Evaluation of the Effects of Food Safety Training on the Microbiological Load Present in Equipment, Surfaces, Utensils, and Food Manipulator's Hands in Restaurants

Training food handlers is essential to ensure food safety. However, the efficacy of training programs relying solely on theoretical information remains uncertain and often fails to induce significant changes in inadequate food practices. Training programs in good hygiene and food safety practices that integrate theoretical and practical approaches have emerged as a vital tool, enabling food handlers to apply their knowledge during work hours and clarify doubts. This study aimed to assess the impact of food safety training based on theoretical and on-the-job training on the microbiological counts of equipment, surfaces, utensils, and food handler (FH) hands. The hygiene and food safety conditions of four restaurants were analyzed through facility checklists, employee questionnaires, and microbiological analyses conducted before and after training. Eight sample collection moments were conducted at each restaurant before and after training. The pre-training results indicate that 15% and 26% of analyses for Enterobacteriaceae and total mesophilic aerobic bacteria (TMB), respectively, did not comply with hygiene safety limits. Additionally, 31% and 64% of Enterobacteriaceae and TMB values, respectively, exceeded safety limits on food handler hands. Positive cases of coagulase-positive Staphylococcus (CoPS) resulted from unprotected wounds on some FH hands. The presence of Listeria monocytogenes in drains was also identified as a concern. Following training, significant differences in results were observed. In many cases, there was a reduction of over 80% in microbial load for Enterobacteriaceae and TMB collected from equipment, surfaces, utensils, and food handler hands. The presence of L. monocytogenes in drains was also eliminated after food safety training. In conclusion, this study underscores the importance of effective training in improving food safety practices.

The Kidney Transplant Lottery: A Highly Sensitized Patient, Without Mismatches and Vein Thrombosis of the Graft; A Case Report

A kidney transplant is the best option for patients with end-stage renal disease. The waiting list period can be long, especially for highly sensitized patients. We describe a 60-year-old woman who received a second transplant and was highly sensitized to vascular access exhaustion, anuric, and performing peritoneal dialysis. At 27 days post-transplant, the patient developed thrombosis of the allograft vein, oliguria, and elevated serum creatinine. Fibrinolysis was attempted, but the patient remained oliguric and with acute graft dysfunction. She had a suction thrombectomy using the Penumbra System, allowing the removal of all thrombi and repermeabilization of the vein graft, resolving the acute graft dysfunction.

Cardiac Tamponade and Primary Biliary Cholangitis: An Unusual Presentation and a Rare Association of Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a disease known for its multiple manifestations, including numerous cardiac complications. While pericardial effusions are common in patients with SLE, cardiac tamponade is rare, and it is even rarer as an initial and isolated clinical manifestation of SLE. We describe a case of a young adult woman who presented with a four-week history of shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. Chest radiography revealed a significant increase in the cardiothoracic index, and transthoracic echocardiography confirmed a life-threatening cardiac tamponade that necessitated emergency pericardiocentesis and high-dose corticosteroids. Following a thorough investigation, we excluded viral infection, malignancy, tuberculosis, and other autoimmune diseases, and the patient was diagnosed with SLE based on the Systemic Lupus International Collaborating Clinics (SLICC) criteria. In this case report, we also present an uncommon association between SLE and primary biliary cholangitis (PBC). While both are autoimmune diseases, the coexistence of these two conditions in the same patient is rare. The report highlights the need for ongoing research to better understand the optimal management strategies for patients with coexisting autoimmune conditions.

The effects of different immunocastration protocols on meat quality traits and boar taint compounds in male Bísaro pigs

Immunocastration can be an alternative to surgical castration in Bísaro pigs when there is a need to keep animals on the farm until at least 8 months old. As an autochthonous breed, some particularities must be addressed when doing immunocastration, for which 3 different protocols were tested and two control groups were made with surgically castrated males (SC) and boars (Bo). Two protocols were made in prepubertal pigs, with two (E2) and three inoculations (L3) in the first cycle, and another in adults (A2) with only two inoculations. Physicochemical parameters and boar taint compounds quantification and sensory analysis of the meat from the studied pigs were assessed. Immunocastration provided intermediate values between surgically castrated pigs and entire males, with low levels of boar taint compounds. The L3 group provided closer results to SC, which was also corroborated by the sensory analysis. Although the other two protocols had no significant differences with Bo, there was a positive tendency towards them. As is, the L3 protocol was promising as a good alternative to surgical castration, maintaining the characteristic attributes of the Bísaro pig meat.

Seasonal Variations on Testicular Morphology, Boar Taint, and Meat Quality Traits in Traditional Outdoor Pig Farming

Traditional outdoor pig farming is renowned for its emphasis on animal welfare and the production of highly valued, quality meat. While seasonality is known to impact certain animals, particularly those raised outdoors, there is a lack of research on Bísaro boars, a native Portuguese breed. This research study was conducted on a total of 20 male entire Bísaro pigs, reared in outdoor pens from 4 to 13 months old, and subsequently slaughtered. The animals were divided into two groups: one slaughtered in winter (Wi, n = 9), and the other in summer (Su, n = 11). The objective was to evaluate testicular morphometry, boar taint compounds, and meat quality traits, including sensory analysis and fatty acid profile. Testicles from the Su group exhibited reduced volume, indicating diminished functionality during that season. While no significant differences were observed in the boar taint compound analysis, panelists could discern a more intense aroma and flavor of boar taint in the Su meat. Other meat quality traits showed no significant variations, but the fatty acid profile displayed higher values in the Wi group. This study reveals that Bísaro boars experience reproductive seasonality, leading to variations in boar taint compounds across the seasons. This information is crucial for farm planning.

