Interpretable Ensembles of Classifiers for Uncertain Data With Bioinformatics Applications

Data uncertainty remains a challenging issue in many applications, but few classification algorithms can effectively cope with it. An ensemble approach for uncertain categorical features has recently been proposed, achieving promising results. It consists in biasing the sampling of features for each model in an ensemble so that less uncertain features are more likely to be sampled. Here we extend this idea of biased sampling and propose two new approaches: one for selecting training instances for each model in an ensemble and another for sampling features to be considered when splitting a node in a Random Forest training. We applied these approaches to classify ageing-related genes and predict drugs' side effects based on uncertain features representing protein-protein and protein-chemical interactions. We show that ensembles based on our proposed approaches achieve better predictive performance. In particular, our proposed approaches improved the performance of a Random Forest based on the most sophisticated approach for handling uncertain data in ensembles of this kind. Furthermore, we propose two new approaches for interpreting an ensemble of Naive Bayes classifiers and analyse their results on our datasets of ageing-related genes and drug's side effects.

Machine learning methods applied to audit of surgical margins after curative surgery for facial (non-melanoma) skin cancer

We aimed to build a model to predict positive margin status after curative excision of facial non-melanoma skin cancer based on known risk factors that contribute to the complexity of the case mix. A pathology output of consecutive histology reports was requested from three oral and maxillofacial units in the south east of England. The dependent variable was a deep margin with peripheral margin clearance at a 0.5 mm threshold. A total of 3354 cases were analysed. Positivity of either the peripheral or deep margin for both squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) was 15.4% at Unit 1, 21.1% at Unit 2, and 15.4% at Unit 3. Predictive models accounting for patient and tumour factors were developed using automated machine learning methods. The champion models demonstrated good discrimination for predicting margin status after excision of BCCs (AUROC = 0.67) and SCCs (AUROC = 0.71). We demonstrate that rates of positive excision margins of facial non-melanoma skin cancer (fNMSC), when adjusted by the risk prediction model, can be used to compare unit performance fairly once variations in tumour factors and patient factors are accounted for.

Machine learning methods applied to risk adjustment of cumulative sum chart methodology to audit free flap outcomes after head and neck surgery

We describe a risk adjustment algorithm to benchmark and report free flap failure rates after immediate reconstruction of head and neck defects. A dataset of surgical care episodes for curative surgery for head and neck cancer and immediate reconstruction (n = 1593) was compiled from multiple NHS hospitals (n = 8). The outcome variable was complete flap failure. Classification models using preoperative patient demographic data, operation data, functional status data and tumour stage data, were built. Machine learning processes are described to model free flap failure. Overall complete flap failure was uncommon (4.7%) with a non-statistical difference seen between hospitals. The champion predictive model had acceptable discrimination (AUROC 0.66). This model was used to risk-adjust cumulative sum (CuSUM) charts. The use of CuSUM charts is a viable way to monitor in a 'Live Dashboard' this quality metric as part of the quality outcomes in oral and maxillofacial surgery audit.

Measuring health expectancy in the European Union

Background

Healthy life expectancy (HLE) is a population health measure that combines mortality and morbidity, which can be calculated using different methods. In this study, we aimed to assess the correlation, reliability and (dis)agreement between two estimates monitored in the European Union (EU), that is, the European Commission's HLE based on self-perceived health (SPH-HLE) and the Institute for Health Metrics and Evaluation's HLE based on disability weight (DW-HLE), by sex, and comparing these results with LE and proportion of life spent in good health (%GH).

Methods

We performed a retrospective study in the EU28 countries, between 2010 and 2017. The HLE methods differ in definition, measurement and valuation of health states. While SPH-HLE relies directly on one question, DW-HLE relies on epidemiological data adjusted for DW. Spearman's r, intraclass correlation coefficient, information-based measure of disagreement and Bland-Altman plots were used to assess reliability, correlation and disagreement in HLE resulting from both methods and in LE or %GH measured by both institutions.

Results

Correlation and reliability between SPH-HLE and DW-HLE were good (better for males), with low disagreement, and were even better for LE between both institutions. The HLE Bland-Altman plots suggest a variability range of approximately 6 years for both sexes, higher for females. There was also an increasing HLE difference between methods with higher average HLE for both sexes.

Conclusions

We showed wide variations between both methods with a clear and different high impact on female and male HLE, showing a tendency for countries with higher health expectancies to yield larger gaps between SPH-HLE and DW-HLE.

Acknowledgements: This presentation was supported by National Funds through FCT - Fundação para a Ciência e a Tecnologia,I.P., within CINTESIS, R&D Unit (reference UIDP/4255/2020)

Key messages

• Different methods for evaluating health expectancy lead to significantly different results.

• There is a systematic tendency with countries with higher health expectancies to yield larger gaps between SPH-HLE and DW-HLE.

Schizophreniform disorder related hospitalizations – a Big Data analysis of a national hospitalization database

Introduction

Patients with schizophreniform disorder(SD) and schizophrenia present similar symptoms, however, SD has a shorter duration, varying between at least 1 month and 6 months.

Objectives

To describe and analyse Schizophreniform disorder related hospitalizations in a national hospitalization database.

Methods

We performed a retrospective observational study using a nationwide hospitalization database containing all hospitalizations registered in Portuguese public hospitals from 2008 to 2015. Hospitalizations with a primary diagnosis of schizophreniform diso72.1-der were selected based on International Classification of Diseases version 9, Clinical Modification (ICD-9-CM) code of diagnosis 295.4x. Birth date, sex, residence address, primary and secondary diagnoses, admission date, discharge date, length of stay (LoS), discharge status, and hospital charges were obtained. Comorbidities were analysed using the Charlson Index Score. Independent Sample T tests were performed to assess differences in continuous variables with a normal distribution and Mann-Whitney-U tests when no normal distribution was registered.

Results

In Portuguese public hospitals, a total of 594 hospitalizations with a primary diagnosis of Schizophreniform disorder were registered during the 8-year study period. Most were associated to the male sex patients, 72.1% (n=428). The mean age at admission was 35.99 years and differed significantly between sexes (males - 34.44; females- 40.19; p<0.001). The median LoS was 17.00 days and the in-hospital mortality was 0.5% (n=3). Only 6.1% (n=36) of the hospitalization episodes had 1 or more registered comorbidities.

Conclusions

Hospitalizations with a primary diagnosis of Schizophreniform disorder occur more frequently in young male patients. This is the first nationwide study analysing all hospitalization episodes in Portugal.

Disclosure

No significant relationships.

Stroke care in people with and without schizophrenia: a retrospective, observational study

Introduction

Serious mental illness tends to course with a higher prevalence of comorbidities and schizophrenia is a disabling disease that affects approximately 1% of the world population. Worldwide, cerebrovascular accidents are an important cause of mortality and disability and in Portugal they are one of the leading causes of death in the general population. There is growing evidence that the prevalence of strokes is higher in people with schizophrenia, with pronounced age and gender variations.

Objectives

To describe the sociodemographic and clinical differences among patients hospitalized with a primary diagnosis of cerebrovascular disease with and without a secondary diagnosis of schizophrenia in Portugal.

Methods

We performed a retrospective observational study using a natiowide hopitalization database containing all hosptalizations registered in Portuguese hosptals from 2008 to 2015. Based on the International Classification of diseases version 9, clinical modification, hospitalizations with a primary diagnosis of stroke were selected (431;433;434), and from those, the ones with a secundary diagnosis of schizophrenia (295.xx) were isolated for a sociodemographic and clinical comparative study. Comorbidities were analysed using the Chalson index score.

Results

Episodes associated with a secondary diagnosis of schizophrenia were younger (mean: 66 vs 73.7 years; p<0.001) and had longer median LoS (10.0 vs 8.0 days; p<0.001). In-hospital mortality was lower in patients with schizophrenia (11.7% vs 13.2%).

Conclusions

The understanding of the association of cerebrovascular accidents with schizophrenia is complex. Although some studies show conflicting evidence, more attention should be given to the investigation of the incidence, prevalence and impact of cerebrovascular diseases within this particular population.

Disclosure

No significant relationships.

Childbirth hospitalizations in Bipolar disorder patients: a nationwide study protocol

Introduction

Bipolar disorder (BD) is usually diagnosed in adulthood, around childbearing age. Research has shown that BD has deleterious effects on pregnant women and birth outcomes. However, few nationwide studies using administrative data have approached this at-risk population focusing specifically on childbirth.

Objectives

This study aims to characterize hospitalizations of women with BD in the peripartum period regarding sociodemographic and clinical variables and to investigate the impact BD has on hospitalization outcomes.

Methods

An observational retrospective study will be performed using an administrative database that comprises routinely collected hospitalization data from all mainland Portuguese public hospitals. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes will be used to identify all women’s admissions for childbirth purposes (V27.X) and codes 296.XX (except 296.2X, 296.3X, 296.9X) will be used to ascertain BD. Episodes will be assigned to one of two mutually exclusive groups (with vs without BD). Multivariate methods will be used to compare both groups concerning key variables and outcomes. This work will comply with the RECORD statement recommendations.

Results

Descriptive and analytical statistics will be conducted in order to describe and characterize this group of patients. Results will be presented as crude and adjusted odds ratio quantifying the risk associated with BD in pregnancy, childbirth and hospitalization outcomes. Findings will be disseminated via publication in peer-reviewed journals.

Conclusions

With this nationwide analysis, we expect to contribute to a better understanding of the demographic and clinical profile of pregnant women with BD and to encourage timely medical and psychological interventions during gestation and childbirth.

