2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

https://biblio.ugent.be/publication/5953422/file/5953443.pdf

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Co-Planar Stereotaxic Atlas of the Human Brain—3-Dimensional Proportional System: An Approach to Cerebral Imaging, J. Talairach, P. Tournoux. Georg Thieme Verlag, New York (1988), 122 pp., 130 figs. DM 268

I have developed "tennis elbow" from lugging this book around the past four weeks, but it is worth the pain, the effort, and the aspirin. It is also worth the (relatively speaking) bargain price. Including appendixes, this book contains 894 pages of text. The entire panorama of the neural sciences is surveyed and examined, and it is comprehensive in its scope, from genomes to social behaviors. The editors explicitly state that the book is designed as "an introductory text for students of biology, behavior, and medicine," but it is hard to imagine any audience, interested in any fragment of neuroscience at any level of sophistication, that would not enjoy this book. The editors have done a masterful job of weaving together the biologic, the behavioral, and the clinical sciences into a single tapestry in which everyone from the molecular biologist to the practicing psychiatrist can find and appreciate his or

Principles of Neural Science

Heart failure (HF) with preserved ejection (HFpEF) is widely prevalent and associated with poor outcome and incompletely understood pathophysiology. In contrast to HF with reduced EF (HFrEF), modern HF pharmacotherapy did not improve outcome in HFpEF, which emphasizes the urgent need to elucidate responsible pathogenetic mechanisms in HFpEF. Over the last decennium, myocardial structure, cardiomyocyte function and intramyocardial signaling were shown to be specifically altered in HFpEF. Myocardial remodelling and dysfunction in HFpEF comprises myocardial hypertrophy and fibrosis and increased cardiomyocyte stiffness. Increased cardiomyocyte stiffness in HFpEF importantly contributes to high left ventricular (LV) diastolic stiffness and results from specific changes in transcriptional and posttranslational modifications of the giant elastic sarcomeric protein, titin. Increased systemic vascular inflammation, endothelial dysfunction and oxidative stress resulting in reduced nitric oxide (NO) bioavailability appear importantly involved in increased diastolic LV stiffness and adverse remodelling in HFpEF. Recently, a new paradigm for HFpEF was proposed, which suggests that prevalent comorbidities, such as overweight/obesity, diabetes, hypertension, chronic pulmonary obstructive disease, anemia and chronic kidney dysfunction drive myocardial dysfunction and remodelling through coronary microvascular endothelial inflammation. Additional demographic characteristics in HFpEF are older age and female predominance, which could contribute to maladaptive cardiovascular structural and functional changes in a synergistic manner with the prevalent comorbidities. Although HFpEF is associated with more impaired cardiovascular abnormalities and worse outcome beyond the level explainable by comorbidities alone, the rationale for an important involvement of noncardiac comorbidities in myocardial dysfunction and remodeling in HFpEF seems plausible. In the following review, this rationale of an important involvement of comorbidities in HFpEF pathophysiology is further addressed in light of the proposed new HFpEF paradigm.

/pdf/impact-of-comorbidities-on-myocardial-remodeling-and-2ykhnqcu1z.pdf

Impact of Comorbidities on Myocardial Remodeling and Dysfunction In Heart Failure with Preserved Ejection Fraction

The intracranial effects of acetazolamide on flow velocities can be monitored noninvasively by transcranial Doppler (TCD) sonography. Extracranial volume flow changes can now reliably be measured with color duplex M-mode systems. The authors tested the volumetric effects of acetazolamide in patients with high-grade unilateral carotid disease to quantify the amount of flow changes. Patients in group 1 had a high-grade > 70% internal carotid artery (ICA) stenosis, without collateral flow through the ophthalmic artery (OA). Patients with occluded ICA were included in group 2 (patent OA collateralization) or group 3 (no OA collateralization) (n = 6 per group). In group 1, common carotid artery (CCA) volume flow in the stenotic (normal contralateral) side increased from 271 (388) ml/min by 52 (54%) with 1 g aceta-zolamide intravenously. Simultaneously, middle cerebral artery (MCA) flow velocities increased from 54 (56) cm/s by 47 (53%). In group 2, extracranial volume flow increased from 166 (444) ml/min by 19 (52)%. MCA flow velocities increased from 43 (65) cm/s by 13 (30)%. In group 3, volume flow increased from 159 (467) ml/min by 2 (46)%. Intracranial flow velocities rose from 49 (54) cm/s by 27 (41)%. Volume flow data showed the expected decline in patients with high-grade ICA stenosis and even more pronounced in patients with occlusion of the vessel. Cerebral reserve capacity was less sufficient in patients with a patent OA, despite an additional supply of 30 ml/min, indicating a hemodynamically critical situation.