Estimating sequence diversity of prion protein gene (PRNP) in Portuguese populations of two cervid species: red deer and fallow deer

Among the transmissible spongiform encephalopathies (TSEs), chronic wasting disease (CWD) in cervids is now a rising concern in wildlife within Europe, after the detection of the first case in Norway in 2016, in a wild reindeer and until June 2022 a total of 34 cases were described in Norway, Sweden and Finland. The definite diagnosis is post-mortem, performed in target areas of the brain and lymph nodes. Samples are first screened using a rapid test and, if positive, confirmed by immunohistochemistry and Western immunoblotting. The study of the genetics of the prion protein gene, PRNP, has been proved to be a valuable tool for determining the relative susceptibility to TSEs. In the present study, the exon 3 of PRNP gene of 143 samples from red deer (Cervus elaphus) and fallow deer (Dama dama) of Portugal was analysed. Three single nucleotide polymorphisms (SNPs) were found in red deer - codon A136A, codon T98A, codon Q226E - and no sequence variation was detected in fallow deer. The low genetic diversity found in our samples is compatible with previous studies in Europe. The comparison with results from North America suggests that the free-ranging deer from our study may present susceptibility to CWD, although lack of experimental data and the necessity of continuous survey are necessary to evaluate these populations.

Characterization of Sodium Alginate-Based Films Blended with Olive Leaf and Laurel Leaf Extracts Obtained by Ultrasound-Assisted Technology

Due to environmental concerns, there is an increasing need to reduce the use of synthetic and non-renewable packaging materials to reduce waste and increase sustainability. This study aimed to characterise sodium alginate edible-based films (SA) incorporated with laurel leaf extract (LLE) and olive leaf extract (OLE) obtained by ultrasound-assisted extraction. Determination of total phenolic content, antioxidant, and antimicrobial activity was performed for the extracts and films. Also, thickness, tensile strength, elongation at break, modulus of elasticity, opacity and colour, moisture content, water vapour permeability (WVP), Fourier-transform infrared spectroscopy (FTIR) spectra, and surface morphology by scanning electron microscope (SEM) analyses were performed for the films. LLE yielded better results in terms of phenolic content (195 mg GAE/g), antioxidant (2.1 TE/g extract) and antimicrobial activity (MIC at 1% for Listeria monocytogenes and Staphylococcus aureus, and 1.8% for Enterococcus faecalis). For the films, the simultaneous incorporation of LLE 1% (w/v) and OLE 1% (w/v) resulted in a significant reduction of approximately 2 log CFU/g against S. aureus. The addition of LLE and OLE extracts also proved to improve barrier properties (lower WVP for SA films with LLE 1% + OLE 1%, 3.49 × 10-11 g m-1 s-1 Pa-1) and promoted changes in resistance and flexibility. The results demonstrated that active alginate-based films can be valuable for enhancing food preservation.

Effect of Immunocastration on Culled Sows-A Preliminary Study on Reproductive Tract, Carcass Traits, and Meat Quality

The Bísaro pig is a Portuguese autochthonous breed greatly appreciated for its meat quality and is mainly reared outdoors. Immunocastration could be a solution to avoid undesirable pregnancies and boar taint in cull sows. The present study tested three immunocastration protocols (with Improvac®) according to their reproductive cycle. The first inoculation was performed two weeks after farrowing (IM1, n = 5), at the beginning of estrus (IM2, n = 5), and one week after the end of estrus (IM3, n = 5), followed by a second administration four weeks apart. A control group (C, n = 5) was also included in the same housing conditions. The sample collection included the reproductive tract for morphometric evaluation, neck fat for the quantification of boar taint compounds, and a portion of the Longissimus thoracis et lumborum for meat quality trait assessment. The reproductive tracts from intact sows (C) were significantly heavier compared to the immunocastrated groups (p < 0.05) (1.403 kg C to 0.508 kg IM1, 0.590 kg IM2, and 0.599 kg IM3), suggesting the regression of the reproductive tract to nonstimulated conditions due to immunization against GnRH. The IM1 group exhibited significantly smaller reproductive tract measurements compared to group C for most of the evaluated segments (p < 0.05). No marked differences were observed in the meat quality traits. Therefore, immunocastration can be used in culling sows to avoid ovarian activity, and it is not detrimental to pork quality traits.

Effect of Sodium Nitrite, Nisin and Lactic Acid on the Prevalence and Antibiotic Resistance Patterns of Listeria monocytogenes Naturally Present in Poultry

The impact of treating minced chicken meat with sodium nitrite (SN, 100 ppm), nisin (Ni, 10 ppm) and lactic acid (LA, 3000 ppm) on the levels of some microbial groups indicating hygiene quality were investigated. Specifically, aerobic plate counts and culture-based counts of psychrotrophic microorganisms and enterobacteria were obtained. Additionally, the prevalence of Listeria monocytogenes and the resistance of 245 isolates from this bacterium to 15 antibiotics were documented. L. monocytogenes was isolated using the ISO 11290-1:2017 method and confirmed with polymerase chain reaction using the lmo1030 gene. Antibiotic resistance was established using the disc diffusion technique (EUCAST and CLSI criteria). Twenty-four hours after treatment, the microbial load (log10 cfu/g) was reduced (p < 0.05) relative to controls in those samples treated with LA, with counts of 5.51 ± 1.05 (LA-treated samples) vs. 7.53 ± 1.02 (control) for APC, 5.59 ± 1.14 (LA) vs. 7.13 ± 1.07 (control) for psychrotrophic microorganisms and 2.33 ± 0.51 (LA) vs. 4.23 ± 0.88 (control) for enterobacteria. L. monocytogenes was detected in 70% (control samples), 60% (samples receiving SN), 65% (Ni) and 50% (LA) (p > 0.05) of samples. All strains showed resistance to multiple antimicrobials (between 3 and 12). In all, 225 isolates (91.8%) showed a multi-drug resistant (MDR) phenotype, and one isolate (0.4%) showed an extensively drug-resistant (XDR) phenotype. The mean number of resistances per strain was lower (p < 0.01) in the control samples, at 5.77 ± 1.22, than in those receiving treatment, at 6.39 ± 1.51. It is suggested that the use of food additives might increase the prevalence of resistance to antibiotics in L. monocytogenes, although additional studies would be necessary to verify this finding by analyzing a higher number of samples and different foodstuffs and by increasing the number of antimicrobial compounds and concentrations to be tested.

