Multicomponent exercise program in older adults with lung cancer during adjuvant/palliative treatment: A secondary analysis of an intervention study

BACKGROUND

Lung cancer is the second most prevalent common cancer in the world and predominantly affects older adults. This study aimed to examine the impact of an exercise programme in the use of health resources in older adults and to assess their changes in frailty status.

DESIGN

This is a secondary analysis of a quasi-experimental study with a non-randomized control group.

SETTING

Oncogeriatrics Unit of the Complejo Hospitalario de Navarra, Spain.

PARTICIPANTS

Newly diagnosed patients with NSCLC stage I-IV.

INTERVENTION

Multicomponent exercise programme that combined resistance, endurance, balance and flexibility exercises. Each session lasted 45-50 minutes, and the exercise protocol was performed twice a week over 10 weeks.

MEASUREMENTS

Mortality, readmissions and Visits to the Emergency Department. Change in frailty status according to Fried, VES-13 and G-8 scales.

RESULTS

26 patients completed the 10-weeks intervention (IG). Mean age in the control group (CG) was 74.5 (3.6 SD) vs 79 (3 SD) in the IG, and 78,9% were male in the IG vs 71,4% in the CG. No major adverse events or health-related issues attributable to the testing or training sessions were noted. Significant between-group differences were obtained on visits to the emergency department during the year post-intervention (4 vs 1; p:0.034). No differences were found in mortality rate and readmissions, where an increasing trend was observed in the CG compared with the IG in the latter (2 vs 0; p 0.092). Fried scale was the unique indicator that seemed to be able to detect changes in frailty status after the intervention.

CONCLUSIONS

A multicomponent exercise training programme seems to reduce the number of visits to the emergency department at one-year post-intervention in older adults with NSCLC during adjuvant therapy or palliative treatment, and is able to modify the frailty status when measured with the Fried scale.

Expression in Escherichia coli, purification and kinetic characterization of LAPLm, a Leishmania major M17-aminopeptidase

The Leishmania major leucyl-aminopeptidase (LAPLm), a member of the M17 family of proteases, is a potential drug target for treatment of leishmaniasis. To better characterize enzyme properties, recombinant LAPLm (rLAPLm) was expressed in Escherichia coli. A LAPLm gene was designed, codon-optimized for expression in E. coli, synthesized and cloned into the pET-15b vector. Production of rLAPLm in E. coli Lemo21(DE3), induced for 4 h at 37 °C with 400 μM IPTG and 250 μM l-rhamnose, yielded insoluble enzyme with a low proportion of soluble and active protein, only detected by an anti-His antibody-based western-blot. rLAPLm was purified in a single step by immobilized metal ion affinity chromatography. rLAPLm was obtained with a purity of ~10% and a volumetric yield of 2.5 mg per liter, sufficient for further characterization. The aminopeptidase exhibits optimal activity at pH 7.0 and a substrate preference for Leu-p-nitroanilide (appK_M = 30 μM, appk_cat = 14.7 s^-1). Optimal temperature is 50 °C, and the enzyme is insensitive to 4 mM Co²⁺, Mg²⁺, Ca²⁺ and Ba²⁺. However, rLAPLm was activated by Zn²⁺, Mn²⁺ and Cd²⁺ but is insensitive towards the protease inhibitors PMSF, TLCK, E-64 and pepstatin A, being inhibited by EDTA and bestatin. Bestatin is a potent, non-competitive inhibitor of the enzyme with a K_i value of 994 nM. We suggest that rLAPLm is a suitable target for inhibitor identification.

Non-destructive evaluation of carcass and ham traits and meat quality assessment applied to early and late immunocastrated Iberian pigs

