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Heart failure (HF) patients represent one of the most prevalent as well as one of the most fragile population encountered in the cardiology and internal medicine departments nowadays. Estimated to account for around 26 million people worldwide, diagnosed patients present a poor prognosis and quality of life with a clinical history accompanied by repeated hospital admissions caused by an exacerbation of their chronic condition. The frequent hospitalizations and the extended hospital stays mean an extremely high economic burden for healthcare institutions. Meanwhile, the number of chronically diseased and elderly patients is continuously rising, and a lack of specialized physicians is evident. To cope with this health emergency, more efficient strategies for patient management, more accurate diagnostic tools, and more efficient preventive plans are needed. In recent years, telemonitoring has been introduced as the potential answer to solve such needs. Different methodologies and devices have been progressively investigated for effective home monitoring of cardiologic patients. Invasive hemodynamic devices, such as CardioMEMS™, have been demonstrated to be reducing hospitalizations and mortality, but their use is however restricted to limited cases. The role of external non-invasive devices for remote patient monitoring, instead, is yet to be clarified. In this review, we summarized the most relevant studies and devices that, by utilizing non-invasive telemonitoring, demonstrated whether beneficial effects in the management of HF patients were effective.

Background Cardiovascular magnetic resonance (CMR) strain imaging is an established technique to quantify myocardial deformation. However, to what extent left ventricular (LV) systolic strain, and therefore LV mechanics, reflects classical hemodynamic parameters under various inotropic states is still not completely clear. Therefore, the aim of this study was to investigate the correlation of LV global strain parameters measured via CMR feature tracking (CMR-FT, based on conventional cine balanced steady state free precession (bSSFP) images) with hemodynamic parameters such as cardiac index (CI), cardiac power output (CPO) and end-systolic elastance (Ees) under various inotropic states. Methods  Ten anaesthetized, healthy Landrace swine were acutely instrumented closed-chest and transported to the CMR facility for measurements. After baseline measurements, two steps were performed: (1) dobutamine-stress (Dobutamine) and (2) verapamil-induced cardiovascular depression (Verapamil). During each protocol, CMR images were acquired in the short axisand apical 2Ch, 3Ch and 4Ch views. MEDIS software was utilized to analyze global longitudinal (GLS), global circumferential (GCS), and global radial strain (GRS). Results Dobutamine significantly increased heart rate, CI, CPO and Ees, while Verapamil decreased them. Absolute values of GLS, GCS and GRS accordingly increased during Dobutamine infusion, while GLS and GCS decreased during Verapamil. Linear regression analysis showed a moderate correlation between GLS, GCS and LV hemodynamic parameters, while GRS correlated poorly. Indexing global strain parameters for indirect measures of afterload, such as mean aortic pressure or wall stress, significantly improved these correlations, with GLS indexed for wall stress reflecting LV contractility as the clinically widespread LV ejection fraction. Conclusion GLS and GCS correlate accordingly with LV hemodynamics under various inotropic states in swine. Indexing strain parameters for indirect measures of afterload substantially improves this correlation, with GLS being as good as LV ejection fraction in reflecting LV contractility. CMR-FT-strain imaging may be a quick and promising tool to characterize LV hemodynamics in patients with varying degrees of LV dysfunction.

