Comparative clinical prognosis of massive and non-massive pulmonary embolism: A registry-based cohort study

AIMS

Little is known about the prognosis of patients with massive pulmonary embolism (PE) and its risk of recurrent venous thromboembolism (VTE) compared with non-massive PE, which may inform clinical decisions. Our aim was to compare the risk of recurrent VTE, bleeding, and mortality after massive and non-massive PE during anticoagulation and after its discontinuation.

METHODS AND RESULTS

We included all participants in the RIETE registry who suffered a symptomatic, objectively confirmed segmental or more central PE. Massive PE was defined by a systolic hypotension at clinical presentation (<90 mm Hg). We compared the risks of recurrent VTE, major bleeding, and mortality using time-to-event multivariable competing risk modeling. There were 3.5% of massive PE among 38 996 patients with PE. During the anticoagulation period, massive PE was associated with a greater risk of major bleeding (subhazard ratio [sHR] 1.72, 95% confidence interval [CI] 1.28-2.32), but not of recurrent VTE (sHR 1.15, 95% CI 0.75-1.74) than non-massive PE. An increased risk of mortality was only observed in the first month after PE. After discontinuation of anticoagulation, among 11 579 patients, massive PE and non-massive PE had similar risks of mortality, bleeding, and recurrent VTE (sHR 0.85, 95% CI 0.51-1.40), but with different case fatality of recurrent PE (11.1% versus 2.4%, P = .03) and possibly different risk of recurrent fatal PE (sHR 3.65, 95% CI 0.82-16.24).

CONCLUSION

In this large prospective registry, the baseline hemodynamic status of the incident PE did not influence the risk of recurrent VTE, during and after the anticoagulation periods, but was possibly associated with recurrent PE of greater severity.

Intracranial subdural haematoma following dural puncture accidental: clinical case

Intracranial subdural hematoma is a rare, but potentially lethal complication of neuraxial procedures. Considering the high frequency of neuraxial techniques in the obstetric population, parturients are more susceptible to this fearful complication. The diagnosis is often masked and delayed because it shares similar clinical characteristics with posdural puncture headache, with headache being the most common symptom. This case report describes a timely diagnosis and successful management of an intracranial subdural hematoma, after unintentional dural puncture during labour epidural analgesia. Postpartum headache following epidural analgesia, remains a clinical challenge for the caring team, requiring a close follow-up and awareness for non-benign causes that require prompt management, avoiding devastating consequences.

Electrochemical oxidation of diclofenac on CNT and M/CNT modified electrodes

Successful electrochemical oxidation of diclofenac, a non-steroidal anti-inflammatory drug considered as an emerging pollutant, was investigated on CNT, Pt/CNT and Ru/CNT modified electrodes based on Carbon Toray in aqueous media.

Norfluoxetine and venlafaxine in zebrafish larvae: Single and combined toxicity of two pharmaceutical products relevant for risk assessment

Antidepressant metabolites are found in natural and waste waters. However, investigation of their toxic effects on aquatic animals, single or in mixture with other occurring psychoactive drugs, has been neglected. Here, effects of 80hpf exposure to norfluoxetine (0.64-400 ng/L), venlafaxine (16-10000 ng/L) or their combination (3.2 ng/L +2000 ng/L, respectively) were investigated in embryos and zebrafish larvae. Mortality, embryonic malformations, sensorymotor reflexes and the expression of 34 genes involved in the toxicants mode-of-action (MoA) and metabolism were evaluated (i.e. monoamine receptors and transporters, nuclear receptors, and detoxification transporters and enzymes). Compared to controls, norfluoxetine treatments only caused depigmentation of embryos and larvae. Venlafaxine-exposed larvae exhibited depigmentation and spinal deformities, impaired sensorymotor reflexes, alterations in the expression of genes belonging to the serotonergic, noradrenergic and dopaminergic pathways, as well as nuclear receptors related to lipid and drug metabolism. The mixture elicited distinct interaction effects, depending on the level of biological organisation analysed and the neurotransmitter pathways affected; synergism (lethality), no interaction (sensorymotor reflexes), antagonism and inverse agonism (gene expression). The results call for investigation of the toxicity of pharmaceutical metabolites single and in mixture, as well as their risk assessment in approaches accounting for possible interactions with other endocrine-disrupting compounds.