Castration is a common practice in Iberian pigs due to their advanced age and high weight at slaughter. Immunocastration (IC) is an alternative to surgical castration that influences carcass and cut fatness. These traits need to be evaluated in vivo and postmortem. The aims of the present work were (a) to determine the relationship between ham composition measured with computed tomography (CT) and in vivo ultrasound (US) and carcass fat thickness measurements, (b) to apply these technologies to early (EIP) and late (LIP) immunocastrated Iberian pigs in order to evaluate carcass fatness and ham tissue composition and (c) to assess meat quality on these animals and to find the relationships between meat quality traits (namely, intramuscular fat (IMF)) and fat depot thicknesses. For this purpose, 20 purebred Iberian pigs were immunocastrated with three doses of Improvac ®, at either 4.5, 5.5 and 9 or 11, 12 and 14 months of age (EIP or LIP; respectively; n = 10 each) and slaughtered at 17 months of age. Fat depots were evaluated in vivo by US, in carcass with a ruler and in hams by CT. Carcass and cut yields, loin meat quality and loin acceptability by consumers were determined. Also, IMF was determined in the loin and three muscles of the ham. Carcass weight was 14.9 kg heavier in EIP vs LIP, and loin backfat thickness (US- and ruler-measured) was also greater in EIP. Similarly, CT-evaluated ham bone and fat contents were greater and smaller for EIP vs LIP, respectively. Loin and ham IMF were also greater in EIP, but the other meat quality parameters were similar. The acceptability of meat by consumers was high and it did not differ between IC protocols. Correlations between several fat depots measured with the different technologies were high. In conclusion, all these technologies allowed fat depot measurements, which were highly correlated despite being obtained at different anatomical locations.

Oil from transgenic Camelina sativa as a source of EPA and DHA in feed for European sea bass (Dicentrarchus labrax L.)

Aquaculture, the fastest growing food production sector cannot continue to rely on finite stocks of marine fish as the primary source of the omega-3 (n-3) long-chain polyunsaturated fatty acids (LC-PUFA), eicosapentaenoic acid (EPA; 20:5n3) and docosahexaenoic acid (DHA; 22:6n-3), for feeds. A four-month feeding trial was conducted to investigate the impact of a de novo oil, with high levels of EPA and DHA, obtained from transgenic Camelina sativa on growth performance, tissue fatty acid profiles, and expression of lipid metabolism genes when used as a replacement for fish oil in feed for European seabass (Dicentrachus labrax). Triplicate groups of 50 juvenile fish (initial weight 16.7 ± 0.92 g) per tank were fed for 4 months with one of three isolipidic and isoproteic experimental diets consisting of a standard diet containing a commercial blend of fish oil and rapeseed oil (CFO), a diet containing transgenic Camelina oil (TCO), or a blend of fish oil and rapeseed oil with enhanced levels of EPA and DHA (EFO) formulated to match the n-3 LC-PUFA profile of the TCO feed. Final weight of fish fed the GM-derived oil was not different to fish fed either CFO or EFO. Slight lower growth performance of fish fed TCO at the beginning of the trial was related to transient reduced feed intake, possibly caused by glucosinolates in the raw Camelina sativa oil. The GM-derived oil improved the nutritional quality of the fish fillet by enhancing total n-3 PUFA levels compared to the fish fed the other two feeds, and maintained flesh EPA and DHA at the same levels as in fish fed the diets containing fish oil. The metabolic response in liver and intestine was generally relatively mild although diets TCO and EFO seemed to trigger a metabolic response consisting of an up-regulation of both β-oxidation (cpt1a) and fatty acid transport (fabp1), possibly reflecting higher levels of LC-PUFA. Overall, the present study indicated that an oil of terrestrial origin, Camelina sativa, when engineered to contain high levels of EPA and DHA can replace fish oil in feeds for European seabass with no detrimental impact on growth or feed efficiency, while also maintaining or increasing tissue n-3 LC-PUFA contents.

Moderate hypofractionated post-prostatectomy radiation therapy is feasible and well tolerated: experience from a single tertiary cancer centre

PURPOSE

Conventional post-prostatectomy radiation therapy comprises 6.5-8 weeks of treatment, therefore, hypofractionated and shortened schemes arouse increasing interest. We describe our experience regarding feasibility and clinical outcome of a post-prostatectomy moderate hypofractionated image-guided radiotherapy schedule MATERIALS AND METHODS: From Oct 2015-Mar 2020, 113 patients, median age of 62 years-old (range 45-76) and prostate adenocarcinoma of low risk (30%), intermediate risk (49%) and high risk (21%) were included for adjuvant (34%) or salvage radiation therapy (66%) after radical prostatectomy (RP). All patients underwent radiotherapy with image-guided IMRT/VMAT to a total dose of 62.5 Gy in 2.5 Gy/fraction in 25 fractions. Sixteen patients (14%) received concomitant androgen deprivation therapy.