Disclosure

No significant relationships.

The impact of depression in Alzheimer’s disease hospitalized patients: a study protocol for a nationwide retrospective study

Introduction

Alzheimer’s disease (AD) is the leading cause of dementia worldwide. About 40-50% of AD patients are also affected by depression, with mounting evidence suggesting its association with worse disease prognosis and negative outcomes, such as lower quality of life, higher mortality and more hospitalizations. However, few studies have specifically measured the association of depression with AD hospitalization outcomes.

Objectives

To characterize depression among all hospitalizations with a registered diagnosis of AD and to explore its association with hospitalization outcomes, including in-hospital mortality, length of stay and discharge destination.

Methods

A retrospective observational study will be conducted following the RECORD statement. A Portuguese nationwide hospitalization database from all mainland public hospitals will be used. Episodes of inpatients ≥65 years old with a primary or secondary diagnosis of AD (ICD-9-CM code 331.0), discharged between 2008-2015, will be selected. Codes 296.2X, 296.3X, 300.4 and 311 will be used to identify episodes with a concomitant registry of depression at any diagnostic position. Descriptive, univariate and multivariate approaches will be used.

Results

A total of 61 361 episodes complying with the fixed criteria will be assigned to one of two groups (with vs without depression). Groups will be compared regarding sociodemographic characteristics, comorbidity profile, type of admission (planned vs urgent) and hospitalization outcomes. Results regarding the association of depression and outcomes will be presented as crude and adjusted odds ratios (OR).

Conclusions

With this nationwide analysis, we expect to contribute to the clarification of depression impact on AD hospitalizations, so that best-practice care may be provided to these patients.

Disclosure

No significant relationships.

Depression among Endometrial Cancer hospitalizations - Preliminary results of a nationwide retrospective study

Introduction

Uterine cancer is the most common gynecologic malignant neoplasm in developed countries. While depression is up to 3-5 times more common in patients with cancer than in the general population, literature is still limited regarding the relation between Endometrial Cancer and depression.

Objectives

To analyze Depression among Endometrial Cancer hospitalizations in mainland Portuguese public hospitals (2008-2015).

Methods

A retrospective observational study was conducted using administrative data from all hospitalizations in Portuguese mainland public hospitals between 2008-2015. All women’s hospitalizations(≥18 years) with a primary diagnosis of Endometrial Cancer (ICD-9-CM 182.x) were selected. Secondary diagnosis of depression was identified with ICD-9-CM 296.2x, 296.3x and 311x codes. Surgical procedures codes 68.4x, 65.6x, 40.3x, 40.5x, 68.6x, 68.9x and 68.8x were used to divide the hospitalizations into surgical vs non-surgical. Groups were compared with Pearson Chi-square test and crude odds ratio(OR) was used to estimate the association between surgery and depression.

Results

From 10227 hospitalizations with a primary diagnosis of Endometrial Cancer, 533 had a registry of depression(5.2%). Annual depression frequency rose from 2.0% (2008) to 8.3% (2015). Among patients with a record of depression, 73.2% had surgery. Women who had surgery were significantly more likely to have registered depression (p<0.001). The OR for depression in surgical vs non-surgical patients was 1.73 (95%IC:1.42-2.10).

Conclusions

Patients hospitalized due to Endometrial Cancer and submitted to surgery had almost two-fold more risk of having a registry of depression. This trend reinforces the importance of early depression screening of these patients, enabling the implementation of timely therapeutic strategies before and after surgery.

Disclosure

No significant relationships.

Early systolic lengthening in patients with ST-elevation myocardial infarction: a novel tool for risk stratification

Funding Acknowledgements

Type of funding sources: None.

Background

After an ST-elevation myocardial infarction (STEMI), the risk of subsequent cardiovascular events is high. Risk stratification at index hospitalization remains a core challenge, especially in patients with subtle changes in LV function. Early systolic lengthening (ESL) may occur in ischemic myocardial segments with reduced contractile force and it has been correlated with infarct size and prognosis in STEMI patients with mildly impaired LV function. In this study, we aimed to evaluate the correlation of ESL with common echocardiographic parameters and its prognostic value in STEMI patients with preserved LV function.

Methods

We retrospectively included all the patients admitted to an intensive care unit with STEMI and a left ventricle ejection fraction ≥55% from January to June of 2016. Patients with inadequate image quality for speckle tracking echocardiographic examination were excluded (n = 14). We evaluated the ESL index, defined as follows: [−100×(peak positive systolic strain/peak negative strain in cardiac cycle)], and ESL duration.

Results

A total of 37 patients were included in the study. Mean age was 63 ± 12 years with a male preponderance (81%). All patients were submitted to complete revascularization. Median values of the ESL index and ESL duration were 7% (IQR, 4%–10%) and 37 msec (IQR, 21–55 msec), respectively. No significant differences were found between ESL index and ESL duration groups, except for a higher prevalence of heart failure at hospitalization in both highest groups, and women were more prevalent in the ESL index higher group (Tables 1 and 2). ESL index was correlated with post-systolic index (PSI) (r2 = 0.34, p = 0.04) and showed a weak correlation with E/A ratio (r2=-0.37, p = 0.02). ESL duration was correlated with ESL index (r2 = 0.76, p &lt; 0.001) and PSI (r2 = 0.43, p = 0.008). During a median follow-up of 3.2 years (interquartile range, 2.9–3.4 years), 7 (18.9%) patients experienced major adverse cardiovascular events (MACE), a composite of heart failure admission, myocardial infarction, and all-cause mortality Both ESL index (HR 2.5; 95%CI 1.2–5.3; P = 0.02) and ESL duration (HR 1.7; 95%CI 1.1–2.7; P = 0.02) were independent predictors of MACE. Both associations remained significant after adjusting for clinical confounders.

Conclusions

In our cohort of STEMI patients with preserved LV function, assessment of ESL yielded important and significant prognostic information on MACE. ESL may be a useful tool to enhance routine risk stratification in this population. Abstract TABLE 1  Abstract TABLE 2

Clinical and echocardiographic features of platypnea-orthodeoxia syndrome: a single-centre experience

Funding Acknowledgements

Type of funding sources: None.

Background

Platypnea-orthodeoxia syndrome (POS) is an uncommon condition characterized by dyspnoea and hypoxemia in the upright position that improves with recumbency.1 Possible causes are intracardiac shunt, pulmonary arteriovenous shunt, and V/Q mismatch.1,2 Echocardiography is the cornerstone of POS diagnosis, with special focus on atrial septal defect (ASD) morphology and right-to-left shunt confirmation.3

Purpose

To evaluate the clinical and echocardiographic features of patients presenting with POS due to a cardiac cause.

Methods

We performed a retrospective analysis of patients diagnosed with POS in our centre between 2015 January and 2021 August. Routine blood tests and transthoracic echocardiogram (TTE) were performed in all patients. Demographics, clinical presentation, blood test results, TTE information, and PFO closure procedure details were recorded.

Results

Seven patients were included, 85.7% female (n = 6). The median (IQR) age was 78 (72-85) years. The most prevalent cardiovascular risk factors were hypertension (100%; n = 7) and overweight/obesity (85.7%; n = 6). Two patients (28.6%) had chronic pulmonary disease. The most common symptoms were fatigue and exercise intolerance (n= 5; 71.4%) and the most frequent sign was persistent hypoxemia (n = 7; 100%), although 28.6% (n = 2) patients did not present the typical positional changes in peripheral oxygen saturation. Haemoglobin levels [14.1 (13.3-15.2)] were within the normal range and serum NTproBNP levels [656 (287-1196)] were slightly elevated. Left ventricle function was preserved in all patients; right ventricle morphology and function were normal in 85.7% (n = 6) patients, low probability of pulmonary hypertension in TTE was found in 85.7% (n = 6), and exuberant Eustachian valve was observed in 14.3% (n = 1). All patients presented atrial septal hypermobility, 87.5% (n = 6) meeting atrial septal aneurysm criteria. Patent foramen ovale was found in 85.7% of patients (n = 6) and ostium secundum ASD in 14.3% (n = 1). POS precipitating factors were aortic root dilation (28.6%; n = 2), chest trauma (14.3%; n = 1), right hip arthroplasty (14.3%; n = 1), atrial septal stretching regarding right volume overload (14.3%; n = 1). The underlying mechanism was unknown in 28.6% (n = 2) of patients. ASD closure was performed in 57.1% (n = 4) of patients: 75% (n = 3) showed residual shunt, but clinical improvement was reported by all. No acute complications were described, except for paroxysmal atrial fibrillation (14.3%; n = 1).

Conclusion

POS diagnosis depends on high clinical suspicion: the most common manifestations are fatigue and persistent hypoxemia. Typical positional changes in oxygen saturation are not present in all patients. Polycythaemia, right chambers dilation, and pulmonary hypertension are not common. Echocardiography is fundamental for diagnosis, allowing right-to-left shunt confirmation and ASD morphology evaluation to outline a successful closure procedure.

Real-world, very long-term follow up survival of incident patients with pulmonary hypertension

Background

Pulmonary hypertension (PH) is a clinical syndrome characterized by an increase in pulmonary artery pressure. Among the five groups of PH, pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) stand out due to their ominous prognosis without specific treatment. However, very long-term outcomes data are scarce.

Purpose

We aimed to assess the very long-term survival of PAH and CTEPH patients followed in a Portuguese PH referral center.