Right ventricular biopsy represents the gold standard for the assessment of myocardial fibrosis and collagen content. This invasive technique, however, is accompanied by perioperative complications and poor reproducibility. Extracellular volume (ECV) measured through cardiovascular magnetic resonance (CMR) has emerged as a valid surrogate method to assess fibrosis non-invasively. Nonetheless, ECV provides an overestimation of collagen concentration since it also considers interstitial space. Our study aims to investigate the feasibility of estimating total collagen volume (TCV) through CMR by comparing it with the TCV measured at histology. Seven healthy Landrace pigs were acutely instrumented closed-chest and transported to the MRI facility for measurements. For each protocol, CMR imaging at 3T was acquired. MEDIS software was used to analyze T1 mapping and ECV for both the left ventricular myocardium (LVmyo) and left ventricular septum (LVseptum). ECV was then used to estimate TCVCMR at LVmyo and LVseptum following previously published formulas. Tissues were prepared following an established protocol and stained with picrosirius red to analyze the TCVhisto in LVmyo and LVseptum. TCV measured at LVmyo and LVseptum with both histology (8 ± 5 ml and 7 ± 3 ml, respectively) and T1-Mapping (9 ± 5 ml and 8 ± 6 ml, respectively) did not show any regional differences. TCVhisto and TCVCMR showed a good level of data agreement by Bland–Altman analysis. Estimation of TCV through CMR may be a promising way to non-invasively assess myocardial collagen content and may be useful to track disease progression or treatment response.

Soil quality and health are terms describing similar concepts, but the latter appeals to farmers and crop consultants as part of a holistic approach to soil management. We regard soil health as the integration and optimization of the physical, biological and chemical aspects of soils for improved productivity in an economic and sustainable manner. This paper describes the process used for the selection of soil quality/health indicators that comprise the new Cornell Soil Health Test. Over 1,500 samples collected from controlled research experiments and commercial farms were initially analyzed for 39 potential soil quality indicators. Four physical and four biological indicators were selected based on sensitivity to management, relevance to functional soil processes, ease and cost of sampling, and cost of analysis. Seven chemical indicators were also selected as they are part of the standard soil nutrient test. Soil health test reports were developed to allow for an overall assessment, as well as the identification of specific soil constraints. The new soil health test is being offered on a for-fee basis starting in 2007. In addition, visible near infrared reflectance spectroscopy was evaluated as a possible tool for low-cost soil health assessment. From preliminary analyses, the methodology shows promise for some but not all of the soil quality indicators. In conclusion, an inexpensive soil health test was developed for integrative assessment of the physical, biological, and chemical aspects of soils, thereby facilitating better soil management.

Understanding the response of soil quality indicators to changes in management practices is essential for sustainable land management. Soil quality indicators were measured for 2 years under established experiments with varying management histories and durations at four locations in New York State. The Willsboro (clay loam) and Aurora (silt loam) experiments were established in 1992, comparing no-till (NT) to plow-till (PT) management under corn (Zea mays L.)–soybean (Glycine max L.) rotation. The Chazy (silt loam) trial was established in 1973 as a factorial experiment comparing NT versus PT and the crop harvesting method (corn silage versus corn grain). The Geneva (silt loam) experiment was established in 2003 with vegetable rotations with and without intervening soil building crops, each under three tillage methods (NT, PT and zone-till (ZT)) and three cover cropping systems (none, rye and vetch). Physical indicators measured were wet aggregate stability (WAS), available water capacity (AWC) and surface hardness (SH) and subsurface hardness (SSH). Soil biological indicators included organic matter (OM), active carbon (AC), potentially mineralizable nitrogen (PMN) and root disease potential (RDP). Chemical indicators included pH, P, K, Mg, Fe, Mn and Zn. Results from the Willsboro and Aurora sites showed significant tillage effects for several indicators including WAS, AWC, OM, AC, pH, P, K, Mg, Fe and Mn. Generally, the NT treatment had better indicator values than the PT treatments. At the Chazy site, WAS, AWC, OM, AC, pH, K and Mg showed significant differences for tillage and/or harvest method, also with NT showing better indicator values compared to PT and corn grain better than corn silage. Aggregate stability was on average 2.5 times higher in NT compared to PT treatments at Willsboro, Aurora and Chazy sites. OM was also 1.2, 1.1 and 1.5 times higher in NT compared to PT treatments at Willsboro, Aurora and Chazy sites, respectively. At the Geneva site WAS, SH, AC, PMN, pH, P, K and Zn showed significant tillage effects. The cover crop effect was only significant for SH and PMN measurements. Indicators that gave consistent performance across locations included WAS, OM and AC, while PMN and RDP were site and management dependent. The composite soil health index (CSHI) significantly differentiated between contrasting management practices. The CSHI for the Willsboro site was 71% for NT and 59% for PT, while at the Aurora site it was 61% for NT and 48% for PT after 15 years of tillage treatments.