Quantitative volumetry in patients with carotid disease--effects of acetazolamide.

Non-invasive brain stimulation techniques such as transcranial direct current or transcranial magnetic stimulation (TMS) have become increasingly important in recent years for the diagnosis and treatment of neuropsychiatric diseases. These techniques are used to stimulate cortical neuronal assemblies.

TMS employs high-intensity (ca. 1 Tesla) pulsed magnetic fields in order to transfer electricity painlessly through the intact skull, in a different manner than is otherwise achievable with ultra-short current stimuli. It indirectly induces current flow in brain tissue, leading to the generation of neuronal action potentials. TMS can be applied repetitively (rTMS) to induce plastic increases in the activation or inhibition of circumscribed brain areas, which can last for hours after the termination of the stimulus.

Transcranial direct current stimulation (tDCS) with weak currents in the range of 1mA became a well-established technique in human neuroplasticity research eight years ago, when its plasticity-promoting effects in the human brain were successfully quantified with the aid of TMS (figure 1).



Figure 1

Transcranial direct current stimulation (tDCS) of the left motor cortex (electrode size, 5 × 7 cm) with a reference electrode over the right orbit



Transcranial alternating current stimulation (tACS) and transcranial random noise stimulation (tRNS) occupy intermediate positions, in the physical sense, between pulsed rTMS and continuous tDCS. These two techniques were presented for the first time at the Third International Conference on Transcranial Magnetic and Direct Current Stimulation, held in Gottingen, Germany, in October 2008.

tACS enables external interference with the cortical oscillations that play a major role in the temporal linkage of different cortical areas, according to the so-called binding hypothesis. High-frequency tRNS generates activating cortical aftereffects, which, unlike those produced by anodal tDCS, are independent of the direction of current flow.

Clinical applications of these techniques were a major theme of the conference, which is held every five years with the participation of the most active researchers in the field around the world. The entire spectrum of transcranial stimulation was covered by approximately 90 oral presentations and 250 posters for an audience of 600 participants from 39 countries (www.tms08.uni-goettingen.de). The conference was supported by the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG), the State of Lower Saxony, the German Federal Ministry of Education and Research (Bundesministerium fur Bildung und Forschung, BMBF), the German Society for Clinical Neurophysiology (Deutsche Gesellschaft fur klinische Neurophysiologie, DGKN), and the Movement Disorder Society (MDS).

The clinical application of transcranial stimulation originally focused on the treatment of patients with depression. A current overview of this topic was given (Padberg, Munich). Numerous early pilot studies yielded conflicting data on the effect of TMS. The largest multicenter trial performed to date involved 301 patients with depression who had not benefited from medical treatment and who underwent either four weeks of stimulation with 3000 TMS impulses per day as antidepressive monotherapy, or else placebo stimulation. It was found that real stimulation resulted in a remission rate approximately twice as high as that which followed placebo stimulation. This positive result led the United States Food and Drug Administration (FDA) to approve TMS in October 2008 for the treatment of patients with medically intractable depression. In contrast, another multicenter trial, which was supported by the German Research Foundation (DFG), addressed a somewhat different application, namely, the primary combination of TMS with antidepressant medication; no significant difference was found between real and placebo stimulation. The clinical relevance of the therapeutic effects that have been achieved is currently a matter of debate, and trials comparing TMS with other established treatments (e.g., antidepressants, lithium, and psychotherapy) are still largely lacking. Only in the case of electroconvulsive therapy (ECT) are there already a number of studies available, some of which show a stronger effect for TMS than for ECT, while others show no difference. Further multicenter studies of TMS for depression that are now in progress should make it possible to determine the role of TMS in the stepwise treatment of depression. Overall, TMS has been found to be well tolerated. It is already being considered as a form of antidepressive treatment in some patients for whom medical therapy has been ineffective, has led to intolerable side effects, or is contraindicated by other, comorbid diseases.