RESULTS

With a median follow-up of 29 months (range 3-60 months) all patients but three are alive. Eleven patients (10%) developed exclusive biochemical relapse while 19 patients (17%) presented macroscopically visible relapse: prostatectomy bed in two patients (2%), pelvic lymph nodes in 13 patients (11.5%) and distant metastases in four patients (4%). The 3 years actuarial rates for OS, bFRS, and DMFS were 99.1, 91.1 and 91.2%, respectively. Acute and late tolerance was satisfactory. Maximal acute genitourinary (AGU) toxicity was G2 in 8% of patients; maximal acute gastrointestinal (AGI) toxicity was G2 in 3.5% of patients; maximal late genitourinary (LGU) toxicity was G3 in 1% of patients and maximal late gastrointestinal (LGI) toxicity was G2 in 2% of patients. There were no cases of severe acute or late toxicity. No relationship was found between acute or late GI/GU adverse effects and dosimetric parameters, age, presence of comorbidities or concomitant treatments.

CONCLUSIONS

Hypofractionated radiotherapy (62.5 Gy in 25 2.5 Gy fractions) is feasible and well tolerated with low complication rates allowing for a moderate dose-escalation that offers encouraging clinical results for biochemical control and survival in patients with prostate cancer after radical prostatectomy.

International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines

The human ageing process is universal, ubiquitous and inevitable. Every physiological function is being continuously diminished. There is a range between two distinct phenotypes of ageing, shaped by patterns of living - experiences and behaviours, and in particular by the presence or absence of physical activity (PA) and structured exercise (i.e., a sedentary lifestyle). Ageing and a sedentary lifestyle are associated with declines in muscle function and cardiorespiratory fitness, resulting in an impaired capacity to perform daily activities and maintain independent functioning. However, in the presence of adequate exercise/PA these changes in muscular and aerobic capacity with age are substantially attenuated. Additionally, both structured exercise and overall PA play important roles as preventive strategies for many chronic diseases, including cardiovascular disease, stroke, diabetes, osteoporosis, and obesity; improvement of mobility, mental health, and quality of life; and reduction in mortality, among other benefits. Notably, exercise intervention programmes improve the hallmarks of frailty (low body mass, strength, mobility, PA level, energy) and cognition, thus optimising functional capacity during ageing. In these pathological conditions exercise is used as a therapeutic agent and follows the precepts of identifying the cause of a disease and then using an agent in an evidence-based dose to eliminate or moderate the disease. Prescription of PA/structured exercise should therefore be based on the intended outcome (e.g., primary prevention, improvement in fitness or functional status or disease treatment), and individualised, adjusted and controlled like any other medical treatment. In addition, in line with other therapeutic agents, exercise shows a dose-response effect and can be individualised using different modalities, volumes and/or intensities as appropriate to the health state or medical condition. Importantly, exercise therapy is often directed at several physiological systems simultaneously, rather than targeted to a single outcome as is generally the case with pharmacological approaches to disease management. There are diseases for which exercise is an alternative to pharmacological treatment (such as depression), thus contributing to the goal of deprescribing of potentially inappropriate medications (PIMS). There are other conditions where no effective drug therapy is currently available (such as sarcopenia or dementia), where it may serve a primary role in prevention and treatment. Therefore, this consensus statement provides an evidence-based rationale for using exercise and PA for health promotion and disease prevention and treatment in older adults. Exercise prescription is discussed in terms of the specific modalities and doses that have been studied in randomised controlled trials for their effectiveness in attenuating physiological changes of ageing, disease prevention, and/or improvement of older adults with chronic disease and disability. Recommendations are proposed to bridge gaps in the current literature and to optimise the use of exercise/PA both as a preventative medicine and as a therapeutic agent.

Performance of the Short Physical Performance Battery in Identifying the Frailty Phenotype and Predicting Geriatric Syndromes in Community-Dwelling Elderly