Methods

Between January 2009 and January of 2020, all incident PH cases were consecutively enrolled in a prospective cohort study. A total of 177 patients were followed up for a median of 5.0 [interquartile range 2.3–8.7] years. Kaplan-Meier survival analysis was used to estimate 1-, 5- and 9-year survival and multivariate regression was used to predict independent prognostic factors.

Results

Mean age was 49±20 years with a clear female preponderance (67%). The most common PH subgroups were congenital heart disease (PAH-CHD) (n=62; 35%), followed by CTEPH (n=52; 29,4%), connective tissue disease (PAH-CTD) (n=31; 17.5%), idiopathic/hereditary PAH (I/HPAH (n=22; 12.4%) and portopulmonary hypertension (PoPH) (n=8; 4.5%) (Table 1). PAH-specific drugs were used in 91% of the patients, dual combination therapy in 47.5%, and triple combination in 12.4%. The remaining 9% successfully received non-pharmacological treatment, namely cardiac surgery in PAH-CHD (n=7) and endarterectomy or angioplasty in CTEPH (n=9). Survival rates at 1-, 5- and 9-years were 97%, 80% and 66%, respectively. Age (hazard ratio [HR] 1.02; 95% CI 1.01–1.04; P=0.049), BNP [HR 2.04 (1.16–3.60); P=0.01], admission for decompensation of heart failure (HF) [HR 3.15 (1.71–5.83); P&lt;0.001] and PH type [P=0.01] were predictors of all-cause mortality. PAH-CHD had the better long-term survival (9-year survival of 83%), whereas PAH-CTD and PoPH were associated with a worse prognosis (9-year survival of 24% and 28%, respectively) (Figure 1). Regarding admissions for decompensated right HF, BNP was an independent predictor [HR 3.39 (2.12– 5.43); P&lt;0.001] and no difference was found between PH etiologies.

Conclusions

In this cohort of incident PH patients, the overall 9-year survival rate was 66%. PAH-CHD patients had better overall prognosis, while patients with PAH-CTD and PoPH had the worst prognosis. Additionally, older age, higher BNP and admission for HF were associated with higher mortality.

Funding Acknowledgement

Type of funding sources: None.

Schizophrenia hospitalizations - a big data approach

Introduction

Schizophrenia is characterized by long hospitalizations and a recurrent use of chronic and acute psychiatric care.

Objectives

The aim of this study was to analyze schizophrenia related hospitalizations in Portugal.

Methods

A retrospective observational study was conducted using a nationwide hospitalization database containing all hospitalizations registered in Portuguese public hospitals from 2008 to 2015.Hospitalizations with a primary diagnosis of schizophrenia were selected and schizophrenia subtypes were grouped using the International Classification of Diseases version 9, Clinical Modification(ICD-9-CM) codes of diagnosis 295.xx.

Results

There was a total of 25,385 hospitalizations in public hospitals of Portugal between 2008 and 2015 with a primary diagnosis of Schizophrenia or other psychotic disorders. A total of 14,279 patients were hospitalized during the study period with an average of 1,78 hospitalizations episodes per patient in the 8-year interval(0.22 hospitalizations/patient/year). 68.0% of the hospitalizations occurred in male patients and the median length of stay was 18.0 days. Mean hospitalization charges were 3,509.7€ per hospitalization, summed to a total charge of 89.1M€. Throughout the study period there was a significant linear decrease in the number of hospitalizations (r = 0.940; B= -47.488; p = 0.001). The last year of the study(2015) had the lowest number of hospitalizations with a total of 2,958 (vs. 3,314 in 2008). When adjusted for the yearly population, there was also a decrease of the number of hospitalizations per 100,000 inhabitants from 31.39 to 28.56 hospitalizations per 100,000 inhabitants between 2008 and 2015, respectively.

Conclusions

We found differences in hospitalization characteristics by gender, age and primary diagnosis.

Disclosure

No significant relationships.

The use of big data in psychiatry – the role of pharmacy registries

Introduction

Administrative databases (AD) are repositories of administrative and clinical data related to patient contact episodes with all sorts of health facilities (primary care, hospitals, pharmacies,…).The large number of patients/contact episodes with pharmaceutical facilities available, the systematic and broad register and the fact that AD provides Real-world data are some of the pros in using AD data.

Objectives

To perform a narrative review on the role of Big Data pharmaceutical registries in Mental Health research.

Methods

We conducted a narrative review using MEDLINE and Google Scholar databases in order to analyse current literature regarding the role of BigData pharmaceutical registries in Mental Health Research.

Results

Administrative variables like drug names and prices may be used and linked to other clinical variables such as patients disease, in-hospital mortality, length of stay,(…). The use of electronic medical records may also contribute to systematic surveillance approaches like local or national pharmacovigilance strategies, identification of patients at risk of developing complications and software pop-up warnings related to medication dosage, duplication and lateral effects. The use of Big Data pharmaceutical registries allows to create predictive epidemiological models regarding drugs lateral effects or interactions and may help to perform pharmacovigilance phase 4 clinical trials. Its use may be applied to the optimization of clinical decision, monitoring of drug adverse events, drug cost and administrative monitoring and as surrogate measures of quality care indicators.

Conclusions

Big Data use in pharmaceutical registries allows to collect large and important clinical and administrative data that may be later used in Mental Health care and research.

Disclosure

No significant relationships.

Integrated quality assessment for diabetes care in Portuguese primary health care using prevention quality indicators

AIMS

This study evaluates the prevention quality indicators (PQI) for Diabetes Mellitus (DM) in Portugal using contemporary data and explores their variability according to Primary Health Care (PHC) quality indicators.

METHODS

We conducted a retrospective observational analysis of secondary data comprising Portuguese PHC indicators by health centres group (ACES) and the National Hospital Morbidity Database. We calculated and analysed age-sex-adjusted rates for each PQI. Worse-performing ACES were identified using the 2017 median PQI values as an assessment cut-off. A multivariate logistic analysis was carried to find variables associated with the likelihood of being a worse-performing ACES for the biennium.

RESULTS

The median values of the indicator PQI93 - Prevention Quality Diabetes Composite were 79 and 65.2 hospitalizations per 100 000 pop, in 2016 and 2017 respectively. Diabetes long term complications (PQI 03) accounted for most of the hospitalizations. The quality indicator in PHC with greater influence on PQI93 was the proportion of DM patients with <65 years with test results for HbA1c < = 6.5%.

CONCLUSIONS

This study shows that some PHC quality indicators are closely related to DM care, and so their monitoring is of high importance. Diabetes long term complications (PQI 03) demand greater attention from PHC professionals.

Electroconvulsive therapy use in psychiatric hospitalizations - a nationwide descriptive study

Introduction

Despite being one of the oldest treatments in the field of Psychiatry, Electroconvulsive therapy (ECT) is used worldwide for various severe and treatment-resistant psychiatric disorders, establishing itself as one of the fastest and most effective treatments.

Objectives

The primary aim of this study was to describe a nationwide epidemiological perspective of the use of ECT in hospitalized psychiatric patients. The secondary aims were to characterize clinical and sociodemographic trends of hospitalized patients who needed ECT.

Methods

A retrospective-observational study was conducted using an administrative database which gathered all hospitalizations registered in Portuguese public hospitals from 2008 to 2015. We selected all hospitalizations with a procedure code 94.27 - Other electroshock therapy defined by the International Classification of Diseases version-9, Clinical Modification.The variables included in the study were birth date, sex, residence address, primary and secondary diagnoses, admission date, discharge date, length of stay (LoS), discharge status from each single hospitalization episode.

Results

There were a total of 879 hospitalizations with ECT during the 8-year period of the study. Most of the hospitalizations occurred in female patients (53.4 vs 46.6%), belonging to the age group of 51-70 years old, with a mean age of 50.5 years old. The median LoS was 43.0 days with an IQR of 27.0-68.0 days. The specific primary diagnosis most frequent in all hospitalizations was Major depressive disorder, recurrent episode representing 19.6% of all ECT related hospitalizations.

Conclusions

In Portugal most of the patients who received ECT were women above middle age, and depressive disorders were the most common indication.

Bipolar disorder hospitalizations – a big data approach

Introduction

Bipolar Disorder (BD) is a mental disorder characterized by long hospitalizations and frequent need for acute psychiatric care. Hospitalizations represent a valuable quality of care indicator in BD.

Objectives

The aim of this study was to describe a nationwide perspective of BD related hospitalizations and to use a BigData based approach in mental health research.

Methods

We performed a retrospective observational study using a nationwide hospitalization database containing all hospitalizations registered in Portuguese public hospitals from 2008 to 2015. Hospitalizations with a primary diagnosis of BD were selected based on International Classification of Diseases version 9, Clinical Modification (ICD-9-CM) codes of diagnosis 296.xx (excluding 296.2x; 296.3x and 296.9x).

Results

A total of 20,807 hospitalizations were registered belonging to 13,300 patients. 33.4% of the hospitalizations occurred in male patients and the median LoS was 16.0 days. Mean age was 47.9 years and male patients were younger(46.6 vs. 48.6; p< 0.001). 59 hospitalizations had a deadly outcome (0.3%). The most common cause of hospitalization in BD was the diagnosis code 296.4x (Bipolar I disorder, most recent episode (or current) manic) representing 34.3% of all hospitalizations, followed by the code 296.5x (Bipolar I disorder, most recent episode (or current) depressed) with 21.4%. The mean hospitalization charges were 3,508.5€ per episode, with a total charge of 73M€ in the 8-year period of this study.

Conclusions

This is a nationwide study using BigData analysis giving a broad perspective of BD hospitalization panorama at a nationwide level. We found differences in hospitalization characteristics by gender, age and primary diagnosis.

