scholarly journals Unstable moyamoya disease: clinical features and impact on perioperative ischemic complications

2015 ◽  
Vol 122 (2) ◽  
pp. 400-407 ◽  
Author(s):  
Takeshi Funaki ◽  
Jun C. Takahashi ◽  
Yasushi Takagi ◽  
Takayuki Kikuchi ◽  
Kazumichi Yoshida ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Moyamoya Disease ◽  
Mr Angiography ◽  
Univariate Analysis ◽  
Underlying Disease ◽  
Sensitivity Analyses ◽  
Rapid Progression ◽  
Factors Associated ◽  
Ischemic Complications ◽  
Direct Bypass

OBJECT Unstable moyamoya disease, reasonably defined as cases exhibiting either rapid disease progression or repeated ischemic stroke, represents a challenge in the treatment of moyamoya disease. Despite its overall efficacy, direct bypass for such unstable disease remains controversial in terms of safety. This study aims to reveal factors associated with unstable disease and to assess its impact on postoperative silent or symptomatic ischemic lesions. METHODS This retrospective cohort study included both pediatric and adult patients with moyamoya disease who had undergone 140 consecutive direct bypass procedures at Kyoto University Hospital. “Unstable moyamoya disease” was defined as either the rapid progression of a steno-occlusive lesion or repeat ischemic stroke, either occurring within 6 months of surgery. The extent of progression was determined through a comparison of the findings between 2 different MR angiography sessions performed before surgery. The clinical variables of the stable and unstable disease groups were compared, and the association between unstable disease and postoperative diffusion-weighted imaging (DWI)–detected lesion was assessed through univariate and multivariate analyses with generalized estimating equations. RESULTS Of 134 direct bypass procedures performed after patients had undergone at least 2 sessions of MR angiography, 24 (17.9%) were classified as cases of unstable disease. Age younger than 3 years (p = 0.029), underlying disease causing moyamoya syndrome (p = 0.049), and radiographic evidence of infarction (p = 0.030) were identified as factors associated with unstable disease. Postoperative DWI-defined lesions were detected after 13 of 140 procedures (9.3%), although only 4 lesions (2.9%) could be classified as a permanent complication. The incidence of postoperative DWI-detected lesions in the unstable group was notable at 33.3% (8 of 24). Univariate analysis revealed that unstable disease (p < 0.001), underlying disease (p = 0.028), and recent stroke (p = 0.012) were factors associated with DWI-detected lesions. Unstable disease remained statistically significant after adjustment for covariates in both the primary and sensitivity analyses (primary analysis: OR 6.62 [95% CI 1.79–24.5]; sensitivity analysis: OR 5.36 [95% CI 1.47–19.6]). CONCLUSIONS Unstable moyamoya disease, more prevalent in younger patients and those with underlying disease, is a possible risk factor for perioperative ischemic complications. Recognition of unstable moyamoya disease may contribute to an improved surgical result through focused perioperative management based on appropriate surgical risk stratification.

Abstract TP165: Mortality After Large Artery Occlusion Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Rahul R Karamchandani ◽  
Jeremy Rhoten ◽  
Edwin Strong ◽  
Brenda Chang ◽  
Sam Singh ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Prediction Models ◽  
Univariate Analysis ◽  
Female Gender ◽  
Artery Occlusion ◽  
Large Artery ◽  
Multivariable Logistic Regression Model ◽  
Factors Associated ◽  
Social Security Death Index

