anaphylactic reactions reported below 5 mg protein ingested were identified. However, in provocation studies and case reports, severe reactions below 5 mg were reported for the following allergens: eggs, fish, lupin, milk, nuts, peanuts, soy, and sesame seeds.ConclusionBased on the literature studied for this review, it can be stated that cross-contamination of the 14 major food allergens below 0.5 mg/100 g is likely not to endanger most food allergic patients when a standard portion of food is consumed. We propose to use the statement “this product contains the named allergens in the list of ingredients, it may contain traces of other contaminations (to be named, e.g. nut) at concentrations less than 0.5 mg per 100 g of this product” for a voluntary declaration on processed food packages. This level of avoidance of cross-contaminations can be achieved technically for most processed foods, and the statement would be a clear and helpful message to the consumers. However, it is clearly acknowledged that a voluntary declaration is only a first step to a legally binding solution. For this, further research on threshold levels is encouraged.</div

Computertomographie zur Diagnose der koronaren Herzkrankheit und Magnetresonanztomographie zur Quantifizierung geretteten Myokards nach Herzinfarkt

In patients with low to intermediate probability of coronary heart disease, there is no generally applied diagnostic algorithm. We compared cardiac computed tomography (CT) angiography with direct referral to invasive coronary angiography in a randomized trial including 340 patients with low to intermediate pre-test probability. Cardiac CT angiography could be used as a safe gatekeeper for invasive coronary angiography without worsening long-term clinical outcomes or increasing radiation dosage but decreasing minor procedural complications. In a second prospective clinical study with 92 patients, we compared the diagnostic performance of myocardial CT perfusion in detecting coronary artery disease with that of myocardial magnetic resonance imaging (MRI) perfusion since the identification of flow-limiting lesions among anatomic stenoses can be helpful in therapeutic decision making. We found a comparable diagnostic accuracy of myocardial CT perfusion and the established myocardial MRI perfusion suggesting that CT perfusion reliably identifies flow-limiting coronary artery stenoses. Whether the combination of anatomical assessment with cardiac CT angiography and functional assessment with myocardial CT perfusion is similarly effective in guiding therapy decisions as invasive coronary angiography with fractional flow reserve should be answered in future research. Salvage of ischemic myocardium is one of the principal therapeutic aims in patients with myocardial infarction. Consequently, the amount of myocardial salvage provides information on therapeutic efficiency. There is a controversial discussion whether MRI allows quantification of myocardial salvage by delineating post-infarctional myocardial edema and fibrosis. In a systematic review and meta-analysis with 38 studies, we evaluated whether the time from symptom onset until reopening of the culprit artery is related to the proportion of nonnecrotic myocardium inside edematous myocardium measured by MRI, the so-called myocardial salvage index. The meta-analysis revealed an inverse relation between the myocardial salvage index and the time from symptom onset until revascularization suggesting that MRI can be of use for assessing therapeutic efficiency. In a second systematic review and meta-analysis with ten studies, we assessed whether the myocardial salvage index on MRI predicts the incidence of major cardiovascular events. We found that a high myocardial salvage index is associated with a low risk of major cardiovascular events during follow-up indicating prognostic value of quantifying myocardial salvage with MRI after myocardial infarction. Both meta-analyses revealed high between-study heterogeneity, which questions the informative value of single measurements. In both meta-analyses, a considerable part of the heterogeneity could be explained by differences in MRI methodologies. Standardization of post-infarctional MRI methodologies may thus address this concern in the future.Für Patienten mit geringer bis mittlerer Wahrscheinlichkeit des Bestehens einer koronaren Herzkrankheit gibt es keinen allgemein angewendeten diagnostischen Algorithmus. In einer randomisierten klinischen Studie erhielten 340 dieser Patienten entweder direkt eine Herzkatheteruntersuchung oder zunächst eine Computertomographie (CT)-Angiographie der Koronargefäße, um zu entscheiden, ob eine Herzkatheteruntersuchung nötig ist. Eine vorgeschaltete CT-Koronarangiographie konnte geringgradige prozedurale Komplikationen reduzieren, ohne dabei die Prognose zu verschlechtern oder die Strahlendosis zu erhöhen. In einer zweiten prospektiven klinischen Studie mit 92 Patienten verglichen wir die diagnostische Genauigkeit in der Erkennung der koronaren Herzkrankheit der myokardialen CT- mit der etablierten Magnetresonanztomographie (MRT)-Perfusion, da die Identifizierung von flusslimitierenden unter anatomischen Stenosen bei Therapieentscheidungen hilfreich ist. Die diagnostische Genauigkeit beider Verfahren zeigte sich ähnlich, sodass die myokardiale CT-Perfusion, flussbegrenzende Koronararterienstenosen effektiv zu identifizieren scheint. Ob die Kombination aus anatomischer Beurteilung mit CTKoronarangiographie und funktioneller Einschätzung mit myokardialer CT-Perfusion Therapieentscheidungen so effektiv herbeiführen kann wie der Einsatz des Herzkatheters inklusive fraktionierter Flussreserve, sollte in Zukunft untersucht werden. Die Rettung ischämischen Myokards ist ein Hauptziel der Herzinfarkttherapie und das Ausmaß des geretteten Myokards kann Aufschluss über die Therapieeffektivität geben. Ob die Darstellung des infarktbedingten myokardialen Ödems sowie der Nekrose mit MRT eine Quantifizierung des geretteten Myokards erlaubt, wird kontrovers diskutiert. In einer Metaanalyse mit Einschluss von 38 Studien fanden wir einen inversen Zusammenhang zwischen der Zeit von Symptombeginn bis zur Wiedereröffnung der verschlossenen Koronararterie und dem Anteil des nichtnekrotischen Myokards innerhalb des infarktbedingten myokardialen Ödems, dem so genannten Myocardial Salvage Index. Dies deutet darauf hin, dass die MRT-Bestimmung des Myocardial Salvage Index bei der Beurteilung der Therapieeffektivität von Nutzen sein kann. In einer zweiten Metaanalyse mit Einschluss von zehn Studien analysierten wir, ob die Bestimmung des Myocardial Salvage Index mit MRT schwere kardiovaskuläre Ereignisse während der Nachsorge vorhersagen kann. Es zeigte sich, dass ein hoher Myocardial Salvage Index mit einer niedrigen Inzidenz schwerer kardiovaskulärer Ereignisse assoziiert ist und somit prognostischen Wert hat. In beiden Metaanalysen zeigte sich eine hohe Heterogenität in den Daten, was die Aussagekraft der Einzelmessungen in Frage stellt. Ein beträchtlicher Teil der Heterogenität konnte durch Unterschiede in der technischen MRTDurchführung erklärt werden. Somit könnte eine Standardisierung der MRT-Durchführung dieses Problem in Zukunft reduzieren