The early identification of seniors at high risk of geriatric syndromes is fundamental for targeting interventions to those who most need them. To date, the predictive value of the Short Physical Performance Battery (SPPB) for multifactorial clinical conditions has not been clearly established. Thus, the aim of the present study was to determine whether the SPPB could identify frailty and predict geriatric syndromes in community-dwelling older adults. Participants comprised men and women aged 60 years and older who participated in the Health and Well-being and Aging Survey in Colombia 2015 (n=4125, 57.6% women). A structured interview was administered to obtain socio-demographic data which included age, sex, ethnicity, socioeconomic status, and urbanicity. The study included the measurement of body mass, grip strength, SPPB, Lawton´s instrumental ADL scale, specific subjective memory complaints (SSMC), frailty phenotype (Fried and FRAIL Scale), and self-reported falls, geriatric syndromes and/or medical conditions. ROC analysis was used to examine the ability of the SPPB test to predict frailty and geriatric syndromes. The cutoff that maximized both sensitivity and specificity for the frailty phenotype was 8 points or below for men and 7 points or below for women. These cutoff values significantly predicted four geriatric syndromes in descending order: mild dementia (♂ ORajus 3.34, and ♀ ORajus 2.79), low grip strength (♂ ORajus 1.98, and ♀ ORajus 2.45), falls (♂ ORajus 1.39, and ♀ ORajus 1.49), and SSMC (♂ ORajus 1.39). In summary, the main finding of the present study was that SPPB score (i.e., ≤ 8 ♂ and ≤ 7 ♀) seems to be a useful measure for identifying the physical frailty phenotype and predicting geriatric syndromes in community-dwelling older adults.

Specific sex and gender factors of pericarditis in women

Introduction

Pericarditis is relatively common in clinical practice and may present as an isolated disease or as a manifestation of a systemic disease. There is an important sex-gap in the evidence on cardiovascular diseases, whereas it is unclear if there are sex-specific differences in the features of patients with acute pericarditis (AP).

Objective

The aim of this study was to evaluate the presence of specific sex and gender factors of pericarditis in women.

Material and methods

We retrospectively included all consecutive patients admitted with acute pericarditis (AP) in an emergency department (ED) of a tertiary care center between 2008 and 2018. Patients without acute pericarditis diagnosis criteria were excluded. We collected patients' baseline characteristics and management data. Recurrence and complicated related to AP at 30-days and 1-year follow-up were assessed.

Results

A total of 729 patients (mean age 42±17.2 years, 33% females) were analyzed. Women were older than men (47.5 yo vs 40 yo, P<0.001). Univariate analysis showed that women presented more prevalence of obesity (11% vs 5%, P<0.01) and chronic kidney disease (6% vs 3%, P<0.05) with previous autoimmune disease (15% vs 3%, P<0.001), and previous immunosuppressive treatment more frequent (15% vs 7%, P<0.01). Women presented more delayed time between beginnings of symptoms until first medical attendance (70 min vs 41 min, P<0.01). No difference was found either echocardiography findings or blood test values. Autoimmune AP was more prevalent in women than men (9% vs 1%, P<0.001). Hence, corticosteroids treatment was more used in women (12% vs 4,5%, P<0.001). In multivariate analysis, six factors were found as specific gender factors of pericarditis in women: Age (OR: 1.02, 95% CI: 1.01–13.2, P<0.01), obesity (OR: 2.27, 95% CI: 1.15–4.49; P<0,05), smoker (OR: 0.39, 95% CI: 0.25–0.59, P<0.001), previous autoimmune disease (OR: 4,29, 95% CI: 1,77–13,21; P<0,01); electrocardiogram diagnosis criteria (OR: 0,18, 95% CI: 0,6–0,52; P<0,001); Autoimmune etiology (adjusted OR: 11,78, 95% CI: 1,99–69,64; P<0,01). No difference was found in recurrence of AP in 30-days and 1-year follow-up (12% vs 13%, P>0.05; 14% vs 13%. P>0.05; respectively).

Conclusion

In our cohort, women with AP attended ED later than men and were less likely to present with typical AP changes in the electrocardiogram. Moreover, women are more commonly affected by specific forms of pericarditis related to autoimmune disease. However, follow-up did not show differences related to gender.