Introduction: Despite randomized trials demonstrating the benefit of endovascular therapy (EVT), large artery occlusion (LAO) acute ischemic stroke (AIS) remains associated with high mortality. Identifying factors associated with mortality for patients presenting with LAO AIS can assist in therapeutic decision-making and prognostication. Hypothesis: Among patients with LAO AIS, factors associated with 90-day mortality include older age, higher presenting NIHSS score, and lower final Thrombolysis in Cerebral Infarction (TICI) score. Methods: From November 2016 to April 2019, we conducted a retrospective analysis from a large healthcare system’s stroke network registry of patients presenting with ICA and/or MCA occlusions. Ninety-day mortality status from registry follow-up was corroborated with the Social Security Death Index. A multivariable logistic regression model was fitted to determine demographic and clinical characteristics associated with 90-day mortality. Results: Among 796 patients with 800 encounters, mean age was 68 years, 52% were women, mean presenting NIHSS was 14, and 97% presented within 24 hours of last known well time. Fifty-one percent were treated with EVT. Mortality rate for the entire cohort was 25%. In a univariate analysis, there were significant differences in age, gender, race, blood glucose, presenting NIHSS, hypertension, atrial fibrillation, CTP core volume, CTP delayed perfusion volume, EVT treatment, number of passes for EVT, final TICI score, and discharge mRS, between patients with and without 90-day mortality. In the multivariable model, increasing age (per 10 years, OR 1.54, 95% CI 1.20, 1.97) and higher discharge mRS (per 1 point, OR 4.47, 95% CI 3.05, 6.55) were associated with 90-day mortality. Female gender (OR 0.57, 95% CI 0.27, 1.18) and final TICI score of 2B or better (OR 0.42, 95% CI 0.18, 1.01) were protective against 90-day mortality. Conclusions: Increasing age and worse discharge functional outcome are associated with 90-day mortality after LAO AIS. Female gender and better revascularization after EVT are associated with lower mortality. Additional studies are required to refine mortality outcome prediction models for patients presenting with LAO AIS.

scholarly journals Factors Associated with Unsuccessful Recanalization in Mechanical Thrombectomy for Acute Ischemic Stroke

2019 ◽  
Vol 9 (3) ◽  
pp. 107-113 ◽  
Author(s):  
Toshiaki Goda ◽  
Naoki Oyama ◽  
Takaya Kitano ◽  
Takanori Iwamoto ◽  
Shinji Yamashita ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Univariate Analysis ◽  
Single Center ◽  
Patient Factors ◽  
Anterior Circulation ◽  
Factors Associated ◽  
Female Sex ◽  
History Of

Introduction: Mechanical thrombectomy (MT) for acute ischemic stroke has become a standard therapy, and the recanalization rate has significantly improved. However, some cases of unsuccessful recanalization still occur. We aimed to clarify patient factors associated with unsuccessful recanalization after MT for acute ischemic stroke. Methods: This was a single-center, retrospective study of 119 consecutive patients with anterior circulation acute ischemic stroke who underwent MT at our hospital between April 2015 and March 2019. Successful recanalization after MT was defined as modified Treatment in Cerebral Ischemia (mTICI) grade 2b or 3, and unsuccessful recanalization was defined as mTICI grades 0–2a. Several factors were analyzed to assess their effect on recanalization rates. Results: Successful recanalization was achieved in 88 patients (73.9%). The univariate analysis showed that female sex (38.6 vs. 67.7%, p = 0.007), a history of hypertension (53.4 vs. 83.9%, p = 0.003), and a longer time from groin puncture to recanalization (median 75 vs. 124 min, p < 0.001) were significantly associated with unsuccessful recanalization. The multivariate analysis confirmed that female sex (OR 3.18; 95% CI 1.12–9.02, p = 0.030), a history of hypertension (OR 4.84; 95% CI 1.32–17.8, p = 0.018), M2–3 occlusion (OR 4.26; 95% CI 1.36–13.3, p = 0.013), and the time from groin puncture to recanalization (per 10-min increase, OR 1.22; 95% CI 1.09–1.37, p < 0.001) were independently associated with unsuccessful recanalization. Conclusion: Female sex and a history of hypertension might be predictors of unsuccessful recanalization after MT for anterior circulation acute ischemic stroke. Further studies are needed to fully evaluate predictors of recanalization.

scholarly journals Risk factors for postoperative ischemic complications in pediatric moyamoya disease

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Xiaofeng Deng ◽  
Peicong Ge ◽  
Rong Wang ◽  
Dong Zhang ◽  
Jizong Zhao ◽  
...  
Keyword(s):  
Risk Factors ◽  
Logistic Regression ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Posterior Cerebral Artery ◽  
Older Age ◽  
Radiographic Findings ◽  
Ischemic Complications ◽  
Direct Bypass ◽  
Ischemic Events