Disclosure

No significant relationships.

Pediatric bipolar disorder: Preliminary results of a retrospective study using a nationwide administrative database

Introduction

Bipolar disorder (BD) is a severe and chronic illness characterized by episodic changes in mood. The average onset of BD symptoms is estimated between 18 and 22 years. However, many adults retrospectively report symptoms onset in childhood or adolescence. Over the last decades, pediatric bipolar disease (PBD) has been the focus of increased attention mainly due to controversies surrounding its prevalence, diagnosis and treatment in the pediatric population.

Objectives

To analyze pediatric hospitalizations related to BD held in mainland Portuguese public hospitals between 2000 and 2015.

Methods

This retrospective observational study analyzed all pediatric (<18 years old) inpatient episodes from 2000 to 2015 with a primary BD diagnosis, using an anonymized administrative database including all hospitalization from mainland Portuguese public hospitals. ICD-9-CM codes 296.x were used (excluding codes 296.2x; .3x and .9x). Age at admission, admission type and date, sex, charges and length of stay (LoS) were analyzed.

Results

A total of 348 hospitalizations were analyzed from 258 patients. Patients were mainly young girls (60.6%), with a mean age of 15.24±1.87 years. The majority of the admissions were urgent (81.0%), and the median LoS was 14 days (IQR: 7; 24). Mean hospitalization charges were 3503.1€ with a total sum of 1.2M€ for all the episodes.

Conclusions

PBD hospitalizations occur predominantly in female patients during adolescence. The majority of them are urgent admissions. Descriptive studies will help to describe and characterize sociodemographic and clinical trends in PBD in order to better prevent acute hospitalizations with inevitable social and economic implications.

Prolonged length of stay in acute psychiatric wards: A descriptive study

Introduction

The psychiatric care paradigm has shifted towards community-centered models. Yet, prolonged hospitalizations are still a reality, with debated impact at healthcare systems and patients.

Objectives

This work aims to describe prolonged hospitalizations in acute psychiatric wards through patients’ sociodemographic and clinical data.

Methods

We analyzed a national hospitalization database that contained all hospitalization episodes registered in Portuguese public hospitals from 2008 to 2015. All episodes with a primary diagnosis of mental disorder defined as ICD-9-CM codes 290.x-319.x were included. Prolonged hospitalizations were defined as having a LoS ≥ P97.5; LOS ≥180 days or LOS ≥1 year. Age, sex, lengh of stay, in-hospital mortality were analysed.

Results

The LoS ≥ P97.5(≥62 days) group comprised 3911 hospitalizations (2.3% of all psychiatric hospitalizations) and 1755 patients. The median LOS was 81 days and the mean age was 51 years. Sex was equally distributed, though a higher frequency of male patients was found on the ≥180 days (n=364) and ≥ 1 year (n=121) groups. Psychotic disorders were the main diagnosis at discharge (n= 1769, 45.2%), followed by mood disorders (n=1057, 27.0%) and dementia (n=451, 11.5%). In-hospital mortality increased in the higher LoS groups (1.1%; 4.4%; 9.1%, respectively).

Conclusions

Overall, middle aged patients with psychotic disorders represent most of the prolonged hospitalizations occurring in acute psychiatric wards. Community-based programs require further development to meet the existing needs.

Disclosure

No significant relationships.

Investigating size effects in graphene-BN hybrid monolayers: a combined density functional theory-molecular dynamics study

We combine Density Functional Theory (DFT) and classical Molecular Dynamics (MD) simulations to study graphene-boron nitride (BN) hybrid monolayers spanning a wide range of sizes (from 2 nm to 100 nm). Our simulations show that the elastic properties depend on the fraction of BN contained in the monolayer, with Young's modulus values decreasing as the BN concentration increases. Furthermore, our calculations reveal that the mechanical properties are weakly anisotropic. We also analyze the evolution of the stress distribution during our MD simulations. Curiously, we find that stress does not concentrate on the graphene-BN interface, even though fracture always starts in this region. Hence, we find that fracture is caused by the lower strength of C-N and C-B bonds, rather than by high local stress values. Still, in spite of the fact that the weaker bonds in the interface region become a lower fraction of the total as size increases, we find that the mechanical properties of the hybrid monolayers do not depend on the size of the structure, for constant graphene/BN concentrations. Our results indicate that the mechanical properties of the hybrid monolayers are independent of scale, so long as the graphene sheet and the h-BN nanodomain decrease or increase proportionately.

Effect of litter birth weight standardization before first suckling on colostrum intake, passive immunization, pre-weaning survival, and growth of the piglets

Within-litter variation in birth weight is a relevant factor in pig production. This study aimed at comparing pre-weaning mortality, colostrum intake (CI), passive immunization, and growth of piglets from litters of uniform (UN) or heterogeneous (HET) birth weights. The study included 52 multiparous sows (Large White × Landrace) and their litters. Two types of litters were constituted based on birth weight, namely: UN or HET, the control group, using piglets from two to three sows farrowing approximately at the same time. At birth, piglets were weighed, identified, and placed in a box under an IR lamp. At the end of farrowing, piglets were re-weighed and allotted to groups UN or HET (12 per litter) with average weights of 1394 and 1390 g, respectively, and allowed to suckle (time 0). They were re-weighed 24 h later to estimate CI and sows' colostrum yield. At time 0, the average intra-litter CV (%) in weight of experimental litters were 9.3 ± 0.8 (SEM) and 27.8 ± 0.7 in groups UN and HET, respectively (P < 0.001). At 2 days of age, blood samples were taken from the piglets of 11 litters five UN and six HET) and serum Immunoglobulin G (IgG) contents were determined. Mean CI/piglet/litter was similar in both groups, that is, 415 ± 13 in UN and 395 ± 13 g in HET (P = 0.28), but was less variable in UN litters (CV = 22.4 ± 2 vs 36.0 ± 2%, P < 0.001). The IgG levels at 2 days of age were higher in piglets from UN litters (22.5 ± 0.8 vs 18.4 ± 0.7 g/l; P < 0.001) but the CV of IgG levels was not different between litter type (P= 0.46). Mortality up to 21 days of age was lower in UN litters (6.4 vs 11.9%, P = 0.03). The BW at 21 days was not different between litter type (P = 0.25) but it was less variable among piglets from UN litters (CV: 17.1 ± 1.3 vs 25.7 ± 1.3%; P = 0.01). Results reveal that CI is less variable and mortality is lower in piglets from litters of UN birth weight. The results infer that genetic improvement to decrease variation in birth weight within-litter could have a positive effect on homogeneous CI and thus contribute to reducing piglet mortality.

Longitudinal characterisation of haematological and biochemical parameters in cancer patients prior to and during COVID-19 reveals features associated with outcome

BACKGROUND

Cancer patients are at increased risk of death from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Cancer and its treatment affect many haematological and biochemical parameters, therefore we analysed these prior to and during coronavirus disease 2019 (COVID-19) and correlated them with outcome.

PATIENTS AND METHODS

Consecutive patients with cancer testing positive for SARS-CoV-2 in centres throughout the United Kingdom were identified and entered into a database following local governance approval. Clinical and longitudinal laboratory data were extracted from patient records. Data were analysed using Mann-Whitney U test, Fisher's exact test, Wilcoxon signed rank test, logistic regression, or linear regression for outcomes. Hierarchical clustering of heatmaps was performed using Ward's method.

RESULTS

In total, 302 patients were included in three cohorts: Manchester (n = 67), Liverpool (n = 62), and UK (n = 173). In the entire cohort (N = 302), median age was 69 (range 19-93 years), including 163 males and 139 females; of these, 216 were diagnosed with a solid tumour and 86 with a haematological cancer. Preinfection lymphopaenia, neutropaenia and lactate dehydrogenase (LDH) were not associated with oxygen requirement (O2) or death. Lymphocyte count (P < 0.001), platelet count (P = 0.03), LDH (P < 0.0001) and albumin (P < 0.0001) significantly changed from preinfection to during infection. High rather than low neutrophils at day 0 (P = 0.007), higher maximal neutrophils during COVID-19 (P = 0.026) and higher neutrophil-to-lymphocyte ratio (NLR; P = 0.01) were associated with death. In multivariable analysis, age (P = 0.002), haematological cancer (P = 0.034), C-reactive protein (P = 0.004), NLR (P = 0.036) and albumin (P = 0.02) at day 0 were significant predictors of death. In the Manchester/Liverpool cohort 30 patients have restarted therapy following COVID-19, with no additional complications requiring readmission.

CONCLUSION

Preinfection biochemical/haematological parameters were not associated with worse outcome in cancer patients. Restarting treatment following COVID-19 was not associated with additional complications. Neutropaenia due to cancer/treatment is not associated with COVID-19 mortality. Cancer therapy, particularly in patients with solid tumours, need not be delayed or omitted due to concerns that treatment itself increases COVID-19 severity.

Prescribing patterns of medication for respiratory diseases - cluster analysis of the Portuguese electronic prescription database

Summary

We aimed to describe, for the first time, the prescribing patterns among patients on persistent respiratory treatment, from the Portuguese electronic prescription and dispensing database. This was a one-year retrospective population-based analysis of prescriptions (n = 39810) for medication for respiratory disease and exacerbations. Cluster analysis was applied based on medication and prescribers' specialty. Prescribing patterns were grouped and labelled as: possible medication for asthma and allergic rhinitis (General Practitioners-GPs and allergists to younger patients); COPD (GPs and pulmonologists to older patients); asthma or Asthma-COPD Overlap (GPs and pulmonologists); exacerbation, infection and relievers. This analysis was an important first step to understand the Portuguese reality on the treatment of respiratory diseases.