Funding Acknowledgement

Type of funding source: None

Kinetics of uranium(VI) lability and solubility in aerobic soils

Uranium may pose a hazard to ecosystems and human health due to its chemotoxic and radiotoxic properties. The long half-life of many U isotopes and their ability to migrate raise concerns over disposal of radioactive wastes. This work examines the long-term U bioavailability in aerobic soils following direct deposition or transport to the surface and addresses two questions: (i) to what extent do soil properties control the kinetics of U speciation changes in soils and (ii) over what experimental timescales must U reaction kinetics be measured to reliably predict long-term of impact in the terrestrial environment? Soil microcosms spiked with soluble uranyl were incubated for 1.7 years. Changes in U^VI fractionation were periodically monitored by soil extractions and isotopic dilution techniques, shedding light on the binding strength of uranyl onto the solid phase. Uranyl sorption was rapid and strongly buffered by soil Fe oxides, but U^VI remained reversibly held and geochemically reactive. The pool of uranyl species able to replenish the soil solution through several equilibrium reactions is substantially larger than might be anticipated from typical chemical extractions and remarkably similar across different soils despite contrasting soil properties. Modelled kinetic parameters indicate that labile U^VI declines very slowly, suggesting that the processes and transformations transferring uranyl to an intractable sink progress at a slow rate regardless of soil characteristics. This is of relevance in the context of radioecological assessments, given that soil solution is the key reservoir for plant uptake.

Development of a High-Throughput Screening Assay to Identify Inhibitors of the Major M17-Leucyl Aminopeptidase from Trypanosoma cruzi Using RapidFire Mass Spectrometry

Leucyl aminopeptidases (LAPs) are involved in multiple cellular functions, which, in the case of infectious diseases, includes participation in the pathogen-host cell interface and pathogenesis. Thus, LAPs are considered good candidate drug targets, and the major M17-LAP from Trypanosoma cruzi (LAPTc) in particular is a promising target for Chagas disease. To exploit LAPTc as a potential target, it is essential to develop potent and selective inhibitors. To achieve this, we report a high-throughput screening method for LAPTc. Two methods were developed and optimized: a Leu-7-amido-4-methylcoumarin-based fluorogenic assay and a RapidFire mass spectrometry (RapidFire MS)-based assay using the LSTVIVR peptide as substrate. Compared with a fluorescence assay, the major advantages of the RapidFire MS assay are a greater signal-to-noise ratio as well as decreased consumption of enzyme. RapidFire MS was validated with the broad-spectrum LAP inhibitors bestatin (IC₅₀ = 0.35 μM) and arphamenine A (IC₅₀ = 15.75 μM). We suggest that RapidFire MS is highly suitable for screening for specific LAPTc inhibitors.

Using chemical fractionation and speciation to describe uptake of technetium, iodine and selenium by Agrostis capillaris and Lolium perenne

To understand the dynamic mechanisms governing soil-to-plant transfer of selenium (Se), technetium-99 (⁹⁹Tc) and iodine (I), a pot experiment was undertaken using 30 contrasting soils after spiking with ⁷⁷Se, ⁹⁹Tc and ¹²⁹I, and incubating for 2.5 years. Two grass species (Agrostis capillaris and Lolium perenne) were grown under controlled conditions for 4 months with 3 cuts at approximately monthly intervals. Native (soil-derived) ⁷⁸Se and¹²⁷I, as well as spiked ⁷⁷Se, ⁹⁹Tc and ¹²⁹I, were assayed in soil and plants by ICP-MS. The grasses exhibited similar behaviour with respect to uptake of all three elements. The greatest uptake observed was for ⁹⁹Tc, followed by ⁷⁷Se, with least uptake of ¹²⁹I, reflecting the transformations and interactions with soil of the three isotopes. Unlike soil-derived Se and I, the available pools of ⁷⁷Se, ⁹⁹Tc and ¹²⁹I were substantially depleted by plant uptake across the three cuts with lower concentrations observed in plant tissues in each subsequent cut. Comparison between total plant offtake and various soil species suggested that ⁷⁷SeO₄^2-, ⁹⁹TcO₄^- and ¹²⁹IO₃^-, in soluble and adsorbed fractions were the most likely plant-available species. A greater ratio of ¹²⁷I/¹²⁹I in the soil solid phase compared to the solution phase confirmed incomplete mixing of spiked ¹²⁹I with native ¹²⁷I in the soil, despite the extended incubation period, leading to poor buffering of the spiked available pools. Compared to traditional expressions of soil-plant transfer factor (TF_total), a transfer factor (TF_available) expressed using volumetric concentrations of speciated 'available' fractions of each element showed little variation with soil properties.