Abstract Background Ischemic events are the most common postoperative complication in bypass surgery for moyamoya disease (MMD), but the risk factors for pediatric MMD remain unclear. The goal of the study was to investigate the risk factors for postoperative ischemic complications in pediatric MMD patients. Methods We retrospectively reviewed a consecutive series of pediatric MMD cases at Beijing Tiantan Hospital, Capital Medical University from June 2010 through June 2019. Preoperative clinical variables and radiographic findings were recorded, and logistic regression analysis was carried out to identify the risk factors for postoperative ischemic events. Results A total of 533 operations in 336 patients were included in this study. Postoperative complications occurred after 51 operations (9.6%), including 40/447 indirect bypass procedures, 9/70 direct bypass procedures, and 2/16 combined bypass procedures. Postoperative ischemic events were the most common complication and occurred in 30 patients after 31 procedures (8.9% per patient; 5.8% per operation), including 26/447 indirect bypass procedures, 4/70 direct bypass procedures, and 1/16 combined bypass procedures, and the incidence of these events did not differ significantly between indirect and non-indirect bypass (5.8% vs 5.8%; p = 0.999). Multivariate logistic regression analyses revealed that older age at operation (OR 1.129, 95% CI 1.011–1.260, p = 0.032) and posterior cerebral artery involvement (OR 2.587, 95% CI 1.030–6.496, p = 0.043) were significantly associated with postoperative ischemic events. Conclusion We speculate that older age at operation and posterior cerebral artery involvement are risk factors for postoperative ischemic events in pediatric MMD patients.

scholarly journals Utilization of Hospice Care in Patients With Acute Ischemic Stroke

2018 ◽  
Vol 36 (1) ◽  
pp. 28-32
Author(s):  
Nabeel Chauhan ◽  
Syed F. Ali ◽  
Yousef Hannawi ◽  
Archana Hinduja
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mental Status ◽  
Hospice Care ◽  
Private Insurance ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Altered Mental Status ◽  
Optimal Timing ◽  
Factors Associated

Background: A significant percentage of terminally ill patients are discharged to hospice care following a devastating stroke. Objective: We sought to determine the factors associated with hospital discharge to hospice care in a large cohort of patients with stroke. Methods: Using the institutional Get With The Guidelines-Stroke database, all consecutive patients with acute ischemic stroke (AIS) who were alive at discharge, from January 2009 until July 2015, were analyzed. Univariate and multivariable statistical analyses were performed to determine the factors associated with discharge to hospice care. Results: Of 2446 patients with AIS, 3.4% died and were excluded of remaining 2363 patients, and 4.2% were discharged to hospice care. Univariate analysis identified patients who were discharged to hospice care to be older, caucasian, Medicare or private insurance, have atrial fibrillation, heart failure and less often had diabetes mellitus or smoked. Altered mentation at presentation and urinary tract infection were more common in patients discharged to hospice. On multivariable analysis, patients transferred to hospice care were older (odds ratio [OR]: 1.04, 95% confidence interval [CI]: 1.01-1.07; P < .001), had a high National Institute of Health Stroke Scale (NIHSS; OR: 1.15, 95% CI: 1.10-1.20; P < .001), and altered mental status at presentation (OR: 2.42, 95% CI: 1.29-4.55; P < .001). Conclusion: In our study, elderly patients with high NIHSS and altered mental status were identified as factors associated with transition to hospice care following AIS. Prospective studies on the optimal timing of initiation of these consults are needed.

scholarly journals Periventricular anastomosis in moyamoya disease: detecting fragile collateral vessels with MR angiography

2016 ◽  
Vol 124 (6) ◽  
pp. 1766-1772 ◽  
Author(s):  
Takeshi Funaki ◽  
Jun C. Takahashi ◽  
Kazumichi Yoshida ◽  
Yasushi Takagi ◽  
Yasutaka Fushimi ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Moyamoya Disease ◽  
Mr Angiography ◽  
Multivariate Analyses ◽  
Univariate Analysis ◽  
Maximum Intensity Projection ◽  
Cross Sectional Study ◽  
Single Institution ◽  
Cross Sectional ◽  
Collateral Vessels