Antimicrobial and Antioxidant Edible Films and Coatings in the Shelf-Life Improvement of Chicken Meat

Meat deterioration during processing, distribution, and display can compromise the quality and safety of products, causing several undesirable changes and decreasing products' shelf-life, which has a negative impact on the industry and consumers. In recent years, studies have been carried out using decontamination techniques and new packaging methodologies to overcome deterioration problems, increase sustainability, and reduce waste. Edible films and coatings obtained from biopolymers such as polysaccharides, proteins, and lipids, combined with active compounds, can be an alternative approach. This article focused on recent studies that used alternative biodegradable polymeric matrices in conjunction with natural compounds with antioxidant/antimicrobial activity on chicken meat. Its impact on physicochemical, microbiological, and sensory characteristics was evident, as well as the effect on its shelf-life. In general, different combinations of active edible films or coatings had a positive effect on the chicken meat. Different studies reported that the main results were a decrease in microbial growth and pathogen survival, a slowdown in lipid oxidation evolution, and an improvement in sensory quality and shelf-life (an increase from 4 to 12 days).

Quantification of Total and Viable Cells and Determination of Serogroups and Antibiotic Resistance Patterns of Listeria monocytogenes in Chicken Meat from the North-Western Iberian Peninsula

Twenty samples of minced chicken meat procured from butcher’s shops in León (Spain; 10 samples) and Vila Real (Portugal; 10 samples) were analyzed. Microbial concentrations (log10 cfu/g) of 7.53 ± 1.02 (viable aerobic microbiota), 7.13 ± 1.07 (psychrotrophic microorganisms), and 4.23 ± 0.88 (enterobacteria) were found. The detection method described in the UNE-EN ISO 11290-1 standard (based on isolation from the chromogenic medium OCLA) with confirmation by the polymerase chain reaction (PCR; lmo1030) (OCLA−PCR), revealed Listeria monocytogenes in 14 samples (70.0% of the total), nine of Spanish origin and five of Portuguese (p > 0.05). The levels of viable and inactivated L. monocytogenes in the samples were determined with a q-PCR using propidium monoazide (PMAxx) as a viability marker. Seven samples tested positive both with the OCLA−PCR and with the q-PCR, with estimated concentrations of viable cells varying between 2.15 log10 cfu/g (detection limit) and 2.94 log10 cfu/g. Three samples tested negative both with the OCLA−PCR and with the q-PCR. Seven samples were positive with the OCLA−PCR, but negative with the q-PCR, and three samples tested negative with the OCLA−PCR and positive with the q-PCR. The percentage of viable cells relative to the total ranged between 2.4% and 86.0%. Seventy isolates of L. monocytogenes (five from each positive sample) were classified in PCR serogroups with a multiplex PCR assay. L. monocytogenes isolates belonged to serogroups IIa (52 isolates; 74.3%), IIc (7; 10.0%), IVa (2; 2.9%), and IVb (9; 12.9%). The susceptibility of the 70 isolates to 15 antibiotics of clinical interest was tested. The strains presented resistance to between three and eight antibiotics. The average number of resistances was greater (p < 0.001) among strains isolated from Spanish samples (6.20 ± 1.08), than in those from Portugal (5.00 ± 1.08). In both groups of strains, a prevalence of resistance higher than 95% was observed for oxacillin, cefoxitin, cefotaxime, and cefepime. The need to handle minced chicken meat correctly, taking care to cook it sufficiently and to avoid cross-contamination, so as to reduce the danger of listeriosis, is emphasized. A combination of culture-dependent and culture-independent methods offers complementary routes for the detection in food of the cells of L. monocytogenes in various different physiological states.

Systemic Bacillus Calmette-Guérin (BCG) Infection With Renal Involvement: A Rare Complication of BCG Immunotherapy

Intravesical instillation of bacillus Calmette-Guérin (BCG) is the adjuvant therapy for superficial urothelial carcinoma of the bladder with the lowest recurrence rates and is well tolerated with minor and self-limiting adverse effects. Serious complications, such as systemic BCG infection, are uncommon as the diagnosis is difficult and, in the majority of cases, Mycobacterium bovis cannot be isolated. We describe a case of a man who presented with prolonged fever associated with polyuria, dysuria, anorexia, and significant weight loss, refractory to several courses of appropriate antibiotic therapy. After an exhaustive investigation, the underlying diagnosis of systemic BCG infection with renal involvement was considered. Antituberculosis treatment resulted in a marked clinical and radiological recovery, supporting this diagnosis.

Hygiene Indicators and Salmonellae on Surfaces of Swine Carcasses from Two Slaughterhouses in Northern Portugal

ABSTRACT

The monitoring of carcass surface contamination along the slaughter line enables verification of slaughter operation hygiene and the use of good manufacturing practices. Pork meat is a common source of human nontyphoidal salmonellosis, one of the most frequently reported foodborne illnesses worldwide. This study was conducted to gather data on microbial loads before and after evisceration on the surfaces of swine carcasses in two slaughterhouses. The presence of Salmonella enterica was evaluated only after evisceration on carcass surfaces and in livers and floor drains (environmental samples) because pigs are common carriers of this pathogen. The contamination of carcass surfaces was evaluated by delimitation of surface area with sterilized templates (100 cm2), and surface samples were collected with gauze swabs. Total aerobic mesophilic bacteria, Enterobacteriaceae, and Escherichia coli were enumerated. Significant differences (P < 0.05) in counts of mesophilic bacteria, Enterobacteriaceae, and E. coli were found on the external carcass surfaces, with higher counts after evisceration. The neck and abdominal areas had higher levels of mesophilic bacteria, Enterobacteriaceae, and E. coli and a high prevalence of Salmonella. Salmonella was detected in only one of the studied slaughterhouses; 19 (7.3%) of 259 analyzed carcass samples were positive for Salmonella, and Salmonella was detected in two livers and two floor drains. A total of 52 Salmonella isolates (44 from carcasses, 5 from livers, and 3 from drains) were recovered. Three Salmonella serovars (Typhimurium 4,5:i- , Wernigerone, and Derby) were identified, and 53.8% of the 52 isolates were multidrug resistant. The results reveal the need for continuous improvement of slaughtering operations and implementation of good manufacturing practices to ensure the safety of pork produced in Portugal.