Prevalence of entanglements of seabirds in marine debris in the central Portuguese coast

Plastic pollution and the subsequent entanglement of marine animals is a global and increasing problem. In this study we present an analysis of the seabirds recorded as entangled by a rehabilitation centre and an associated marine animal stranding network, along the central coast of Portugal, between 2008 and 2018. Results show a high annual rate of entangled seabirds (average 6.9%) compared to other studies and fisheries related materials are a relevant cause of seabird entanglement (82%) compared to other debris. When comparing age classes, juveniles were more vulnerable to entanglement than other age classes in the species studied. Regarding the rehabilitation of entangled seabirds, the release rate was higher in non-fishing material entanglement cases. In conclusion, this study highlights the impact of fisheries related material on marine fauna and the need for reinforcement of the existing legislation for protecting seabirds and the implementation of mitigation measures associated with fishing activities.

Isolated apical perfusion defect in SPECT-CT scans, is there any prognostic value?

Background

Myocardial perfusion imaging (MPI) plays a significant role in diagnostic and therapeutic decision making in coronary artery disease (CAD). An isolated apical defect in the 17th segment in SPECT/CT scans is a common finding, sometimes attributed to the apical thinning phenomenon. However, the clinical significance of apical thinning or other isolated apical defects is unknown.

Purpose

The purpose of this study is to assess the prognostic impact of an isolated apical perfusion defect (17th segment) in patients (P) with suspicion of significant CAD.

Methods

A cohort of 612 consecutive P that underwent a MPI test with a SPECT/CT scanner, between January 2017 and December 2017, in a single nuclear medicine centre, was included in this retrospective study.

The inclusion criteria for this study were either a normal perfusion exam (group 1 – G1) or only an isolated apical defect in the 17th segment, either reversible suggesting ischemia (group 2 – G2) or fixed suggesting necrosis (group 3 – G3). Images with and without attenuation correction were analysed. Mean follow-up was 29±4 months.

The chi square test was used for categorical variables, and analysis of variance for continuous variables. Binary logistic regression was used to control for confounding.

Results

A total of 612 P were included (57% male sex, mean age of 69±10) and divided in G1 (n=494, 80.7%), G2 (n=62, 10%) and G3 (n=56, 9.2%). P in G3 had higher body mass index (31±7, p=0.028) and higher prevalence of dyslipidemia (84%, p=0.001), while P in G1 had lower ejection fraction at rest (54±15, p=0.001). There was no association between the presence of isolated apical defect and all- cause mortality (G1 = 7.3% vs G2 = 6.5% vs G3 = 5.4%, p=0.851). There was a statistically significant difference between groups in the referral for coronary angiography in the bivariate analysis (G1 = 7.9% vs G2 = 35.5% vs G3 = 10.7%, p=0.001), but this association did not remain when accounted for potential confounders (angina, ejection fraction, previous CAD and diabetes) – OR=3.94, 95% CI: [0.968–16.093], p=0.056.

In those P that underwent coronary angiography, there was no statistically significant difference between the 3 groups in revascularization of significant CAD (G1 = 38.5% vs G2 = 36.4% vs G3 = 50%, p=0.830). During the follow-up time, 11 P of group 1 suffered an acute coronary syndrome (ACS), but there were no events in group 2 or 3.

Conclusion

Isolated apical myocardial defect on a SPECT/CT exam has no association with all-cause mortality in this patients. There is no significant difference in referral for coronary angiography or need for coronary revascularization between P with normal exams and P with isolated apical defects.