OBJECT The authors’ aim in this paper was to determine whether periventricular anastomosis, a novel term for the abnormal collateral vessels typical of moyamoya disease, is reliably measured with MR angiography and is associated with intracranial hemorrhage. METHODS This cross-sectional study sampled consecutive patients with moyamoya disease or moyamoya syndrome at a single institution. Periventricular anastomoses were detected using MR angiography images reformatted as sliding-thin-slab maximum-intensity-projection coronal images and were scored according to 3 subtypes: lenticulostriate, thalamic, and choroidal types. The association between periventricular anastomosis and hemorrhagic presentation at onset was evaluated using multivariate analyses. RESULTS Of 136 eligible patients, 122 were analyzed. Eighteen (14.8%) patients presented with intracranial hemorrhage with neurological symptoms at onset. Intra- and interrater agreement for rating of the periventricular anastomosis score was good (κw = 0.65 and 0.70, respectively). The prevalence of hemorrhagic presentation increased with the periventricular anastomosis score: 2.8% for Score 0, 8.8% for Score 1, 18.9% for Score 2, and 46.7% for Score 3 (p < 0.01 for trend). Univariate analysis revealed that age (p = 0.02) and periventricular anastomosis score (p < 0.01) were factors tentatively associated with hemorrhagic presentation. The score remained statistically significant after adjustment for age (OR 3.38 [95% CI 1.84–7.00]). CONCLUSIONS The results suggest that periventricular anastomosis detected with MR angiography can be scored with good intra- and interrater reliability and is associated with hemorrhagic presentation at onset in moyamoya disease. The clinical utility of periventricular anastomosis as a predictor for hemorrhage should be validated in further prospective studies.

Abstract 286: Factors Associated with Non-survival From In-hospital Maternal Cardiac Arrest: An Analysis of Get with the Guidelines (gwtg) Data

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Carolyn M Zelop ◽  
Richard E Shaw ◽  
Dana P Edelson ◽  
Steven S Lipman ◽  
Jill M Mhyre ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Univariate Analysis ◽  
The United States ◽  
Sensitivity Analyses ◽  
Hospital Death ◽  
P Value ◽  
Test Model ◽  
Final Model ◽  
Factors Associated ◽  
Risk Of Death

Introduction: Maternal mortality has risen in the United States during the 21 st century. Factors influencing outcome of maternal cardiac arrest (MCA) remain largely unexplored. Hypothesis: We sought to further elucidate the factors affecting maternal death from in-hospital (IH) MCA. Methods: Our query of the American Heart Association’s GWTG ® -Resuscitation voluntary registry from 2000-2017 revealed 561 index cases of in IH MCA with complete outcome data. Logistic regression was performed using hospital death as the primary outcome and included variables with a p value = 0.1 or less based upon univariate analysis. Age, race, year of arrest, pre-existing conditions, first documented pulseless rhythm, and location of arrest were used in the model. Sensitivity analyses and assessment of variable interaction were also performed to test model stability. Results: Among 561 cases of MCA, 57.2% (321/561) did not survive to hospital discharge. In-hospital death was not associated with maternal age, race and year of event. In the final model (see table), IH death was significantly associated with prearrest hypotension/hypoperfusion (p=0.009). While MCA cases with a shockable vs non-shockable first documented pulseless rhythm had similar outcomes, those with an indeterminate rhythm were less likely to die, (p=0.014). The occurrence of MCA outside of the delivery suite (referent group) or operating room was associated with a significantly higher risk of death: ICU/Recovery Room (p=0.001) and ER/other (p= 0.012). In a sensitivity analysis, removal of the indeterminate group did not alter outcomes regarding first documented pulseless rhythm or arrest location. Area under the curve for the final model was 0.715 (95% CI 0.673-0.757). Conclusions: Our study identified several novel factors associated with IH death of our MCA cohort. More research is required to further understand the pathophysiologic dynamics affecting outcomes of IHCA in this unique population.