Objective The coronary sinus Reducer is a recently introduced device to treat patients with severe angina symptoms refractory to optimal medical therapy and not amenable for conventional revascularisation. We aimed to assess the safety and efficacy of the Reducer in a real-world cohort of patients with refractory angina. Methods This is a single-centre retrospective registry. Patients with severe angina symptoms, objective evidence of myocardial ischaemia using any adequate non-invasive modality and without options for conventional revascularisation were regarded eligible for Reducer implantation. Results Twenty-three patients (74 % male, mean age 70 ± 8 years, 91.3 % previous bypass surgery, 82.6 % previous percutaneous intervention, 47.8 % previous myocardial infarction, 52.2 % diabetes mellitus) underwent Reducer implantation. The safety endpoint (successful implantation of the first device without device-related adverse events) was met in all patients. After a median follow-up of 9 (8–14) months the efficacy (any reduction in Canadian Cardiovascular Society (CCS) class and revascularisation-free survival) was reached in 17 patients (74 %): 8 patients (34.8 %) improved by 1 CCS class, 7 (30.4 %) by 2 CCS classes and 2 (8.7 %) by 3 CCS classes. One patient died 4 months after implantation because of progressive heart failure (not associated with Reducer implantation). Conclusion In this single-centre real-world experience, Reducer implantation was safe and demonstrated excellent clinical efficacy in the treatment of refractory angina at mid-term follow-up.

Background Several models have been proposed to refer patients (pts) with possible axial spondyloarthritis (axSpA) from primary care to the rheumatologist. Objectives To compare and evaluate the performance of all published referral models for axSpA in the Leiden SPondyloarthritis Caught Early (SPACE) cohort. Methods Ten referral models were found in literature and were tested in the Leiden SPACE cohort, which includes pts with back pain (≥3 months, ≤2 years, onset <45 years; n=192) referred to the rheumatology outpatient clinic of the LUMC. Imaging was omitted from all models if used, as it is unfeasible for screening in primary care. The Brandt model refers pts if HLA-B27+ or inflammatory back pain (IBP)+ (based on 3 criteria1) present; in Brandt I, pts are IBP+ if one IBP criterion present, in Brandt II if 2 etc. The Braun model registers presence of psoriasis (PSOR), buttock pain (BP) and improvement of back pain by exercise; referral if ≥2 features present. If ≤1 feature present HLA-B27 is tested; positive pts are referred.2 In the Braun alt. model, alternating BP is used instead of BP. MASTER refers pts if ≥2/4 features are present: IBP, HLA-B27, family history (FH) for ankylosing spondylitis, good response to NSAIDs.3 RADAR refers pts if ≥2/5 features are positive: IBP, HLA-B27, FH for SpA, good response to NSAIDs, extra-articular manifestations (EAM). RADAR 2/3 refers pts if ≥2/3 of the following are positive: IBP, good response to NSAIDs, EAM.4 CaFaSpA refers pts with ≥1 or ≥2 points (pt) (good response to NSAIDs, FH for SpA and IBP (ASAS); all 1pt).5 The performance of the models was evaluated (sensitivity, specificity, positive predictive value (PPV), positive likelihood radio (LR+)) using classification by ASAS axSpA criteria as external standard. For erroneously referred pts (i.e. not fulfilling the ASAS criteria, “false positive”; FP), post-test probability (PTP) for axSpA was calculated based on LR product for presence of SpA features (LR product ≥78 (equaling PTP ≥80%) as cut-off for probable axSpA). Erroneously not referred (“false negative”; FN) pts met ASAS axSpA criteria. Results In total, 74/192 pts fulfilled the ASAS axSpA criteria; 48 with imaging+. Most models performed well with regard to sensitivity/specificity. The Braun alt. model has the most balanced sensitivity/specificity and highest LR+. All models including HLA-B27 yield ASAS imaging+ FN pts, 14-23% with radiographic sacroiliitis. The PPV of the models is generally low, indicating that many pts are referred erroneously. On the other hand, of these “FP pts”, 6-16% have a PTP ≥80% for axSpA and are therefore correctly referred. Conclusions Most referral models performed well in SPACE. However, this cohort includes pts already referred from primary care, probably causing overestimation of performance. All models yield pts, who have advanced disease as indicated by fulfilling ASAS imaging+ but are not referred. On the other hand, large numbers of pts referred unnecessarily might lead to a burden for health care systems. Further studies should be conducted in primary care to evaluate these models in their target population. References Brandt ARD 2007;66:1479-84. Braun Rheum 2013;52:1418-24. Poddubnyy J Rheumatol 2011;38:2452-60. Sieper ARD 2013;72:1621-7. Weel AC&R 2013 Sep 19. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2044