Funding Acknowledgement

Type of funding source: None

Exploring the association of predisposing factors of Cerebral Palsy and developmental defects of enamel: a case-control study

AIM

To evaluate the occurrence of developmental defects of enamel (DDE) in children and adolescents with Cerebral Palsy (CP) and to analyze the effect of common factors in the etiology of CP on the occurrence of DDE.

METHODS

A case-control study was carried out using the modified DDE index to classify enamel defects. The study group (SG) consisted of 45 participants with CP aged between three and 14 years. The control group (CG) consisted of 88 normotypical schoolchildren, paired by gender and age group. Caregivers answered a questionnaire on their socioeconomic status and medical history. The Chi-square tests, bivariate and multivariate analysis were performed (level significance < 0.05).

RESULTS

The occurrence of DDE in SG and CG was 60% and 64.8%, respectively (p value = 0.726). The most frequent defect observed in SG was diffuse opacity (44.4%), followed by demarcated opacity (26.7%) and enamel hypoplasia (2.2%). No difference was observed in the defect's distribution among both groups (p value = 0.083). For SG, the bivariate analysis revealed a statically significant association between the presence of DDE and age group 7-14 years old and maternal schooling below 11 years. After adjusting for confounding variables, age, family income and maternal schooling were not associated with DDE.

CONCLUSION

In conclusion, the occurrence of DDE was high and similar in both groups. The pre, peri or post-natal factors associated with CP were not significant for the presence of DDE.

Candida nivariensis: Identification strategy in mycological laboratories

Candida nivariensis is a cryptic fungal species classified within the Candida glabrata complex. It was described for the first time in 2005 by the means of DNA sequencing. We report a rare case of C. nivariensis deep-seated infection occurring in a 77-year-old man hospitalized for cysto-prostatectomy. Phenotypic testing based on the direct examination and the macroscopic features of the in vitro culture initially suggested C. glabrata species, while MALDI-TOF mass spectrometry enables correct identification. The isolate was found resistant to fluconazole, like in almost 20% of the reported cases. Herein, we present our practical strategy to reliably characterize this rare cryptic species. To date, MALDI-TOF mass spectrometry-based analysis showed very good results for such a purpose.

Evaluation of efficacy and safety of rituximab in combination with mycophenolate mofetil in patients with nonspecific interstitial pneumonia non-responding to a first-line immunosuppressive treatment (EVER-ILD): A double-blind placebo-controlled randomized trial

INTRODUCTION

Nonspecific interstitial pneumonia (NSIP) are rare but severe diseases, with high mortality and morbidity, with no effective pharmacological treatment allowing for long-term remission, and therefore no clear therapeutic recommendations. Classic immunosuppressants are used as first-line treatment, with only one third of patients being responders and no clear recommendations exist for the choice of the second-line therapy. The EvER-ILD study is the first one to prospectively evaluate the efficacy and safety of rituximab and mycophenolate mofetil (MMF) versus placebo and MMF in a broad range of NSIP patients that did not respond to a first-line therapy. A pharmacokinetic-pharmacodynamic analysis based on rituximab serum concentrations will allow identification of potential factors associated with therapeutic response and/or adverse effects.

METHODS

EvER-ILD study is a French multicenter, prospective, randomized, double blind, placebo-controlled, superiority trial. Patients with severe and progressive NSIP non-responding to a first line immunosuppressive treatment will be randomized in 2 groups of treatment: one course of rituximab plus 6 months MMF (RTX-MMF group) and one course of placebo plus 6 months MMF (Placebo-MMF group). The primary outcome is the change in Forced Vital Capacity (FVC, % of predicted) from baseline to 6 months. Several clinical, biological, and quality of life secondary outcomes will be measured at 3, 6 and 12 months. A sample size of 122 patients (61 patients per group) would allow to show a point difference between groups in the change of FVC at 6 months, based on a common standard deviation for FVC change of 8% with a power of 90%, alpha 5% two-sided, and anticipating an extreme 10% drop-out rate.