Assessment of extracranial-intracranial bypass in Moyamoya disease using 3T time-of-flight MR angiography: Comparison with CT angiography

VASA ◽  
2014 ◽  
Vol 43 (4) ◽  
pp. 278-283 ◽  
Author(s):  
Qian Chen ◽  
Rongfeng Qi ◽  
Xiaoqing Cheng ◽  
Changsheng Zhou ◽  
Song Luo ◽  
...  
Keyword(s):  
Image Quality ◽  
Moyamoya Disease ◽  
Mr Angiography ◽  
Time Of Flight ◽  
Consecutive Series ◽  
Tof Mra ◽  
Bypass Patency ◽  
Significant Difference ◽  
Contrast Technique ◽  
Vessel Integrity

Background: To evaluate the value of time-of-flight MR angiography (TOF MRA) for the assessment of extracranial-intracranial (EC-IC) bypass in Moyamoya disease in comparison with computed tomography angiography (CTA). Patients and methods: A consecutive series of 23 patients with Moyamoya disease were analyzed retrospectively. Twenty three patients underwent 25 procedures of extracranial-intracranial bypass. Cranial CTA was performed within one week after the surgery to assess bypass patency. Then TOF MRA was scanned within 24 h after CTA on a 3T MRI system. Using 5-point scales (0 = poor to 4 = excellent), two radiologists rated the image quality and vessel integrity of bypass for three segments (extracranial, trepanation, intracranial). Results: Image quality was high in both CTA and TOF MRA (mean quality score 3.84 ± 0.37 and 3.8 ± 0.41), without statistical difference (p = 0.66). Mean scores of TOF MRA with respect to bypass visualization were higher than CTA in the intracranial segment (p = 0.026). No significant difference of bypass visualization regarding the extracranial and trepanation segments was found between TOF MRA and CTA (p = 0.66 and p = 0.34, respectively). For the trepanation segment, TOF MRA showed pseudo lesions in 2 of all 25 cases. Conclusions: 3T TOF MRA, a non-contrast technique not exposing the patients to radiation, proved to be at least equal to CTA for the assessment of EC-IC bypass, and even superior to CTA with respect to the intracranial segment. In addition, readers should be aware of a potential overestimation showing focal pseudo lesions of the bypass at the trepanation segment in TOF MRA.

Association between Blood Urea Nitrogen-to-creatinine Ratio and Three-Month Outcome in Patients with Acute Ischemic Stroke

2019 ◽  
Vol 16 (2) ◽  
pp. 166-172 ◽  
Author(s):  
Linghui Deng ◽  
Changyi Wang ◽  
Shi Qiu ◽  
Haiyang Bian ◽  
Lu Wang ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Blood Urea Nitrogen ◽  
Univariate Analysis ◽  
Density Lipoprotein ◽  
Hydration Status ◽  
Creatinine Ratio ◽  
Urea Nitrogen

Background: Hydration status significantly affects the clinical outcome of acute ischemic stroke (AIS) patients. Blood urea nitrogen-to-creatinine ratio (BUN/Cr) is a biomarker of hydration status. However, it is not known whether there is a relationship between BUN/Cr and three-month outcome as assessed by the modified Rankin Scale (mRS) score in AIS patients. Methods: AIS patients admitted to West China Hospital from 2012 to 2016 were prospectively and consecutively enrolled and baseline data were collected. Poor clinical outcome was defined as three-month mRS > 2. Univariate and multivariate logistic regression analyses were performed to determine the relationship between BUN/Cr and three-month outcome. Confounding factors were identified by univariate analysis. Stratified logistic regression analysis was performed to identify effect modifiers. Results: A total of 1738 patients were included in the study. BUN/Cr showed a positive correlation with the three-month outcome (OR 1.02, 95% CI 1.00-1.03, p=0.04). However, after adjusting for potential confounders, the correlation was no longer significant (p=0.95). An interaction between BUN/Cr and high-density lipoprotein (HDL) was discovered (p=0.03), with a significant correlation between BUN/Cr and three-month outcome in patients with higher HDL (OR 1.03, 95% CI 1.00-1.07, p=0.04). Conclusion: Elevated BUN/Cr is associated with poor three-month outcome in AIS patients with high HDL levels.