HIGHLIGHTS

The adjusted Global Anti-Phospholipid Syndrome Score as predictor of damage accrual measured by Damage Index for APS: a longitudinal study

Objective

To analyze the association between the average “adjusted” Global anti-phospholipid syndrome Score (aGAPSS) over time, as a surrogate of disease activity, and change in Damage Index for APS (DIAPS) during follow-up in patients with thrombotic and non-thrombotic APS.

Methods

200 APS patients (138 primary, 62 associated to other autoimmune diseases) were included. DIAPS change was calculated as the difference between basal DIAPS and DIAPS at the end of follow-up. The aGAPSS was calculated for each patient at baseline and on a yearly basis for up to 6 years (minimum 3 years). The average score per patient was computed and considered the reference aGAPSS. Linear regression models were designed to analyze the association between mean aGAPSS and DIAPS change. Moreover, factors associated to high (increase of DIAPS ≥1 during follow-up) vs low (increase of DIAPS &lt;1 during follow-up) damage accrual were assessed.

Results

A higher mean aGAPSS value was associated to a DIAPS increase during follow-up (b = 0.04, p&lt; 0.001) in the multivariate analysis. Higher mean aGAPSS values were found in patients with a DIAPS increase ≥1 during follow-up compared with patients with an increase of &lt; 1 point [9.22 (95% C.I. 7.58–10.86) vs 6.72 (95% C.I. 6.0–7.43), p= 0.003]. aGAPSS increased the odds a DIAPS increment of ≥ 1 point during follow-up [OR = 1.12 (95% C.I. 1.04–1.21, p= 0.003].

Conclusions

Our data support the utility of longitudinal assessing of the aGAPSS score in predicting damage accrual, measured by DIAPS, in APS.

Predictive value of the Adjusted Global Anti-Phospholipid Syndrome Score on clinical recurrence in APS patients: A longitudinal study

OBJECTIVE

To assess the effect of the average adjusted global APS score (aGAPSS) over time on recurrence of clinical manifestations in APS patients through a retrospective longitudinal study.

METHODS

The study included 200 patients with APS. The aGAPSS was calculated for each patient at baseline and on a yearly basis for either up to 6 years (minimum 3 years) or just before the clinical event in patients who experienced clinical recurrence. The mean score per patient was computed. In patients under vitamin K antagonists (VKA) the percentage of time spent within the therapeutic range (TTR) was calculated. Cox-regression analysis was performed to determine the cut-off value of the aGAPSS with the strongest association with clinical recurrence.

RESULTS

Higher average aGAPSS values were found in patients who experienced clinical recurrence in comparison to patients who did not [8.81 (95% C.I. 7.53-10.08) vs 6.38 (95% C.I. 5.64-7.12), p = 0.001], patients with thrombotic recurrence compared to patients with obstetric recurrence [9.48 (95% C.I. 8.14-10.82) vs 4.25 (95% C.I. 0.85-7.65), p = 0.006], and patients with arterial thrombosis compared to patients with venous thrombosis [10.66 (S.D. 5.48) vs 6.63 (S.D. 4.42), p = 0.01]. aGAPSS values > 13 points were associated with the highest risk of recurrence in multivariate analysis [HR = 3.25 (95% C.I. 1.93-5.45, p < 0.0001]. TTR was not statistically different between patients who had thrombosis recurrence and patients who had not.

CONCLUSIONS

Our data support the role of periodic (annual) monitoring of the aGAPSS score in predicting clinical recurrence in patients with APS.

Impact of sleep apnea treatment with CPAP on recurrence of atrial fibrillation after catheter ablation

Funding Acknowledgements

Type of funding sources: None. Main funding source(s): None

Background

Sleep apnea, as well as other risk factors such as obesity and high blood pressure, increase the risk of recurrence of atrial fibrillation after catheter ablation. But the true impact of sleep apnea treatment on recurrence of atrial fibrillation is less well defined.

Purpose

Assess the impact of untreated sleep apnea and treatment with CPAP (continuous positive airway pressure) on the risk of atrial fibrillation recurrence in patients undergoing catheter ablation.

Methods

We performed a retrospective analysis of 160 patients undergoing catheter ablation of paroxysmal or persistent atrial fibrillation in our institution, in a period between November of 2015 and November of 2021. We compared two groups: with atrial fibrillation recurrence and without atrial fibrillation recurrence, in a follow-up period of eighteen months. We analysed the clinical characteristics, diagnosis of sleep apnea, treatment with CPAP, echocardiographic findings (indexed volume of left atrium and left ventricular ejection fraction), cardiovascular risk factors and other comorbidities (table 1). Survival analysis of atrial fibrillation recurrence was performed using a Cox Regression analysis (figure 1).

Results

During a mean follow-up time of 22,8 ± 19,9 months, 46 patients (28,8%) had atrial fibrillation recurrence and none died. The recurrence was associated with hypertension, alcohol habits and untreated sleep apnea. Untreated sleep apnea was associated with a 4-fold increased risk of atrial fibrillation recurrence (HR 3,74; 95% CI 1,89-7,42; p &lt;0,001). In patients with sleep apnea (n = 41), CPAP treatment was associated with a 74% decreased risk of recurrence (HR 0,26; 95% CI 0,10-0,72; p = 0,009).