MRI for measuring therapy efficiency after revascularisation in ST-segment elevation myocardial infarction: a systematic review and meta-regression analysis

Objective To summarise existing data on the relation between the time from symptom onset until revascularisation (time to reperfusion) and the myocardial salvage index (MSI) calculated as proportion of non-necrotic myocardium inside oedematous myocardium on T2-weighted and T1-weighted late gadolinium enhancement MRI after ST-segment elevation myocardial infarction (STEMI).Methods Studies including patients with revascularised STEMI and stating both the time to reperfusion and the MSI measured by T2-weighted and T1-weighted late gadolinium enhancement MRI were searched in MEDLINE, EMBASE and ISI Web of Science until 16 May 2020. A mixed effects model was used to evaluate the relation between the time to reperfusion and the MSI. The gender distribution and mean age in included patient groups, the timing of MRI, used MRI sequences and image interpretation methodology were included in the mixed effects model to explore between-study heterogeneity.Results We included 38 studies with 5106 patients. The pooled MSI was 42.6% (95% CI: 38.1 to 47.1). The pooled time to reperfusion was 3.8 hours (95% CI: 3.5 to 4.0). Every hour of delay in reperfusion was associated with an absolute decrease of 13.1% (95% CI: 11.5 to 14.6; p&lt;0.001) in the MSI. Between-study heterogeneity was considerable (σ2=167.8). Differences in the gender distribution, timing of MRI and image interpretation among studies explained 45.2% of the between-study heterogeneity.Conclusions The MSI on T2-weighted and T1-weighted late gadolinium enhancement MRI correlates inversely with the time to reperfusion, which indicates that cardioprotection achieved by minimising the time to reperfusion leads to a higher MSI. The analysis revealed considerable heterogeneity between studies. The heterogeneity could partly be explained by differences in the gender distribution, timing and interpretation of MRI suggesting that the MRI-assessed MSI is not only influenced by cardioprotective therapy but also by patient characteristics and MRI parameters