scholarly journals POS1234 IMPACT OF THE CHANGE IN ADMINISTRATION ROUTE OF TOCILIZUMAB AND ABATACEPT, DUE TO THE COVID-19 LOCKDOWN ON DISEASE ACTIVITY IN PATIENTS WITH RHEUMATOID ARTHRITIS

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 900.1-900
Author(s):  
L. Diebold ◽  
T. Wirth ◽  
V. Pradel ◽  
N. Balandraud ◽  
E. Fockens ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Physical Activity ◽  
Disease Activity ◽  
Univariate Analysis ◽  
Route Of Administration ◽  
Anxiety And Depression ◽  
Administration Route ◽  
Factors Associated ◽  
The Impact

Background:Among therapeutics used to treat rheumatoid arthritis (RA), Tocilizumab (TCZ) and Abatacept (ABA) are both biologic agents that can be delivered subcutaneously (SC) or intravenously (IV). During the first COVID-19 lockdown in France, all patients treated with IV TCZ or IV ABA were offered the option to switch to SC administration.Objectives:The primary aim was to assess the impact of changing the route of administration on the disease activity. The second aim was to assess whether the return to IV route at the patient’s request was associated with disease activity variation, flares, anxiety, depression and low physical activity during the lockdown.Methods:We conducted a prospective monocentric observational study. Eligibility criteria: Adult ≥ 18 years old, RA treated with IV TCZ or IV ABA with a stable dose ≥3 months, change in administration route (from IV to SC) between March 16, 2020, and April 17, 2020. The following data were collected at baseline and 6 months later (M6): demographics, RA characteristics, treatment, history of previous SC treatment, disease activity (DAS28), self-administered questionnaires on flares, RA life repercussions, physical activity, anxiety and depression (FLARE, RAID, Ricci &Gagnon, HAD).The primary outcome was the proportion of patients with a DAS28 variation>1.2 at M6. Analyses: Chi2-test for quantitative variables and Mann-Whitney test for qualitative variables. Factors associated with return to IV route identification was performed with univariate and multivariate analysis.Results:Among the 84 patients who were offered to switch their treatment route of administration, 13 refused to change their treatment. Among the 71 who switched (48 TCZ, 23 ABA), 58 had a M6 follow-up visit (13 lost of follow-up) and DAS28 was available for 49 patients at M6. Main baseline characteristics: female 81%, mean age 62.7, mean disease duration: 16.0, ACPA positive: 72.4%, mean DAS28: 2.01, previously treated with SC TCZ or ABA: 17%.At M6, the mean DAS28 variation was 0.18 ± 0.15. Ten (12.2%) patients had a DAS28 worsening>1.2 (ABA: 5/17 [29.4%] and TCZ: 5/32 [15.6%], p= 0.152) and 19 patients (32.8%) had a DAS28 worsening>0.6 (ABA: 11/17 [64.7%] and TCZ: 8/32 [25.0%], p= 0.007).At M6, 41 patients (77.4%) were back to IV route (26 TCZ, 15 ABA) at their request. The proportion of patients with a DAS28 worsening>1.2 and>0.6 in the groups return to IV versus SC maintenance were 22.5%, 42.5% versus 11.1% and 22.2% (p=0.4), respectively. The univariate analysis identified the following factors associated with the return to IV route: HAD depression score (12 vs 41, p=0.009), HAS anxiety score (12 vs 41, p=0.047) and corticosteroid use (70% vs 100%, p=0.021), in the SC maintenance vs return to IV, respectively.Conclusion:The change of administration route of TCZ and ABA during the first COVID-19 lockdown was infrequently associated with a worsening of RA disease. However, the great majority of the patients (77.4%) request to return to IV route, even without disease activity worsening. This nocebo effect was associated with higher anxiety and depression scores.Disclosure of Interests:None declared

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