Conclusions

Treatment with CPAP was associated with lower risk of recurrence of atrial fibrillation after catheter ablation in patients with sleep apnea.

Benefit of sleep study in all patients with atrial fibrillation and BMI&gt; 28,0 Kg/m2 before catheter ablation

Funding Acknowledgements

Type of funding sources: None. Main funding source(s): None

Background

Sleep apnea is a known risk factor for atrial fibrillation recurrence after catheter ablation. Despite this, in recent atrial fibrillation guidelines, it is unclear in which patients to test sleep apnea before catheter ablation.

Purpose

Evaluate if body mass index (BMI) has a good discriminative power to predict sleep apnea in patients with atrial fibrillation proposed to catheter ablation.

Methods

We retrospectively studied 160 consecutive patients undergoing catheter ablation of paroxysmal or persistent atrial fibrillation in our institution. We evaluated recurrence of atrial fibrillation after catheter ablation and analysed diagnosis of sleep apnea, body mass index, treatment with CPAP, echocardiographic findings (indexed volume of left atrium and left ventricular ejection fraction), cardiovascular risk factors and other comorbidities and clinical characteristics. Receiver operator characteristics (ROC) curve and area under the curve (AUC) were obtained to determine the discriminative power of body mass index as predictor of sleep apnea. Optimal cut-point value was obtained (Youden index) and patients were divided according to this value.

Results

During a mean follow-up time of 22,8 ± 19,9 months, 46 patients (28,8%) had atrial fibrillation recurrence and none died. The recurrence was associated with hypertension, alcohol habits and untreated sleep apnea (HR 3,74; 95% CI 1,89-7,42; p &lt;0,001). Optimal cut-point value for predicting sleep apnea in patients with atrial fibrillation proposed to catheter ablation was BMI of 28,0 Kg/m2 (AUC 0,733, p = 0,001, 95% CI 0,640-0,827). The group of patients with BMI of 28,0 Kg/m2 had a 4-fold increased risk of sleep apnea (OR 3,95, 95% CI 1,85-8,42, p =0,001) and 2-fold risk of atrial fibrillation recurrence (HR 1,96; 95% CI 1,10-3,51; p = 0,023).

Conclusions

In this group of patients undergoing catheter ablation of atrial fibrillation, a BMI ≥ 28,0 Kg/m2 was independent predictor of sleep apnea and recurrence of atrial fibrillation after catheter ablation. In patients with atrial fibrillation proposed to catheter ablation and BMI ≥ 28,0 Kg/m2 is reasonable to do a sleep study before catheter ablation.

Scrapie at Abattoir: Monitoring, Control, and Differential Diagnosis of Wasting Conditions during Meat Inspection

Wasting disease in small ruminants is frequently detected at slaughterhouses. The wasting disorder is manifested by the deterioration of the nutritional and physiological state of the animal indicated by thinness, emaciation, and cachexia. Evidence of emaciation and cachexia, alone, are pathological conditions leading to carcass condemnation during an inspection. Several diseases are associated with a wasting condition, including scrapie, pseudotuberculosis, tuberculosis, paratuberculosis, Maedi Visna, and tumor diseases. On the other hand, parasitic diseases, nutrition disorders, exposure or ingestion of toxins, metabolic conditions, inadequate nutrition due to poor teeth, or poor alimentary diet are conditions contributing to poor body condition. Classical and atypical scrapie is naturally occurring transmissible spongiform encephalopathies in small ruminants. The etiological agent for each one is prions. However, each of these scrapie types is epidemiologically, pathologically, and biochemically different. Though atypical scrapie occurs at low incidence, it is consistently prevalent in the small ruminant population. Hence, it is advisable to include differential diagnosis of this disease, from other possibilities, as a cause of wasting conditions detected during meat inspection at the abattoir. This manuscript is a review of the measures in force at the abattoir for scrapie control, focusing on the differential diagnosis of gross lesions related to wasting conditions detected in small ruminants during meat inspection.

Predictors of patient and system delay for primary percutaneous coronary intervention

Background

The delay times of the patient and the system for primary percutaneous coronary intervention (p-PCI) have a determining impact on the prognosis of patients with acute myocardial infarction with ST segment elevation (STEMI).

Purpose

To identify the predictors of patient and system delay for p-PCI in the period of 2020 at a reference hospital for p-PCI.

Methods

Patients submitted to p-PCI in the period from March to September 2020 were included and compared with the same period in 2019. We analyzed the differences between the two groups regarding the patient's delay times, time from the onset of symptoms to the first medical contact (FCM) and the system (time from the first contact with the health system to p-ICP). Data collection of the patient's previous history, coronary intervention performed and post-PCI follow-up was performed using the electronic patient record. Univariate analysis and logistic regression models from multivariate analysis were used to determine the predictors of “patient delay” and “system delay” and adjusted for confounding factors. The analysis was performed with a significance level of 5%.

Results

We included in the study 255 patients who underwent p-PCI, of which 122 in the period from 2020 and 133 in the period from 2019. Regarding the characteristics of the population, there were no significant differences between the two periods. Regarding the patient's delay time, there were no statistically significant differences. The variable first medical contact with a non p-PCI center was the only variable associated with system delay&gt;90 minutes in the multivariate analysis, OR (6.18: 95% CI, 1.91–20), p=0.002. There was a statistically significant association between the period of 2020 (pandemic period) and total ischemia time, but with a negative effect, dependent variable adjusted for confounding factors [adjusted OR: −0.10; 95% CI: −107.61 to −5.57; p=0.03].

Conclusion

In this study, the patient's admission to a non p-PCI centers was identified as the only predictor of longer delay until p-PCI (system delay). However, these results should serve as a contribution to decision making in order to mitigate risks, regardless of any associated catastrophe and eventually alert the population not to neglect the symptoms suspected of acute myocardial infarction.