Mechanical and electronic properties of boron nitride nanosheets with graphene domains under strain

Hybrid structures comprised of graphene domains embedded in larger hexagonal boron nitride (h-BN) nanosheets were first synthesized in 2013. However, the existing theoretical investigations on them have only considered relaxed structures. In this work, we use Density Functional Theory (DFT) and Molecular Dynamics (MD) simulations to investigate the mechanical and electronic properties of this type of nanosheet under strain. Our results reveal that the Young's modulus of the hybrid sheets depends only on the relative concentration of graphene and h-BN in the structure, showing little dependence on the shape of the domain or the size of the structure for a given concentration. Regarding the tensile strength, we obtained higher values using triangular graphene domains. We find that the studied systems can withstand large strain values (between 15% and 22%) before fracture, which always begins at the weaker C–B bonds located at the interface between the two materials. Concerning the electronic properties, we find that by combining composition and strain, we can produce hybrid sheets with band gaps spanning an extensive range of values (between 1.0 eV and 3.5 eV). Our results also show that the band gap depends more on the composition than on the external strain, particularly for structures with low carbon concentration. The combination of atomic-scale thickness, high ultimate strain, and adjustable band gap suggests applications of h-BN nanosheets with graphene domains in wearable electronics.

We investigate the mechanical and electronic properties of hBN nanosheets with graphene domains under strain. We find that the structures withstand large strain values and present highly adjustable band gaps, ranging from 1.0 to 3.5 eV.

Epicardial fat tissue: a new tool for identification of coronary artery disease patients?

Introduction

Epicardial fat (EF), the true visceral fat depot of the heart, has been strongly correlated with both coronary artery disease (CAD) incidence and severity. However, the methods for its measurement were not always affordable. Its measurement by echocardiography is fast, accessible and easily reproducible, turning it into a promising clinical tool for assessing cardiovascular risk to predict the incidence of CAD.

Purpose

To determine the correlation between EF tissue dimensions measured by transthoracic echocardiography and the presence of CAD.

Methods

We prospectively analysed data from 196 consecutive patients admitted for acute coronary syndrome in our coronary care unit. All patients underwent diagnostic coronary angiography and echocardiogram during stay. EF dimensions were obtained with transthoracic echocardiography by measuring maximum EF diameter (mm) at the basal right ventricular free wall (PLAXB) level and mid-right ventricular free wall (PLAXM) level [in paraesternal long-axis view (PLAX)] and maximum right-ventricle free wall EF diameter at basal (PSAXB) level and papillary-muscle (PSAXM) level [in paraesternal short-axis view (PSAX)]. All measures were taken at end-systole. Patients were divided in 2 groups according to the presence of significant CAD (sCAD) or not (nCAD), defined as having at least 1 diseased epicardial vessel with a stenosis &gt;50%.

Results

One-hundred and sixty-three (83.2%) had significant CAD. 22 patients (11.2%) were admitted for unstable angina, 60 patients (30.6%) for non-ST elevation myocardial infarction and 93 patients (47,4%) for ST-elevation myocardial infarction. Mean EF diameters were as follows: PLAXB (19,3±5.1 mm), PLAXM (11.3±2.6), PSAXB (10,6±2.8), PSAXM (10.5±2.8). We found a direct correlation between number of diseased epicardial coronary vessels and epicardial fat thickness in PLAXB (r=0.506, p&lt;0.001), PLAXM (r=0.372, p&lt;0.001), PSAXB (r=0.445, p&lt;0.001) and PSAXM (r=0.372, p&lt;0.001). EF was significantly different between groups: PLAXB (20,6±4.4 vs. 13.8±3,8, p&lt;0.001), PLAXM (11.8±2.5 vs. 9.0±1.9, p&lt;0.001), PSAXB (11.1±2.7 vs. 8.3±2.3, p&lt;0.001) and PSAXM (11.0±2.6 vs. 8.2±4, p&lt;0.001). Receiver operating characteristic curve analysis showed that the predictive value of mean right ventricular EF [(PLAXB+PSAXB)/2] for significant CAD was 0.895 (AUC=0.895, CI 95% 0.818–0,972, p&lt;0.001). For a [(PLAXB+PLAXM)/2] value of 12.57 mm, sensitivity was 86.3% and specificity was 79.3%.

Conclusions

In a population of high suspicion of acute coronary syndromes, echocardiographic EF is a sensitive and specific marker of the presence of significant coronary disease and could become an important tool for coronary risk prediction.

Figure 1

Funding Acknowledgement

Type of funding source: None

Inequalities after STEMI in National Health Service: is there really a postcode lottery?

Background and purpose

Failure to address the impact of social determinants of health attenuates efficacy of proven prevention recommendations, namely because important considerations related to socioeconomic disadvantage are not captured by existing cardiovascular disease (CDV) risk stratification methods. We aimed to assess how socioeconomic determinants influence recurrent MI and all-cause death after myocardial infarction (MI) in Portugal.

Methods

We conducted a retrospective, observational cohort study, including all patients with a ST-elevation MI (STEMI) admitted to and discharged alive from an intensive cardiac care unit between 2004 and 2017 (n=1809). The median (interquartile range) follow-up was 6 (4–9) years. We used survival models to assess the relationship between their municipal (i) income by purchasing power per capita (PPC), (ii) geographical accessibility to health care, (iii) illiteracy, iv) residential socioeconomic deprivation and recurrent MI and all-cause mortality. To assess residential socioeconomic deprivation, each individual's residential postcode was matched to the recently validated Portuguese version of European Deprivation Index (EDI). The index was categorized into quintiles (Q1-least deprived to Q5-most deprived).

Results

The mean age was 64±14 years; 74% were male. Regarding individual socioeconomic variables, PPC (HR 1.19; 95% CI 0.97–1.47 for Tertile 1 vs Tertile 2; HR 1.28; 95% CI 1.04–1.56 for Tertile 1 vs Tertile 3 and HR 1.07; 95% CI 0.85–1.34 for Tertile 2 vs Tertile 3) and medical appointments in primary health centers per inhabitant (HR 0.90; 95% CI 0.75–1.09 for Tertile 1 vs Tertile 2; HR 1.23; 95% CI 0.95–1.61 for Tertile 1 vs Tertile 3 and HR 1.37; 95% CI 1.06–1.76 for Tertile 2 vs Tertile 3) were predictors of all-cause mortality, but not recurrent MI; however, in multivariate analysis adjusted for sex, age and ejection fraction, this association was no longer significant (HR 1.00; 95% CI 0.99–1.00 and, HR 1.00; 95% CI 0.89–1.17, respectively). Additionally, no evident association between illiteracy and all-cause mortality or MI was present. Concerning EDI, demographic data was similar among the quintiles (Table 1). Although EDI quintiles were not associated with all-cause mortality (HR 1.17; 95% CI 0.82–1.66 for Q5 vs Q1), the EDI was an independent predictor of recurrent MI (Figure 1). On multivariate analysis, adjusted for age, sex, hypertension, diabetes and LDL cholesterol, the HR for the most deprived (Q5) to the least deprived (Q1) quintile was 1.91 (95% CI 1.05–3.49) for MI.

Conclusions

Our study shows clear socioeconomic differentials in cardiovascular outcomes in patients with STEMI which suggests that accounting for socioeconomic deprivation might improve risk prediction and therefore disease prognosis.

Funding Acknowledgement

Type of funding source: None

Left atrial emptying fraction: a powerful predictor of events in severe aortic stenosis

Background

Increasing evidence suggests that left atrial (LA) structural and functional changes have an important role in risk stratification and prediction of clinical outcomes. We know from multiple data that left atrial maximum volume (LAVI), measured at end-systole, is a powerful prognostic marker in multiple patient groups. However, recent studies have suggested that this marker may not be the best representative of diastolic function as it does not image the full spectrum of atrial mechanics. Another measure of LA function is the left atrial emptying fraction (LAEF), which has proved to be a significant prognostic marker in many patient groups. Less known is its role in event prediction in severe aortic stenosis patients, a disease with a very important burden in modern societies.

Purpose

The authors hypothesised that LAEF is a powerful predictor of clinical outcomes at 1 year in patients with severe aortic stenosis.

Methods

We retrospectively evaluated 151 patients referred to our echocardiography laboratory with the diagnosis of severe aortic stenosis. All patients underwent transthoracic echocardiography. LA maximum volume was indexed to body surface area. LAEF was calculated as LAVI-LA minimum volume divided by LAVI. Patients were followed for 1 year regarding clinical outcomes. Clinical outcome was defined as a composite of hospital admission for a cardiovascular (CV) cause, emergency department recurrence for a CV cause or CV death. Logistic binary regression was used to evaluate associations of LAEF with the outcome.

Results

A total of 51.7% of patients (n=78) were males. Mean patient age was 76.6±8.0 years. A total of 38.4% of patients were diabetics (n=56), 96% had dyslipidaemia (n=145) and 25% (n=37) had atrial fibrillation. Mean left ventricular ejection fraction (LVEF) was 60.6±7.3, and mean LAVI was 41.4±12.1. In a multivariable regression model including clinical and echocardiographic markers, higher LAVI and pulmonary artery systolic pressure (PASP) were associated with lower LAEF. Receiver operating characteristic curve analysis showed that the predictive value of LAEF for outcomes at 1 year was 0.693 (AUC=0.693, CI 95% 0.578–0.809, p=0.002), performing better than other echocardiographic markers such as LAVI (AUC=0.567, CI 95% 0.440–0.694, p=0.286), PASP (AUC=0.582, CI 95% 0.451–0.714, p=0.191) and LVEF (AUC=0.590, CI 95% 0.464–0.716, p=0.153). After adjustment of baseline characteristics, a LAEF less than 41.3% remained a good predictor of clinical outcomes at 1 year (OR 2.615, CI 95% 1.085–6.305, p=0.32).