ETHICS AND DISSEMINATION

The protocol was approved by the French Research Ethics Committee (CPP Tours Ouest 1 2016-R28) on November 10, 2016, and by the French competent authority (ANSM, reference 160771A-22) on December 1st, 2016. This article refers to protocol V2, dated November 18, 2016. An independent data safety monitoring board will review safety and tolerability data for the duration of the trial. Results will be disseminated via peer reviewed publication and presentation at international conferences.

TRIAL REGISTRATION NUMBER

NCT02990286 (clinicaltrials.gov), EudraCT 2016-003026-16 (European Medicines agency).

Is the Patient Activation Measure a valid measure of osteoarthritis self-management attitudes and capabilities? Results of a Rasch analysis

BACKGROUND

The Patient Activation Measure (PAM-13) was developed using Rasch analysis to assess knowledge, skills and confidence in the management of one's health. Previous studies report positive relationships between PAM-13 scores, self-management behaviours and longitudinal health outcomes in adults with chronic disease. There is little extant measurement property evidence for the use of PAM-13 in specific osteoarthritis (OA) populations. This study tested measurement properties of the PAM-13 in people living with hip and knee OA.

METHODS

Item response frequency analysis was conducted. Rasch analysis evaluated the fit of the PAM-13 data to the Rasch model. Model-data fit was evaluated using infit and outfit statistics; person/item reliability and person separation indices were computed. Unidimensionality was evaluated using Principal Components Analysis of Rasch residuals and the data were assessed for item redundancy. Differential Item Functioning (DIF) examined bias in respondent subgroups and correlations tested relationships between PAM-13 and other patient-reported outcomes.

RESULTS

Two-hundred-and-seventeen PAM-13 surveys were completed; there were no missing responses, floor or ceiling effects. Person and item reliability were acceptable (0.98 and 0.87 respectively) with good separation (person separation index 2.58). Unidimensionality was evaluated, with 49.4% of the variance explained by the first eigenvector. There was evidence of potential local response-dependence. The Rasch fit statistics were acceptable (except for item-2). There were some issues identified with targeting of the PAM-13 items to people with higher ability and the item difficulty order was different to that proposed in original cohorts. Significant DIF was identified for sex and educational level for a small number of items. PAM-13 scores were moderately correlated with depressive symptoms on the Depression Anxiety Stress Scale and Assessment of Quality of Life-6D. There were small correlations between PAM-13 and Knee injury and Osteoarthritis Outcome Score pain and activities of daily living scores.

CONCLUSIONS

This study provides some evidence of adequate person and item reliability, unidimensionality, and construct validity to support the use of PAM-13 to measure patient activation in people living with hip and knee OA. Possible limitations regarding targeting, different item difficulty order, DIF and local response dependence should be investigated in future research.

Evolution of the use of antioxidants in anti-ageing cosmetics

OBJECTIVE

Skin health and beauty are a cornerstone of general well-being in humans. Anti-ageing cosmetics are used to provide a healthy and youthful appearance. Among the different cosmetic actives, antioxidants are incorporated in anti-ageing products due to their beneficial effects in preventing and minimizing the signs of skin ageing. This work aims to understand how anti-ageing formulations changed in the past 7 years regarding pure antioxidants composition.

METHODS

Data were collected from anti-ageing formulations commercialized in main stores and pharmacies in the Portuguese market. The study started on 2011 and was updated with products launched or whose composition has been renewed on 2013, 2015 or 2018.

RESULTS

Ascorbic acid and tocopherol and their derivatives were consistently the most used antioxidants in anti-ageing formulations; followed by niacinamide and retinyl palmitate. Seven ascorbic acid derivatives are currently used in anti-ageing formulations while only three tocopherol derivatives were identified in this study. Several combinations of antioxidants were routinely found, mainly tocopherol (or tocopherol derivatives) with other antioxidants and tocopherol with tocopherol derivatives. We have not identified emerging antioxidants with great impact in anti-ageing formulations even though niacinamide and retinyl palmitate exhibited over 10% more usage in 2018.