Funding Acknowledgement

Type of funding sources: None.

Three-dimensional late gadolinium enhancement increases the diagnostic yield of cardiovascular magnetic resonance to detect low voltage in the right ventricular outflow tract

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac magnetic resonance (CMR) using late gadolinium enhancement (LGE) fails to detect scar tissue in patients with electroanatomical abnormalities and biopsy-proven structural heart disease. It has shown conflicting data regarding existence of structural abnormalities in patients with idiopathic premature ventricular contractions (PVCs) from the right ventricular outflow tract (RVOT). Three- dimensional (3D) LGE enables high-spatial resolution more appropriate to the thin-walled right ventricle than two-dimensional (2D) LGE.

Objective

Our aim was to evaluate if the use of 3D-LGE would improve the performance of CMR to detect low voltage areas in the RVOT of patients with PVCs.

Methods

Since May 2020 we performed 3D-LGE CMR in 11 consecutive patients that underwent ablation of frequent PVCs. A control group of 11 consecutive patients that underwent catheter ablation by the same operator and had a 2D-LGE CMR performed before ablation was also studied. All patients had normal 2D-LGE CMR. A 3D electroanatomical bipolar voltage map of the RVOT was performed in sinus rhythm (0.5 mV-1.5 mV colour display). Areas with electrograms &lt;1.5 mV represented the LVA. The area adjacent to the pulmonary valve usually displays voltage between 0.5 and 1.5 mV and is classified as transitional-voltage zone. Presence of LVAs outside this transitional-voltage zone were estimated.  We compared the accuracy of CMR for detecting LVA in the two groups: 3D LGE and 2D LGE.

Results

The median number of points used for the voltage map was 344 (242-450). 18 patients (82%) displayed LVAs. The site of origin of the PVCs was the RVOT in 17 patients and the left ventricular outflow tract (LVOT) in 5. Comparison between groups is displayed in the table.  2D LGE CMR failed to demonstrate abnormalities of the RVOT in any of the patients that presented with LVAs. 3D CMR showed presence of fibrosis (Figure) in 3 out of 9 patients with LVAs (33%).

Conclusion

CMR using 3-D LGE techniques showed an increased power to diagnose structural abnormalities. This technique may be a better choice in initial stages of RVOT disease. All sampleN = 223D-LGE CMRN = 112D-LGE CMRN = 11p-valueAge in years, median (Q1-Q3)47 (35-68)62 (34-55)42 (34-55)0.243Male gender, n (%)8 (36)3 (27)5 (46)0.330PVCs RVOT/LVOT17/59/28/30.500Nº points in the map, median (Q1-Q3)344 (242-450)350 (259-450)300 (158-345)0.076Low voltage areas, n (%)18 (82)9 (82)9 (82)0.707Abstract Figure.

A new approach to atrial flutter ablation using functional substrate mapping with wavefront discontinuity during sinus rhythm

Funding Acknowledgements

Type of funding sources: None.

Background

Ultra high-density (UHD) mapping allows accurate identification of local abnormal electrograms and low voltage within a small area range, allowing precise identification of reentry circuits. Areas with high isochronal density in a small area known as deceleration zones (DZ) are responsible for reentry.

Purpose

Identify the DZ and areas of low voltage in sinus rhythm (SR) and evaluate the feasibility of performing atrial flutter (AFL) ablation by targeting those zones.

Methods

We prospectively enrolled patients in SR referred for AFL ablation (either typical or atypical). An isochronal late activation mapping (ILAM) during SR with UHD catheter was performed, annotating latest deflection of local electrograms. DZ were defined as areas with &gt;3 isochrones within 1cm radius, prioritizing zones with maximal density. Atrial flutter was then induced and ILAM during flutter was performed for comparison. Voltage mapping was also assessed (0.1-0.5mV). Ablation targeted DZ in SR that displayed the higher voltage. DZ in SR were compared to DZ in AFL. Number of radiofrequency (RF) applications needed to terminate AFL were assessed. After AFL termination, complete line of the slow conduction zone was completed, and pulmonary vein isolation (PVI) was done in case of left AFL. Categorical variables are presented in absolute and relative values and median and interquartile range were used for numerical variables, as well t-student test for correlation of numerical variables.

Results

We studied 6 AFL (4 atypical, 66.7%) in 5 patients, 2 male (40%), median age 70 (64- 72). UHD ILAM in SR with 2195 points (1212-2865) and 2197 points (1356-3102) in AFL (p = 0.62).  The UHD ILAM identified a median of (QR) DZ in SR, that colocalized with AFL isthmus and DZ in AFL in 100%. DZ were not always located in low voltage areas. Aiming at the higher voltage in the DZ terminated the AFL in all cases, with a median RF time of 38 (25-58) seconds and AFL was no longer inducible. However, according to protocol, the complete line of slow conduction zone was done, with a median RF time of 1049.5 (274-1194) seconds (p = 0,009).

Conclusions

Isochronal mapping in sinus rhythm with UHD catheters can display the functional substrate for reentry in AFL, allowing a substrate guided ablation in case of non-inducible AFL. Targeting the areas of high isochronal density, is effective in terminating AFL, obviating the need for extensive ablation. Abstract Figure.

Assessment of wavefront propagation speed on the right ventricular outflow tract: deceleration zones associated with the presence of low voltage areas

Funding Acknowledgements

Type of funding sources: None.

Background and aims

Activation wavefront is rapid and uniform in normal myocardium. Fibrosis is associated with deceleration zones (DZ) and late activated zones. The presence of low voltage areas (LVAs) in the right ventricular outflow tract (RVOT) of patients with premature ventricular contractions (PVCs) from this origin has been described previously. The aim of this study was to evaluate in sinus rhythm, the RVOT endocardial activation duration (EAD) and the presence of DZs, in patients with PVCs and in controls.