Background Currently, in primary care no satisfactory referral model exists for referral to the rheumatologist of patients with chronic back pain (CBP) with possible axial spondyloarthritis (axSpA). Recently, a non-invasive, inexpensive and easily applicable two-step referral strategy was developed, based on a computer-generated model.1 Objectives The aim of our study was to validate this two-step referral strategy in the SPondyloArthritis Caught Early (SPACE)-cohort. Methods In the first step of the referral strategy, the presence of psoriasis, alternating buttock pain (ABP) and improvement of back pain by exercise (IBPE) are registered. If ≥2 of these anamnestic features are present, the patient is referred to a rheumatologist. In the second step, if ≤1 anamnestic feature is present, HLA-B27 testing is performed; if the result is positive, the patient is also referred. The required data was obtained from the SPACE-cohort, in which patients with CBP (≥3 months, ≤2 years, onset <45 years) were included (n=192). The model was tested in this cohort; the performance of the model was evaluated by calculating sensitivity, specificity and likelihood ratios (LR) using classification by ASAS axSpA criteria as external standard.2 For the patients which were erroneously referred or erroneously not referred, post-test probabilities for axSpA were calculated based on LR products for the presence of SpA features3, with a LR product of ≥78 which equals a probability of ≥80% defined as cut-off value for probable axSpA. Results A total of 74/192 patients had axSpA (ASAS), 61 of which would have been referred according to the strategy, yielding a sensitivity of 82.4%. The 13 false negatives are obligatory HLA-B27 negatives, have ≥1 SpA feature and sacroiliitis on imaging, 3/13 (23%) of which on X-ray. The referral strategy would have referred a total of 93/192 patients, yielding a specificity of 72.9%. Of the false positive patients, 8/32 (25%) would have been referred erroneously due to HLA-B27 positivity in absence of ≥2 SpA features. Half of these 32 patients (n=16; 50%) had a combination of ABP and IPBE, which are features of inflammatory back pain, which itself is not specific for axSpA. Although none of these false positives fulfil the ASAS axSpA criteria, 6/32 (19%) had probable axSpA (probability ≥80%) (figure). Conclusions The two-step referral strategy performed well in the SPACE-cohort. These results show the potential of simple referral strategies for the early recognition of axSpA. However, all patients in this study had already been referred to the rheumatologist. Thus, the performance of this model in its target population (i.e. primary care) remains to be addressed in further studies. References Braun, Rheumatol 2013;52:1418-24. Rudwaleit, ARD 2009;68:777-83. Rudwaleit, ARD 2004;63:535-43 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1901