CONCLUSION

This insight is relevant to the cosmetic industry providing a better understanding of the scientific-based formulation of modern cosmetics and supports the need for innovative antioxidants in anti-ageing cosmetics.

Distinct Profiles of Consumers of Psychoactive Substances in People Attending French Sexual Transmitted Infections Centers

The objective of this cross-sectional survey was to assess the prevalence of psychoactive substance use (PSU) in people attending 11 French Sexual Transmitted Infection Centers, and to specify their profiles (PSU and link with risky sexual behaviors) using the ascending hierarchical clustering method. Among the 5220 individuals who completed the survey, 55.6% were men and the median age was 24 years [IQR: 20-31]. Among the participants, 2751 (52.7%) reported PSU at least once in their life. Ascending hierarchical clustering identified seven distinct profiles of participants based on their PSU. This study shows a high prevalence of PSU and alcohol consumption in this young population. Moreover, subgroup analysis allowed identifying groups of psychoactive substance users who presented specific risks or vulnerabilities and who should be priority targets for interventions, particularly sexual minority groups.

Comparison of neurosensory devices in detecting cutaneous thresholds related to protective sensibility: A cross-sectional study in São Paulo, Brazil

AIMS

To quantify the static and moving cutaneous sensibility threshold of diabetic patients using a neurosensory device for quantitative pressure detection.

METHODS

Three hundred thirty-four (n = 334) patients with type 2 diabetes and no previous history of wounds on the feet were studied using the one- and two-point static (1SP;2 SP) and one- and two-point moving (1MP;2 MP) tests through the pressure-specified sensory device (PSSD) on the cutaneous territory of the dorsal first web, hallux pulp, and medial calcaneal. In addition, patients were evaluated using the Semmes-Weinstein monofilament (SWM) No. 5.07 and tuning fork (128 Hz), which were used as normality parameters to detect the loss of protective sensibility. The same examinations were used to assess the control group (228 nondiabetic).

RESULTS

Altered values were observed for the static and moving tests over the three studied nerve territories. In comparing the sensibility threshold between diabetic patients who were sensitive and nonsensitive to SWM 5.07, we observed that this filament is not the most indicated for identifying the loss of sensibility in these patients. The prevalence of patients at risk varied between 85 and 89%. The biochemical marker associated with these high rates was HbA1c (p = 0.02).

CONCLUSIONS

Numeric quantification of the pressure threshold allowed us to determine the functional deficit of nerve fibers. Our findings suggest that the neurosensory device should be used as an adjuvant tool to evaluate the degree of loss of sensation on the skin.

Validation of Anthropometric Measures Self-Reported in a Randomized Controlled Trial of a Web-Based Platform for Weight Loss

INTRODUCTION

A great number of weight loss interventions have been delivered through digital solutions. Analysis of the effectiveness in terms of weight loss is fundamental to understand the real potential of digital technologies as tools for delivery of weight loss interventions. For this, we need accurate and reliable anthropometric data. For reasons of convenience, self-reported weight and height often replace actual measurements in these interventions. This might lead to misclassification of BMI status during selection of participants and to bias in the assessment of the outcomes. Therefore, it is fundamental to have validation studies of self-reported web-based data.

OBJECTIVES

We aimed to validate online self-reported height, weight and BMI in a POEmaS trial subsample.

METHODS

We included 12.5% of the POEmaS' population (n=159). Anthropometric data reported on the web-platform were compared to measured data by paired T-tests. Agreement was assessed by Bland-Altman plots. Multinomial regression was used to investigate factors associated with self-reported weight validity.

RESULTS

There was no significant difference between reported and measured weight (0.4 kg, SD 1.7; p=0.13) and BMI (0.03 kg/m2, SD 0.87; p=0.06). Reported height was on average 0.4 cm (SD 1.2) higher than the measured ones (p<0.001). For all anthropometric data, >=95% of the cases were within the limits of agreement. Higher measured BMI was the only factor associated with low accuracy of weight report. Each unit increase in BMI increased the odds that the reported weight was lower than the one measured (OR 1.13; 95%CI 1.01-1.26).