Methods

Consecutive patients with frequent (&gt;10.000/24 h) idiopathic PVCs with inferior axis subjected to ablation that had an activation and voltage map of the RVOT performed in sinus rhythm. A control group of patients without PVCs that underwent ablation of supraventricular arrhythmias was also studied. Patients with structural heart disease, previous ablation or conduction disease were excluded. The RVOT EAD was measured as the time interval between the earliest and the latest activated region. Also evaluated the number of 10 ms isochrones throughout the RVOT and the maximal number of 10 ms isochrones within 1 cm, and a DZ was defined as a zone with &gt; 3 isochrones within 1 cm. Low voltage areas (LVA) were defined as areas with local electrogram amplitude &lt;1.5 mV.

Results

42 patients, 29 in the PVC group and 13 control subjects. The site of origin of the PVCs was the RVOT in 23 patients and the LVOT in 6. The characteristics of the two groups are displayed in the Table. Patients with PVCS had longer RVOT EAD, total number of isochrones and presence of DZ was also significantly higher (See table).  LVAs were more frequent in PVCs from the RVOT than from the LVOT (83% vs 33%, p = 0.033). Patients with LVA had longer EAD 60 (52-67) vs 36 (34-40) ms, p &lt; 0.0001 (Figure A) and more DZ than patients without LVA 95% vs 0%, p &lt; 0.0001 (Figure B and C).

Conclusions

The velocity of the wavefront propagation was slower and DZs were more frequently present in patients with PVCs and were associated with presence of LVAs. All sampleN= 42PVCsN = 29ControlsN = 13p-valueAge in years, median (Q1-Q3)56 (35-65)58 (38-66)53 (28-67)0.648Male gender, n (%)19 (45)14 (48)5 (39)0.401Nº points in the map, median (Q1-Q3)410 (338-589)467 (345-660)345 (333-465)0.056Activation duration in ms, median (Q1-Q3)41.8 (36-61)56 (41-66)39 (35-41)0.001Nº isochrones, median (Q1-Q3)4 (4-6)5 (4-6)4 (4-4)0.037Presence of DZs, n (%)20 (48)20 (69)0 (0)&lt;0.0001Presence of LVAs, n(%)21 (50)21 (72)0 (0)&lt;0.0001Abstract Figure.

Echocardiographic but not clinical response to CRT is an independent predictor of a better survival free from arrhythmic events

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac resynchronization therapy (CRT) is of proven benefit in heart failure patients, improving mortality and reducing hospital admissions. There is however uncertainty if the arrhythmic risk is reduced in responders.

Purpose

We aimed to assess if patients with a CRT implanted for primary prevention had less arrhythmic episodes if they responded to this therapy and if echocardiographic and clinical responses to CRT differ regarding the occurrence of ventricular arrhythmias.

Methods

We prospectively enrolled patients that underwent CRT implant for primary prevention according to ESC guidelines. Patients were classified as responders if they fulfilled one of four criteria (echocardiographic or clinical) at six months after implant: a 5% absolute improvement in LV ejection fraction (LVEF), a 15% improvement in LVEF, a 15% decrease in LV end-diastolic volume or a decrease in NYHA class. During follow-up with device interrogation, arrhythmic ventricular events (AVE) were classified as appropriate ICD therapies or sustained ventricular tachycardia either occurring in ICD monitoring zones or undetected by the device due to a slower rare, but clinically documented. All patients were further classified according to type of pacing, biventricular or LV only. Demographic characteristics of patients were also assessed.

Results

We enrolled 73 patients, 58 (79.5%) male, median age of 72 (65-77) years. Median LVEF was 28 (22-35) % (p = 0.95 between groups), ischemic etiology in 36 (46.6%, p = 1.00). The two groups with and without AVE did not differ significantly regarding clinical, echocardiographic, and electrocardiographic characteristics (table). CRT echocardiographic response criteria were met by 50 (68.5%) of patients and clinical criteria by 53 (72.6%) patients. AVE occurred in 15 (20.5%) patients. In univariate regression analysis, echocardiographic response was associated with reduced AVE (OR 0,14; p = 0,005). Clinical response to CRT was not associated with AVE (p = 0.07). LV only pacing was associated with a higher probability of AVE (OR 5.1; p = 0.038). In Cox regression multivariate analysis, response to CRT was the only independent predictor of better survival free from AVE (HR 0.28;CI 95%, p = 0.044) and LV only pacing was not associated with more episodes of ventricular arrhythmias (p = 0.17). Conclusions: Echocardiographic, but not clinical response to CRT therapy, is the only independent predictor of a higher survival free from arrhythmic events. In spite controversies regarding the arrhythmogenic role of LV pacing, this was not associated with higher ventricular arrhythmic events. Abstract Figure.

T-cell Prolymphocytic Leukemia, Cerebriform Variant

T-cell prolymphocytic leukemia (T-PLL) is a very rare and aggressive lymphoproliferative disorder. We present a 70-year-old man with complaints of fatigue, low urinary output, and peripheral edema for one month. Objectively, he presented diminished respiratory sounds bilaterally and peripheral edema. Analytical study revealed mild anemia and mild lymphomonocytosis, acute kidney injury, and urinalysis with proteins, leukocytes, erythrocytes, and cylinders. Chest radiography was consistent with pleural effusion. Subsequent study showed new onset of thrombocytopenia with a progressive increase of lymphocytosis, in association with inguinal adenopathies and splenomegaly. Immunophenotypic study of peripheral blood and lymph node biopsy were compatible with the diagnosis of T-PLL. Negative serology for human T-cell lymphotropic virus type 1 (HTLV-1) excluded adult T-cell leukemia. Progressive changes in the peripheral blood smear were seen, finally showing the presence of lymphocytes with a cerebriform nucleus, revealing this variant. There was a rapid catastrophic progression, spontaneous tumor lysis syndrome, and death.