Conclusions

In this cohort of severe aortic stenosis patients, a reduced LAEF was associated with greater incidence of cardiovascular events, being a stronger predictor than LAVI, PASP or LVEF. This study suggests that LA dysfunction over LA volumes correlates better with clinical outcomes.

Funding Acknowledgement

Type of funding source: None

Strauss formula: a great and easy tool to manage congestion in acute heart failure

Background

Approaching the congestive patient is a complex task that requires the combination of different assessment methods. The Strauss formula uses variations in haemoglobin and haematocrit to estimate plasma volume variations (PVV) and haemoconcentration. However, this formula was only validated in outpatients followed with chronic heart failure. We aimed to assess the applicability of this formula to hospitalized patients for acute heart failure (AHF).

Methods

We conducted a single-centre, retrospective, observational study of 302 patients who were admitted to our hospital for AHF during 2016 and were discharged alive. Baseline clinical, laboratory and demographic characteristics were evaluated at admission and the Strauss formula was applied, as PVV (%) = 100 x [(Hb A / Hb D) x (1 − Hct D) / (1 − Hct A)] − 100), where A = admission and D = discharge. At discharge, we considered that a positive change (≥0%) in PV regarding the admission was linked to an increase in PV (haemodilution); a negative change (&lt;0%) correlated to a decrease in the PV (haemoconcentration). The primary endpoint was a composite of cardiovascular death (CV-death) and HF readmission at 3-months.

Results

Mean age was 76±11 years and 57% were male. At baseline, 92% were on clinical-haemodynamic profile B, with a median NT-proBNP of 2157 (IQR 1161–4242) pg/dL, a mean of glomerular filtration rate (GFR) of 63±57 mL/min/m2, a mean haemoglobin of 12±2 g/dL and a mean haematocrit of 38±6%. At discharge, the median plasma volume variation was −1.1% (IQR – 9.6 to 7.8) and the distribution of PVV values in the histogram reveals that a large proportion of patients (44%) increased or maintained plasma volume (PVV ≥0% – haemodilution). The group of patients who decreased plasma volume at discharge was slightly younger (75 vs 78 years, p=0.044), showing higher numerical decreases in NT-proBNP, gamma-glutamyl transferase (gGT) and bilirubin at discharge. A positive change in PV (PVV &gt;0%) during admission almost doubled the risk for readmission and CV-death at 3-months [OR 1.9 (95% CI: 1.1 to 3.1, p=0.026], after adjusting for age and sex.

Conclusions

In this work, we demonstrate that PVV, as calculated by the Strauss formula, increases or is unchanged in 44% of patients admitted with AHF and is strongly associated with a composite of 3-months CV death and HF readmission. Tools to guide the management of residual congestion are of great importance to assess the optimal discharge timing.

Funding Acknowledgement

Type of funding source: None

Primary care organizational model mix and avoidable hospitalization: an ecological study in Portugal

Background

In Portugal, there are different organizational models in primary health care (PHC), mainly regarding the payment scheme. USF-B is the only type with financial incentives to the professional (pay-for-performance). Our goal was to assess the relationship between groups of primary healthcare centres (ACES) with higher proportion of patients within USF-B model and the rate of avoidable hospitalizations, as proxy of primary care quality.

Methods

We conducted a cross-sectional study considering the 55 ACES from mainland Portugal, in 2017. We used data from public hospitalizations to calculate the prevention quality indicator (avoidable hospitalizations) adjusted for age and sex, using direct standardization. The main independent variable was the proportion of patients in one ACES registered in the USF-B model. Unemployment rate, proportion of patients with family doctor and presence of Local Health Unit (different organization model) within ACES were also considered. The association was assessed by means of a linear regression model.

Results

Age-sex adjusted PQI value varied between 490 and 1715 hospitalizations per 100,000 inhabitants across ACES. We observed a significant effect of the proportion of patients within USF-B in the crude PQI rate (p = 0.001). However, using the age-sex adjusted PQI, there was not a statistical significant association (p = 0.504). This last model was also adjusted for confounding variables and the association remains non-significant (p = 0.865).

Conclusions

Our findings suggest that, when adjusting for age and sex, there is no evidence that ACES with more patients enrolled in a pay-for-performance model is associated with higher quality of PHC (using avoidable hospitalizations as proxy). Further studies addressing individual data should be performed.

This work was financed by FEDER funds through the COMPETE 2020 - POCI, and by Portuguese funds through FCT in the framework of the project POCI-01-0145-FEDER-030766 “1st.IndiQare”.

Key messages

Adjusting PQI to sex and age seems to influence its value more than the type of organizational model of primary health care. Groups of primary healthcare centres with more units under the pay-for-performance scheme was not associated with different rate of avoidable hospitalizations.

Efficiency of groups of primary healthcare centres: a frontier analysis of primary care in Portugal

Background

Primary health care (PHC) is the cornerstone of several health systems. The Portuguese PHC is organized in five mainland regions (ARS), that oversee 55 local groups of primary healthcare centres (ACES). We assessed the efficiency of all 55 ACES in mainland Portugal, as well as organizational and socioeconomic determinants of the efficiency.

Methods

A cross-sectional non-parametric frontier analysis was performed for 2017. The first model included two inputs (i.e. number of physicians and number of nurses) and a single output (i.e. number of PHC visits), while the second model included an additional output, i.e. Prevention Quality Indicator (PQI) overall composite (avoidable hospitalizations) adjusted for age and sex - as undesirable output. In a second stage, a (multivariate) Tobit regression was used to assess organizational and socioeconomic determinants of efficiency.

Results

In the first model, only 8 ACES (14.5%) were on the efficiency frontier, while 25 ACES should readjust their human resource balance. In the second model, 9 ACES (16.4%) were considered efficient. When considering quality, one ACES previously considered inefficient moved to the frontier and two ACES lost their benchmark position. The second-stage analysis indicates that groups with a higher proportion of PHC units with pay-for-performance incentives were associated with higher efficiency.

Conclusions

Most ACES have the potential to improve their production levels., A better management of human resources can contribute to improve overall efficiency. ACES with a higher proportion of units with pay-for-performance schemes seem to be more efficient. These findings contribute to the evaluation of policies to integrate and scale up PHC services locally, such as the recent primary care networks in the NHS UK.

This work was financed by FEDER funds through the COMPETE 2020 - POCI, and by Portuguese funds through FCT in the framework of the project POCI-01-0145-FEDER-030766 “1st.IndiQare”.

Key messages

Most Portuguese ACES have the potential to improve their outputs given their current level of human resources. Local groups that aggregate more PHC units with pay-for-performance schemes are associated with high efficiency.

Small for gestational age very preterm infants present a higher risk of developing bronchopulmonary dysplasia

INTRODUCTION

Several studies assessed the influence of a low birth weight on bronchopulmonary dysplasia (BPD), but not all could find a significant association. Our aim was to assess the association between low birth weight and BPD in preterm infants, prospectively recruited at 11 level III Portuguese neonatal centers.

METHODS

Obstetrical and neonatal data on mothers and preterm infants with gestational ages between 24 and 30 weeks, born during 2015 and 2016 after a surveilled pregnancy, were analyzed. Neonates were considered small for gestational age (SGA) when their birthweight was below the 10th centile of Fenton's growth chats and BPD was defined as the dependency for oxygen therapy until 36 weeks of corrected age. Statistical analysis was performed using IBM SPSS® statistics 23 and a p-value <0.05 was considered statistically significant.

RESULTS

Out of 614, a total of 494 preterm infants delivered from 410 women were enrolled in the study; 40 (8.0%) infants with SGA criteria. SGA were more often associated with a single pregnancy, had greater use of antenatal corticosteroids, increased prevalence of gestational hypertensive disorders, C-section, rupture of membranes below 18 hours, rate of intubation in the delivery room, use of surfactant treatment, oxygen therapy, mechanical ventilation need, BPD, cystic periventricular leukomalacia, nosocomial sepsis and pneumonia; had lower prevalence of chorioamnionitis, and lower Apgar scores. The multivariate analysis by logistic regression, adjusted for BPD risk factors revealed a significant association between SGA and BPD: OR = 5.2 [CI: 1.46-18.58]; p = 0.01.

CONCLUSION

The results of this study increase the scientific evidence that SGA is an independent risk factor for BPD.

To be or not to be hospitalised with tuberculosis in Portugal

SETTING: In Portugal, as in other countries, tuberculosis (TB) is considered a disease that should be managed on an ambulatory basis. However, hospitalisation remains important to manage some at-risk groups and complications.OBJECTIVE: To identify the possible risk factors associated with hospitalisations in TB patients in Portugal.DESIGN: Data extraction through two national databases (one for registration of TB cases and the other with hospitalisation information in public health facilities) between 2007 and 2013. Univariate and multivariate analysis of demographic and clinical variables was performed.RESULTS: We identified 4421 hospitalisations. Chronic diseases, cancer, substance abuse, a higher social/economic risk, extra-pulmonary TB, lung cavitary disease and previous uncompleted treatment were more frequent among hospitalised patients. Human immunodeficiency virus coinfection, cancer, alcohol abuse, extra-pulmonary TB and uncompleted previous TB treatment were the most important predictors of hospitalisation with TB. The hospitalisation rate among TB patients in Portugal was lower when compared with other countries with lower and higher incidences.CONCLUSION: Immune dysfunctions and progression of chronic diseases are associated with more severe forms of TB and frequent adverse effects which can be sufficiently severe to necessitate hospital admission. Despite having an intermediate TB incidence, the hospitalisation rate in Portugal is not higher than that of other countries.