DISCUSSION

Self-reported weight and BMI change showed good agreement with measured ones. Since these are the primary outcomes of the POEmaS trial, the findings of the validation study suggest that the outcomes' accuracy is high and that it does not vary across gender, age, study group. These findings are relevant to digital health researchers and assessors and suggest that digital health interventions for weight loss might rely on self-reported assessment of outcomes. This might be particularly useful when other modes of assessment, such as anthropometry and e-scales, are not feasible or not available. However, we acknowledge that these results might not be applicable to low educated populations.

The stability of imaging biomarkers in radiomics: a framework for evaluation

This paper studies the sensitivity of a range of image texture parameters used in radiomics to: (i) the number of intensity levels, (ii) the method of quantisation to select the intensity levels and (iii) the use of an intensity threshold. 43 commonly used texture features were studied for the gross target volume outlined on the CT component of PET/CT scans of 50 patients with non-small cell lung carcinoma (NSCLC). All cases were quantised for all values between 4 and 128 intensity levels using four commonly used quantisation methods. All results were analysed with and without a threshold range of  -200 HU to 300 HU. Cases were ranked for each texture feature and for all quantisation methods with the Spearman's rank correlation coefficient determined to evaluate stability. Results showed large fluctuations in ranking, particularly for low numbers of levels, differences between quantisation methods and with the use of a threshold, with values Spearman's Rank Correlation for many parameters below 0.2. Our results demonstrated the sensitivity of radiomics features to the parameters used during analysis and highlight the risk of low reproducibility comparing studies with slightly different parameters. In terms of the lung cancer CT datasets, this study supports the use of 128 intensity levels, the same uniform quantiser applied to all scans and thresholding of the data. It also supports several of the features recommended in the literature for such studies such as skewness and kurtosis. A recommended framework is presented for curation of the data analysis process to ensure stability of results.

Anaphylaxis in an emergency department: a retrospective 10-year study in a tertiary hospital

Summary

Background. Anaphylaxis is a potentially fatal medical emergency. The frequency of hospital admissions for anaphylaxis seems to be increasing in the recent decades. Objective. Characterize the patients admitted for anaphylaxis to the adult emergency department (ED) of a tertiary care hospital over a 10-year period, discriminating aetiologies, clinical features and therapy administered. Methods. Retrospective, descriptive and inferential study, evaluating age, sex, Manchester triage system, suspected allergen, site of allergen exposure, comorbidities, cofactors, clinical findings and symptoms, treatment and management. Patients admitted between January 2007 and December 2016 were included. Results. Forty-three patients were enrolled: 23 males, mean age 54.3 ± 16.2 years, n = 22 had history of allergic disease. Two patients were triaged as non-urgent. The most frequently suspected causes of anaphylaxis were: drugs (33%, n = 14), Hymenoptera venoms (23%, n = 10), foods (21%, n = 9) and iodinated contrast products (12%, n = 5). Adrenaline was used in 88% of the episodes (n = 38), 55% of which (n = 21) intramuscularly. Mortality was registered in one case. At discharge, adrenaline auto-injector was prescribed in 7% (n = 3) of the patients, and Allergy and Clinical Immunology consultation (ACIC) was requested in 65% of the episodes (n = 28). Statistically significant associations (p minor 0.05) were established: a, anaphylaxis to drugs associated with a low intramuscular adrenaline use and with frequent oxygen therapy; b, anaphylaxis to food associated with intramuscular adrenaline administration; c, anaphylaxis to Hymenoptera venom associated with male sex; and d, anaphylaxis to iodinated contrasts associated with referral to ACIC and with shock. All obese patients developed shock. Conclusions. Anaphylaxis is a life-threatening condition that requires early recognition. Although most patients received adrenaline, administration was not always performed by the recommended route and only a few patients were prescribed adrenaline auto-injector.