Radionuclide transfer to wildlife at a 'Reference site' in the Chernobyl Exclusion Zone and resultant radiation exposures

This study addresses a significant data deficiency in the developing environmental protection framework of the International Commission on Radiological Protection, namely a lack of radionuclide transfer data for some of the Reference Animals and Plants (RAPs). It is also the first study that has sampled such a wide range of species (invertebrates, plants, amphibians and small mammals) from a single terrestrial site in the Chernobyl Exclusion Zone (CEZ). Samples were collected in 2014 from the 0.4 km² sampling site, located 5 km west of the Chernobyl Nuclear Power complex. We report radionuclide (¹³⁷Cs, ⁹⁰Sr, ²⁴¹Am and Pu-isotopes) and stable element concentrations in wildlife and soil samples and use these to determine whole organism-soil concentration ratios and absorbed dose rates. Increasingly, stable element analyses are used to provide transfer parameters for radiological models. The study described here found that for both Cs and Sr the transfer of the stable element tended to be lower than that of the radionuclide; this is the first time that this has been demonstrated for Sr, though it is in agreement with limited evidence previously reported for Cs. Studies reporting radiation effects on wildlife in the CEZ generally relate observations to ambient dose rates determined using handheld dose meters. For the first time, we demonstrate that ambient dose rates may underestimate the actual dose rate for some organisms by more than an order of magnitude. When reporting effects studies from the CEZ, it has previously been suggested that the area has comparatively low natural background dose rates. However, on the basis of data reported here, dose rates to wildlife from natural background radionuclides within the CEZ are similar to those in many areas of Europe.

474 Isolated pulmonary endocarditis

INTRODUCTION

Isolated pulmonary endocarditis is a rare entity, especially in patients without predisposing factors, being its current incidence less than 1% of the total cases of infectious endocarditis. This is due to the lower right heart pressures and a decrease of intravenous drug-consum, being most of the cases nowadays, related to congenital right-heart diseases or pacemakers and defibrillators implants.

CLINICAL CASE

A 35 year-old man, tobacco smoker and intravenous cocaine consumer since he was 25, was admitted to our Emergency Department for fever up to 40ºC, cough and dyspnea started three days before admission. In the anamnesis he refereed intravenous consum of cocaine and sharing of syringes the last week. On physical examination he was tachycardic and signs of heart right failure were present such as jugular ingurgitation and peripheral edema. No murmurs were heard. No respiratory failure was detected at any time. Blood test analysis showed high levels of protein C reactive and leukocytosis. Blood cultures were positive for S. aureus (OXA-S) in the first 24h. Chest X-ray (image 1) showed a necrotizing bilateral pneumonia that was confirmed with the presence of cavitated images in the pulmonary CT (image 2). Antibiotic treatment was started with daptomicine + cloxaciline. With the suspicion of right endocarditis a transthoracic echocardiography was performed, showing the presence of a big vegetation (4x1cm) on the pulmonary valve that caused moderate pulmonary insufficiency (images 3, 4). Neither tricuspid nor left side valves were involved. Biventricular function was conserved and hyperdynamic. Endocarditis diagnosis was definitive and due to the presence of multiple right embolisms and the big size of the vegetation, the patient underwent cardiac surgery. Intra-surgical finding demonstrated a big vegetation of almost 5 cm (image 5) depending of the posterior pulmonary valve that was removed; the posterior valve needed to be repaired. Posterior clinical evolution was correct without complications, completing 17 days of i.v. antibiotics (cloxaciline) before discharge.

CONCLUSIONS

Right endocarditis is a rapidly progressive disease due to the fact that staphylococcus are the most frequent microorganisms involved. Valvular destruction and secondary embolic phenomena are the rule. Tricuspid valve is involved most of the times being the isolated pulmonary valve affection very uncommon.

Abstract 474 Figure. CT, Echo and surgical images

P1721 Reversible heart right failure. Pulmonary hypertension induced by Tyrosine Kinase Inhibitors

BACKGROUND

Pharmacologically induced pulmonary hypertension (PH) is infrequent nowadays and it is included in the type 1 of the classification of PH.

Tyrosine kinase inhibitors (TKI) are the cornerstone of the treatment of many haemotopoietic stem cell diseases. Dasatinib is a second-generation TKI used in chronic myeloid leukemia (CML) and as an infrequent cardiovascular side-effect (< 0,50%) could induce PH, usually reversible but life threatening. Only a few case series are published.