P883 Hepatocellular carcinoma presenting as a tumor thrombus extending from the inferior vena cava to the right atrium in echocardiography

Case

A 74 year-old white male with COPD, type 2 Diabetes, Atrial Fibrillation and a Pacemaker presented to our hospital for a routine echocardiography follow-up for mild to moderate Aortic Stenosis. His past social history was positive for moderate alcohol consumption but negative for tattoos, recent travel, illicit drug use, blood transfusion or chemical exposure. During evaluation in the echocardiography lab the patient had symptoms of dyspnea, fatigue and abdominal distension. He was hemodynamically stable and physical examination was positive for signs os ascites and inferior limb oedema, but disclosed no scleral icterus, asterixis, spider angiomata or overt hepatomegaly. There was a recent weight gain of 10kg. Cardiac and pulmonary auscultation was unrevealing. The echocardiogram revealed moderate left ventricle dysfunction (EF ∼40%), moderate aortic stenosis and a dilated inferior vena cava (31mm) with an image of a mobile mass in the confluence of the central hepatic vein with the inferior vena cava with extension to the right atrium. Initial blood chemistry and blood count revealed macrocytic anaemia; slight increased y-GT, C-reactive protein and NT-proBNP (6210pg/mL). The patient was admitted and anticoagulation with subcutaneous enoxaparin was initiated with echocardiographic follow-up. An abdominal ultrasound was performed which a hyperecogenic mass (71x47mm) adjacent to the right and left supra-hepatic veins, highly suggestive of hepatocelullar carcinoma. A triple-phase abdominal CT confirmed a nodular lesion 70x50mm on segment VIII, compatible with hepatocellular carcinoma (Fig.1). A cardiac magnetic resonance was performed documenting the tumor extension to the inferior vena cava and right atrium, suggestive of tumor thrombus (Fig.2). Multidisciplinary meeting enrolled the patient in palliative care. The right heart failure picture was refractory to medical treatment and the patient progressed to multi organ failure and a consumptive state. He died approximately 20 days after diagnosis.

Discussion

Intravascular tumor extension, also known as Tumor thrombus (TT) is a rare complication of some forms of cancer. In the late stages of Hepatocellular carcinoma (HCC) a TT can form in the portal or hepatic vein. These are usually detected during tumor workup or during evaluation of cardiorespiratory symptoms in a patient with a known abdominal carcinoma. Tumor invasion to the portal system is quite common while invasion to the inferior vena cava (IVC) and/or heart without invasion of the portal system is rare. Tumor extension to the RA or IVC, most patients were either symptomatic, had cirrhosis, or both. Our patient presented mainly with signs of right heart failure refractory to medical treatment and had no signs of portal invasion or hypertension in the various image modalities. The prognosis for a HCC with extension to the IVC or RA is grim, with a 1 to 4 months of mean survival regardless of treatment choice.

Abstract P883 Figure.

93 A hemodynamic challenge in assessment of echocardiographic mitral regurgitation severity

DIscussion

This case illustrates the importance of assessment of hemodynamic status of the patient during echocardiographic evaluation of mitral regurgitation severity, and presents a pharmacological strategy to compensate hypotensive effects of sedative agents used during TEE.

P235 A happy ending for a dancing thrombus on the right atrium

Discussion

Large right atrial thrombus in the setting of PTE is a clinical situation in which there is no consensus regarding clinical management. In most cases, management is dictated by haemodynamic status of the patient. In the setting of a hemodynamically stable patient, systemic anticoagulation can be an option. Surgery, fibrinolysis and percutaneous aspiration have also been advocated. Successful treatment of right heart thrombus with anticoagulation alone has been reported, but there are also reports of unsuccess with that strategy. This is a case of a successful treatment with anticoagulation alone and so, we currently consider that the choice of treatment strategy based on hemodynamic status continues to be the wisest strategy to adopt.

Abstract P235 Figure. Thrombus before and after

P862 A conservative strategy for a frequently fatal post-myocardial infarction mechanical complication

Discussion

Post-myocardial infarction ventricular septal defect (VSD) is a complication that, regardless of the treatment strategy has a high mortality rate, especially when patient presents in cardiogenic shock. However, when patient is stable and especially when comorbidities imposes a high interventional risk medical treatment can be an option. So far, this is a successful case of a medically managed post-myocardial infarction VSD.

Abstract P862 Figure. Ventricular Septal Defect

P320 Left atrial mechanics in moderate mitral valve disease: earlier markers of damage

BACKGROUND

Left atrial (LA) mechanics is impaired in mitral valve disease, but it is not clear whether reservoir, conduit or contractile functions are differentially impaired in stenosis (MS) or regurgitation (MR). We aimed to study LA mechanics in patients with moderate MR or moderate MS and identify discriminators of disease.

METHODS

We conducted a prospective, observational study of 100 patients with isolated moderate MR and 100 patients with moderate MS. LA mechanics with speckle tracking echocardiography (STE) assessed LA reservoir (LA ɛsys and SRs), conduit(LAɛe, SRe), and contractile (LAɛa, SRa) functions. Left ventricle (LV) functional parameters were assessed as well, including LV ejection fraction (LVEF), LV end-diastolic diameter (LVDD) and LV global longitudinal strain (LV-GLS).

RESULTS

The mean age was 67 ± 14 years and 75% were female. Mean left ventricular ejection fraction (LVEF), LV end-diastolic diameter (LVDD), LV global longitudinal strain (LV-GLS) and systolic pulmonary artery pressure (sPAP) did not differ between MR and MS (table 1).LA indexed volume (LAVi) and LA strain did not vary between MR and MS, but strain rate did. SRs and SRe had better values in MR, whereas SRa had worse values in MR (table 1). SRe (&lt;-0.7%) had the superior discriminative power for MR, with an area under the curve of 0.85, sensitivity of 76% and specificity of 85%.

CONCLUSIONS

LA strain rate phases were the only parameters that varied between MR and MS. Contractile phase strain rate was more impaired in MR and conduit phase strain rate in MS. This highly specific data reflect the earlier hemodynamic changes occurring in LA in the setting of mitral valve disease.

mMR mMS P value LVEF (±SD,%) 57.4 ± 6.4 59.6 ± 4.6 0.145 LV-GLS (±SD, %) -17.7 ± 4.5 -17.1 ± 3.5 0.587 sPAP (±SD, mmHg) 30.3 ± 10.5 32.4 ± 8.3 0.387 LAVi (± SD, ml/m2) 46.3 ± 6.4 48.2 ± 7.4 0.281 LAɛs (± SD, %) 15.8 ± 7.3 13.3 ± 9 0.062 LAɛe (± SD, %) 8.4 ± 4.7 7.1 ± 5.4 0.074 LAɛa (± SD, %) 6.3 ± 4.8 7.4 ± 4.5 0.081 LA SRs (± SD, %) 0.8 ± 0.4 0.6 ± 0.3 0.004 LA SRe (± SD, %) -0.9 ± 0.5 -0.5 ± 0.3 &lt;0.001 LA SRa (± SD, %) -0.5 ± 0.4 -0.8 ± 0.5 0.007

Electronic, optical and thermoelectric properties of boron-doped nitrogenated holey graphene

We employ first principles calculations to investigate the electronic, optical, and thermoelectric properties of ten boron-doped nitrogenated holey graphene (NHG) monolayers. We find that most of the proposed structures remain stable during ab initio molecular dynamics simulations, in spite of their increased formation energies. Density functional theory calculations employing a hybrid functional predict band gaps ranging from 0.73 eV to 2.30 eV. In general, we find that boron doping shifts optical absorption towards the visible spectrum, and also reduces light reflection in this region. On the other hand, the magnitude of optical absorption coefficients are reduced. Regarding the thermoelectric properties, we predict that boron doping can enhance the figure of merit ZT of NHG by up to 55%. Our results indicate that boron-doped NHG monolayers may find application in solar cells and thermoelectric devices.

P766 Elegibility for CLOSE and REDUCE trials of real world patients with Transient Ischemic Attack (TIA) or Acute Ischemic Stroke (AIS) and Patent Foramen Ovale (PFO)

Introduction

In the last decade there has been an intense discussion in which therapeutic option is most suitable for patients with TIA or cryptogenic AIS and a PFO. Recently two randomised studies (CLOSE and REDUCE) have been published tackling this question. Both have showed preference in lower recurrence rates in the group assigned for PFO closure. The eligibility criteria of these types of studies frequently are very restricted, becoming difficult to ascertain the best therapeutic option for a large number of patients.

Goal

Analyse a real world cohort of patients with TIA or cryptogenic AIS with PFO and identify the eligibility of these patients for the inclusion in the CLOSE and REDUCE trials.

Methods

We made a retrospective observational analysis of a cohort of patients discussed in a multidisciplinary meeting (Cardiology and Neurology departments) of our Hospital in which is made the decision of PFO closure vs conservative management between November 2017 and November 2018. We included all the patients with probable TIA or AIS and PFO. Demographic, clinical, image and therapeutic data was registered. The inclusion and exclusion criteria used in CLOSE and REDUCE trial were applied.