Another type of application of TMS in depression is so-called magnetoconvulsive therapy (MCT), a treatment analogous to electro-convulsive therapy (ECT), in which TMS at very high frequency and intensity is used in order to induce a generalized seizure that will have an antidepressant effect. Only small pilot studies of MCT are available at present, and no large, controlled trials have yet been performed. The current state of research is similar for tDCS in depression, on which preliminary results from a number of trials that are now in progress were presented at the Gottingen conference. There was intense discussion of further possibilities for optimizing this form of therapy with respect to the site, intensity, frequency, and intervals of stimulation, the type of pulse, the direction of current flow (Sommer, Gottingen), and the technique of grouped stimulation (the so-called theta burst stimulation technique), which appears to hold particular promise.

Other potential clinical applications for neuroplasticity-inducing stimulation techniques were studied in a small number of placebo-controlled Phase II trials, including the treatment of patients with chronic pain (Antal/Nitsche, Gottingen, BMBF Competence Network for Headache). When used to treat chronic pain, approximately two weeks of either rTMS or tDCS produces transient improvement (ca. 30% to 60% improvement on the Visual Analog Scale), similar to the improvement produced by invasive motor cortex stimulation (a neurosurgical technique that has been used to treat chronic pain for roughly 20 years). In addition to many talks by researchers from abroad, Germany was represented by studies on the use of transcranial stimulation to treat tinnitus (Langguth, Regensburg), in stroke and motor rehabilitation (Hummel, Hamburg), in schizophrenia (Falkai and Wobrock, Gottingen, with patients still being recruited till June 2009) and epilepsy (Rosenow, Marburg). The results of treating (focal) epilepsy with rTMS and tDCS are mixed; the best interpretation of the available data seems to be that focal stimulation directly over the (neocortical) epileptogenic area can lead to a transient reduction in seizure frequency that usually lasts for several weeks. One session was devoted to basic research in the field carried out on experimental animals. For example, tDCS was shown to be effective against epilepsy in a rat model (Liebetanz, Gottingen). Overall, the transcranial stimulation techniques are a form of therapy with few adverse effects. The main risk of rTMS is the very rare induction of epileptic seizures; with tDCS, there have been a few reported cases of a local, reversible skin rash due to faulty electrode contacts. In the next few years, major advances are expected in current flow modeling (figure 2), in the combined use of transcranial stimulation and associated measuring techniques such as magnetic resonance spectroscopy and positron emission tomography, and in the possibility—which recently became reality—of categorizing activated brain areas more precisely with transcranial stimulation while functional magnetic imaging is being performed at the same time.



Figure 2

Calculation of intracranial current density with cathodal tDCS of the motor cortex (Institute for Machine Elements and Construction Technology [IMK] of the University of Kassel, Germany; "Bernstein Cooperation," National Network for Computational Neuroscience, ...

International conference on transcranial magnetic and direct current stimulation.

Dopamine D(3) receptor deficiency sensitizes mice to iron deficiency-related deficits in motor learning

Pain that has become chronic has lost its warning function and is associated with dysfunction of the so-called pain network. Systematic brain stimulation aims to normalize this network by modulating neuronal activities. Non-invasive DC stimulation (tDCS) or repetitive transcranial magnetic stimulation (rTMS) are considered effective in pain treatment. Here, the stimulation of the primary motor cortex (M1) plays a central role. If the pain is not adequately controlled by tDCS and rTMS, invasive procedures such as motor cortex stimulation (MCS) or deep brain stimulation are available as a last resort.

/pdf/new-results-on-brain-stimulation-in-chronic-pain-2s8icn3aqr.pdf

Walter Paulus

Papers

Impact of Comorbidities on Myocardial Remodeling and Dysfunction In Heart Failure with Preserved Ejection Fraction

Quantitative volumetry in patients with carotid disease--effects of acetazolamide.

International conference on transcranial magnetic and direct current stimulation.

Dopamine D(3) receptor deficiency sensitizes mice to iron deficiency-related deficits in motor learning

New Results on Brain Stimulation in Chronic Pain