The rice root-knot nematode, Meloidogyne graminicola is an important pathogen, impacting rice, wheat and possibly vegetable production in South-East Asia. Ten isolates of M. graminicola from broad geographic areas were compared using traditional and molecular methods. Total body length, oesophageal length, maximum body width and tail length were measured in 40 juveniles and the perineal patterns of 10 females per isolate were compared. Pathogenicity was determined on a variety of hosts. The internally transcribed spacer (ITS) region was amplified and sequenced to confirm the identity and phylogenetic relationships of the isolates. Substantial variation observed in morphometric measurements among and within isolates did not correlate with the geographic source of the isolates. All the isolates were similar in host range, but the M. graminicola -Florida isolate differed from the other nine isolates in that it was not pathogenic to rice cvv. Labelle, LA 110, Cocodrie, BR 11 or Mansuli, suggesting that M. graminicola consists of more than one race. ITS sequences of all 10 isolates matched with those of M. graminicola in GenBank and formed a single clade in the phylogenetic analysis with minor variations among and within isolates. Multiple ITS sequences occurred within individual juveniles in some of the isolates.

Disclosure: O. Abawi: None. T. Du Toit: None. G. Sommer: None. C.D. Vögel: None. M. Groessl: None. U. Halbsguth: None. S.E. Hannema: None. C. de Bruin: None. E. Charmandari: None. E.L. van den Akker: None. C.E. Flueck: None. Introduction: Treatment of children with Congenital Adrenal Hyperplasia (CAH) aims at balancing steroid replacement, hyperandrogenism and hypercortisolism. Optimal treatment and its assessment however remain a conundrum. Currently, specialists integrate clinical and conventional laboratory parameters such as 17-hydroxyprogesterone (17OHP) and androstenedione (A4). In recent years, 11-oxygenated androgens (11oxyAs) have been proposed as promising biomarkers, but their merit in treatment monitoring is not yet established. Aim: To investigate potential biomarkers of treatment quality in children with CAH by comprehensive serum steroid profiling. Methods: This prospective, observational cohort study was conducted at 4 academic pediatric endocrinology outpatient clinics and included children with genetically confirmed 21-hydroxylase deficiency. At 2 consecutive visits (mean 4.1 ± 0.7 months apart), a targeted and untargeted panel of conventional adrenal and additional peripheral steroids was analysed in serum using liquid chromatography-mass spectrometry. This included 11β-hydroxy (11OH)-androstenedione (11OHA4), 11keto-A4 (11KA4), 11OH-testosterone (11OHT), and 11keto-T (11KT). At each visit, the pediatric endocrinologist classified patients as undertreated, optimally treated or overtreated based on detailed clinical and endocrinologic evaluation, including serum 17OHP and A4 profiling. Mixed-effects logistic regression analyses on log-steroid concentrations adjusted for age, sex, BMI-z, pubertal status, CAH subtype (classic vs non-classic) and random effects for unique patients were performed to investigate odds ratios (OR) of being undertreated vs optimally treated. False discovery rate adjusted P<0.05 was considered significant. Results: We included 138 visits (86 [62%] optimal treatment, 52 [38%] undertreatment) from 72 patients, of whom 31 (43%) girls, 59 (82%) had classic CAH, and 31 (43%) were prepubertal. Mean age at first visit was 10.6 ± 5.2 years, mean BMI-z was 0.6 ± 1.1. Ten out of 17 conventional steroids, including 17OHP and 21-deoxycortisol but not A4, were associated with undertreatment. All 11oxyAs were associated with undertreatment: 11OHA4 (OR 3.64, SE 1.42, P=0.008), 11OHT (OR 2.91, SE 1.09, P=0.012), 11KT (OR 2.77, SE 1.00, P=0.01), and 11KA4 (OR 2.64, SE 0.84, P=0.009). The strongest association with undertreatment was found for the sum of 11oxyAs (OR 4.04, SE 1.70, P=0.008). Discussion: We show that 11oxyAs have the strongest association with undertreatment in children with CAH. This study supports the inclusion of 11oxyAs in the biochemical work-up of CAH to improve treatment monitoring and underscores the importance of analysing unconventional steroids in CAH by comprehensive steroid profiling. Following on, our steroid profiling can now be extended to characterise other forms of CAH and cases of suspected overtreatment. Presentation: Thursday, June 15, 2023