Results

25 patients were analysed, 56.0% (n = 14) were male. Median age of 47 years. Median RoPE score 7. The commonest cardiovascular risk factors were hypertension (36.0%, n = 9) and smoking (28.0%, n = 7). Eight patients met criteria for cortical cryptogenic AIS, three had lacunar strokes, two had TIA with findings in cerebral imaging and twelve presented with TIA without findings in cerebral imaging. Transesophagic echocardiography was performed in 92.0% (n = 23) of patients, transthoracic echocardiography with bubble study was performed in two cases. At the time of data collection, six patients were waiting completion of the workup. PFO closure was performed in three cases. Closure was proposed in other two. When applying the eligibility criteria of CLOSE and REDUCE the main reasons for exclusion in the REDUCE trial were TIA without cerebral imaging (48.0%, n = 12), incomplete antiphospholipid antibody syndrome screening (36.0%, n = 9) and age greater than 59 years (28.0%, n = 7). The main reasons for exclusion in the CLOSE trial were TIA without cerebral imaging (48.0%, n = 12), age greater than 60 years (28%, n = 7) and failing to meet the designated echocardiography criteria (20.0%, n = 5).

Conclusion

2 real world patients met eligibility criteria for the REDUCE trial and 3 for CLOSE. The main reason for exclusion in both REDUCE and CLOSE was TIA without cerebral imaging (48.0% n = 12). Older patients, and patients with a prothrombotic condition were also excluded. Multidisciplinary meetings are essential to ascertain the most beneficial therapeutic option for these patients. It is our believe that the management of risk factors should be similar in a TIA and a AIS and also that the presence of a prothrombotic condition should favor the closure of PFO.

P875 A suspected case of extra-pulmonary tuberculosis presenting as effusive-constrictive pericarditis

Case presentation

A 33 year-old black female, born in Angola, staying in Portugal 1 week before admission presented to the emergency department of our hospital with a history of worsening but recurring pleuritic chest accompanied by dyspnea, fatigue, peripheral oedema and sweating in the past 4 years. Initial workup in Angola and more recently in Namibia was unrevealing. The patient had taken 3 months of antituberculous agents and a systemic corticosteroid and was medicated with furosemide and spironolactone. Since then the symptoms persisted and multiple admissions for decompensated heart failure followed. At presentation median blood pressure was 60mmHg, heart rate 90 beats per minute, temperature 37,6ºC. Auscultation had signs of pulmonary congestion and muffled heart sounds, the neck veins were distended. An electrocardiogram showed sinus rhythm and low-voltage complexes in limb and precordial leads. Initial transthoracic echocardiogram revealed a thickened pericardium with circunferencial effusion and marked respiratory variation (&gt;25%) of the mitral and tricuspid inflow doppler velocities. Pericardiocentesis was performed with improved dyspnea and blood pressure after drainage of 650 mL of serohematic fluid. Echocardiographic follow-up showed a mild circunferencial pericardial effusion and extensive areas of thickened crypted pericardium with fibrin strands containing heterogeneous fluid (figure 1). There were signs of constriction. A cardiac CT revealed no calcium deposition. Fluid cytology was predominant for lymphocytes and biochemistry, cultures, polymerase chain reaction and immunochemistry were inconclusive and no pathologic agent was isolated. The image findings in the transthoracic echocardiogram coupled with the demographics and past clinical history of the patient prompt the initiation of antituberculous therapy in association with systemic corticosteroids in an attempt to ameliorate the pericardial constriction. Despite initial therapeutic response, constriction was deemed irreversible and pericardiectomy was performed. The workup for definitive diagnosis is still undergoing.

Discussion

Effusive-constrictive pericarditis is defined by a pericardial effusion with signs of concurrent pericardial constriction. In these cases the scarred pericardium not only constricts cardiac volume but can also accommodate pericardial fluid under increased pressure leading to signs of cardiac tamponade. The initial approach should be the treatment of the underlying condition but if such remains ineffective, pericardiectomy is the remaining option and is reserved for patients in which constriction becomes severe and/or persistent. This condition is more prevalent with tuberculous pericarditis and when suspected presumptive treatment should be initiated in immunocompetent patients from endemic regions. Antituberculous treatment regimens in conjunction with systemic corticosteroids have shown to prevent complications from pericardial constriction.

Abstract P875 Figure.

435 Left ventricular reverse remodeling and angiotensin ii receptor blocker neprilysin inhibitor - a real-world data

BACKGROUND

Although sacubitril/valsartan (ARNI) improves the NYHA functional class and prognosis in patients with heart failure with reduced ejection fraction (HFrEF), its impact on reverse remodelling is uncertain. We assessed left ventricular reverse remodeling in a cohort of HFrEF patients treated with ARNI.

METHODS

We conducted a single-centre, retrospective, observational study of 200 HFrEF patients started on ARNI during 2018. Of these, we analysed 100 patients treated with the maximum, target dose (97/103 mg bid). Baseline clinical, laboratory and demographic characteristics were evaluated and a clinical and echocardiographic follow-up, including left ventricular ejection fraction (LVEF), left ventricular global longitudinal strain (GLS), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV) and mitral valve regurgitation (MR), were conducted from ARNI initiation to a 3-month landmark.

RESULTS

Mean age was 59 ± 13 years and 85% were male. At baseline, 63% were on NYHA II, 34% in NYHA III and 3% in NYHA IV functional class. Mean systolic blood pressure was 125 ± 16 mmHg, median NT-proBNP was 773 pg/dL (IQR 386-1569) and mean LVEF 27 ± 7%. Median time between initiation of the drug and reaching the target dose was 10 weeks. Functional class significantly improved; at baseline, 37% of patients were in NYHA III-IV; 3 months after target dose, only 6% remained in NYHA III-IV (p = 0.005). Half of patients (48.6%) improved LVEF (from 27 ± 7% to 31 ± 10%, mean increase 4.2 ± 8.8%; 95%CI 2.1 to 6.3, p &lt; 0.001) and in one quarter (24.6%) LVEF improved over 35% (p &lt; 0.001). In a echocardiographic subgroup analysis, including a random sample of 35 patients, we found a significant improvement in GLS 1.5 ± 2.9 (95%CI 0.4 to 2.6%, p = 0.009), a significant decrease in LVESV and LVEDV 29 ± 3 mL (95%CI -42.6mL to -15.4mL, p &lt; 0.001) and 31 ± 47ml (95% CI -48 to -15, p &lt; 0.001), respectively, and a significant improvement in MR severity (p = 0.001).

CONCLUSIONS

We observed that in an HFrEF patient population treated with ARNI there was a significant clinical improvement, who may be explained by a robust impact on reverse remodelling, even on a short-time of follow-up. An interesting finding was that 24.6% improved LVEF above the 35% cut-off, and therefore lost an indication for a prophylactic implantable cardioverter defibrillator.

P1366 Low-flow, low-gradient severe aortic stenosis: might mitral regurgitation be a culprit?

Introduction

According to current guidelines, given a patient with low-gradient (aortic valve maximum velocity &lt; 4m/s and/or aortic valve mean gradient &lt;40mmHg), aortic valve area (AVA) &lt; 1cm2 and low-flow (stroke volume (SV) &lt; 35mL/min/m2), with preserved left ventricle function (ejection fraction (EF) ≥50%), an integrated approach for assessment of aortic stenosis severity is proposed. We aimed to investigate whether mitral regurgitation can play a role in those cases, possibly being responsible for low antegrade systolic flow.

Methods

We retrospectively analysed 121 consecutive transthoracic echocardiograms (TTEs) of patients with severe aortic stenosis, with AVA &lt; 1.0cm2 as assessed by continuity equation. Patients with low ejection fraction (&lt; 50%) were excluded. We therefore included 84 patients (females 53,6%, mean age 79,1+-10 years). Stroke volume was assessed by Doppler at the left ventricle outflow tract (LVOT). We then compared the prevalence of more than mild mitral regurgitation among patients with low-gradient and low-flow and the other patients.

Results

15 patients had both low-gradient, low-flow and preserved ejection fraction. There was a significant association regarding the presence of more than mild mitral regurgitation among these patients (p = 0.028, OR = 4.7, CI 95% 1.1-20.1). In these patients, it was also observed a higher prevalence of atrial fibrillation (p = 0.03, OR = 6.9, CI 95% 1.74-27.1), lower longitudinal systolic function of right ventricle as measured by TAPSE (16.6 vs 21.5mm, p = 0.028), and a tendency towards higher left atrial volume (113 vs 87mL, p = 0.06).

Conclusions

Given the findings that the prevalence of more than mild mitral regurgitation is higher in patients with severe aortic stenosis as assessed by AVA with both low-gradient, low-flow and preserved ejection fraction, we suggest that the presence of more than mild mitral regurgitation should be considered on the approach of aortic stenosis classification of these patients.

P1298 A conservative strategy for an uncommon complication of endocarditis

Discussion

Infective endocarditis of mechanical prosthesis has different presentations depending on the involvement of prosthesis and periprosthetic structures, and it is associated with high morbidity and mortality. Pseudoaneurysm of the intervalvular fibrosa is an uncommon complication, furthermore when complicating with dissection to near structures such as RVOT and the PT in this case. Treatment is mainly surgical, however, in this case the surgical risk was too high due to comorbidities and a conservative strategy was adopted. It seems that it was a reasonable strategy as the patient evolution was unremarkable when regarding endocarditis. Unfortunately, he ended up dying from probably unrelated complications.

Abstract P1298 Figure. Pseudoaneurysm with fistulization