CASE DESCRIPTION: We present a 51-year-old woman who was diagnosed of a CML when she was 46. Initially, she underwent therapy with imatinib but after 5 years of treatment she developed resistance to this drug, and dasatinib was prescribed as a second line drug. After 3 months of continuous treatment, she started with dry cough and effort dyspnea. Blood analysis, EKG and Chest X-Ray were made but did not show outstanding findings. An unspecific viral infection was the final diagnosis. The patient clinical condition deteriorated with major dyspnea and edemas in the lower limbs. A TTE showed moderate tricuspid regurgitation and severe HP systolic pulmonary artery pressure (sPAP) of 80 mmHg. The pulmonary acceleration time was shortened and a mesosistolic knock was present. Systolic dysfunction of the right ventricle and pericardial effusion (image 1,2,3,4) were noted. The right atrium was not dilated. Cava vein was dilated but with inspiratory collapse >50%. The left ventricular function was preserved, but first degree diastolic dysfunction was found. Other causes of PH were excluded (types 2, 3, 4). A CT pulmonary angiogram did not show segmental perfusion defects. Finally, a right heart catheterization confirmed the TTE findings: severe precapillary PH without postcapillary component. After the diagnosis was confirmed, TKI was stopped and double targeted therapy with ambrisentan + tadalafil was started. After 6 months of treatment a new TTE was made with complete reversal of the secondary changes in the myocardium induced by the PH. No tricuspid regurgitation was detected nor any indirect sign of PH was found. (image 5,6).

CONCLUSIONS

Drug-induced PH is rare nowadays and most cases were described in the seventies in the USA related with the epidemic of anorexigenic drugs. Although the pathogenesis still remains unclear, treatment includes immediately stopping the offending agent.

Echocardiography due to its accessibility, reproducibility, consistence and low cost should be the first diagnostic tool to be considered, because as it is known, in the early stages of the disease, before developing right disfunction, clinical and conventional tests are non-specific.

Abstract P1721 Figure. Echo images: previous and afte treatment

1094 Exercise syncope as initial symptom of constrictive pericarditis in a young patient

Introduction

Constrictive pericarditis is a form of diastolic heart failure that arises because an inelastic pericardium inhibits cardiac filling. Syncope is a rare initial symptom of constrictive pericarditis.

Clinical case

A 22-year-old man with previous medical history of viral meningitis when he was 3 months-old but without any family history of cardiac disease or sudden cardiac death, was admitted to the Emergency Department for syncope. During the last year, he had suffered several episodes of intense exercise-related syncope. The patient denied having prodromes, chest pain, palpitations or any other symptoms. The physical exam of the patient was normal with stable vital signs. Normal S1 and S2 heart sounds were present, no murmurs or gallop. There were no signs of heart failure, only a minimal jugular ingurgitation. An electrocardiogram (ECG) revealed sinus rhythm, signs of bi-atrial enlargement (prominent P-wave with P mitral morphology in DI-II leads, with enhanced negative deflection in V1), and negative asymmetric T-waves in inferior (DII-III-aVF) and V6 leads. Chest X-ray showed minimal calcium density in the inferior pericardial silhouette. The patient was admitted in the Cardiology Department for aetiological study. A transthoracic echocardiogram revealed a marked protodiastolic cleft in the interventricular septum, with 40% variations of the transmitral flow with the respiratory changes and dilation of the cava vein, with absent respiratory collapse. A marked thickening and calcification of the inferoposterior pericardium was also seen. Considering these results, the diagnosis of constrictive pericarditis was suggested (Fig. A, B, C). Blood tests for autoimmune disease screening, as well as infectious diseases, including Quantiferon test, HIV, HVC, HVB and other viral serologies were done, with negative results. A cardiac magnetic resonance was requested, which confirmed the echocardiographic findings, with bi-atrial enlargement and markedly thickened pericardium with loss of signal, suggestive of calcification. Left and right ventricle had normal dimensions and contractility. The CT coronary angiography revealed normal coronary anatomy. Extensive calcification and pericardial thickening were shown, with myocardial infiltration in the lateral-basal area (Fig D). It was considered important to rule out any additional arrhythmic aetiology of the exercise syncope. Therefore, a stress test and, an electrophysiologic study were done, both with normal results. The patient remained asymptomatic and a pericardiectomy was indicated given the severe thickening and calcification of the pericardium and frequent syncopal episodes that our patient suffered.

Conclusions

Syncope as the initial symptom in the absence of significant right heart failure signs is a very unusual form of presentation of idiopathic constrictive pericarditis given the severe thickening and calcification of the pericardium of our patient.

Abstract 1094 Figure.