Impact of Age, Education Level and Occupation on the Ability to Use the ICIQ-bladder Diary: Results From A Community Cohort Study Using a Predefined Clinical History

OBJECTIVE

To assess difficulties in filling the International Consultation on Incontinence Questionnaire Bladder Diary (ICIQ-BD), determining the most troublesome items and patients' characteristics (age, education level, and professional activity) related to these difficulties.

METHODS

A text composed of a clinical history of a fictitious patient with Lower Urinary Tract Symptoms (LUTS) was designed. 95 healthy volunteers (49 females, 46 males, mean age 45.6 ± 17.3 years) were asked to fill in the ICIQ-BD according to the data from the fictitious clinical history. Filling errors were analyzed, and patients' demographic characteristics tested as predictors.

RESULTS

Bladder Sensation Score is the most problematic item of the ICIQ-BD, with only 38% of patients accurately filling this item. No association was found between total number of errors and age or education level, but participants working in less specialized professions had more difficulty in filling the BD (mean: 7.00 vs 3.94 errors, P= .002).

CONCLUSION

ICIQ-BD is a reliable tool to assess for LUTS, but filling the Bladder Sensation Score item was more likely to be incorrectly filled by manual workers and volunteers with less intellectually demanding current professions.

Scurvy, Starvation, and Flea Infestation - A Case Report From 21st Century Europe

Scurvy is a disease caused by vitamin C deficiency, historically associated with long sea voyages, periods of famine and war. Currently, it is often misdiagnosed and underreported, as physicians tend to consider it a disease of the past.

We present the case of a 79-year-old female who was admitted to the Emergency Department complaining of pruritus. The patient lived alone and in poor hygiene conditions. Diet was scarce. One week before admission she was in contact with flea-ridden stray dogs. Sometime later she noted several fleas and multiple pruritic small papules, crusts, and excoriations on her torso, limbs, palms, soles, and scalp. Physical examination showed the patient to be pale, emaciated, and poorly groomed. Laboratory analysis showed microcytic anemia. Flea bites were treated with oral antihistamines and prednisolone. Follow-up one month later showed weight gain and partial resolution of skin lesions. However, multiple small ecchymosis on both lower and upper limbs, and occasional perifollicular petechias on her lower extremities, were noted. Additional workup showed undetectable serum vitamin C levels. A diagnosis of scurvy was made. The patient was treated with 1000 mg per day of oral vitamin C for one month leading to complete recovery.

We present this case to remind that early recognition of vitamin C deficiency and appropriate supplementation are essential in patients with scurvy. Physicians should be aware of classic signs, symptoms, and social factors associated with this forgotten disease.

Relapsing Candida parapsilosis Endocarditis With Septic Embolization: A Case Report

Candida endocarditis is a rare infection that is becoming an emerging and growing health concern, especially among risk groups such as the elderly and the immunosuppressed. It is associated with high morbidity and mortality. Dilemmas about Candida endocarditis treatment are still around, particularly about the treatment options and their duration. We report a case of Candida parapsilosis prosthetic valve endocarditis with septic embolisms. An elderly male patient with a biological prosthetic valve presented with fever and constitutional symptoms. Abdominal computed tomography (CT) showed an area suggestive of splenic emboli. Transesophageal echocardiography showed a vegetation attaching to the prosthetic valve. Due to several comorbidities, he was not considered a candidate for surgical treatment. He was treated with antifungal drugs (liposomal amphotericin B and caspofungin) and was discharged with per os fluconazole. Later he presented with evidence of lumbar spondylodiscitis due to septic embolization and relapsing fungemia with multidrug-resistant isolates was documented. Unfortunately, the patient outcome was ill-fated and he died in hospital due to sepsis-related to the candidemia and also nosocomial urinary sepsis. Here, we illustrate the complexity of diagnosing and managing fungal endocarditis due to its complications and poor prognosis.

Diclofenac-Induced Immune Hemolytic Anemia: A Case Report and Review of Literature

Non-steroidal anti-inflammatory drugs are widely used for pain management. Most frequently, adverse reactions affect the gastrointestinal tract and hematological side effects usually relate to the gastrointestinal manifestations. Drug-induced immune hemolytic anemia is a rare and frequently underdiagnosed complication that is associated with poor outcomes including organ failure and even death.

A 76-year-old female patient was treated with intramuscular diclofenac, thiocolchicoside, and diazepam for low back pain. Five days following diclofenac exposure, the patient was admitted to the Emergency Department with complaints of asthenia, nausea, vomiting, and diarrhea. Hemolysis and a positive direct antiglobulin test were detected on laboratory testing. Further causes of hemolytic anemia were excluded and a diagnosis of diclofenac-induced immune hemolytic anemia was established. Glucocorticoid therapy initiated on admission and drug eviction led to complete recovery. Long-term follow-up showed no recurrence of anemia.

Here, we present the unusual case of a successful recovery of a 76-year-old patient with diclofenac-induced immune hemolytic anemia, a rare but immediate life-threatening condition of a frequently used drug in clinical practice.

Effects of age, weight, and housing system on prevalence of dead on arrival and carcass condemnation causes in laying hens

Causes of condemnation and dead on arrival (DoA) birds were studied at the slaughterhouse and effects of age, BW, and housing system were investigated. A total of 1,156 (0.18%) birds were found DoA and 20,754 carcasses out of 629,331 (3.30%) were condemned during postmortem inspection. The main reasons for condemnation were peritonitis, septicemia, salpingitis, emaciation, and tumors. The mean percentages of condemnation by septicemia and emaciation differed according to age and BW groups and were more common in batches of younger (≤87 wk) and lighter (≤1.88 kg) birds. Moreover, peritonitis and ascites differed significantly between age groups, occurring more frequently in batches of older hens. The presence of tumors of the reproductive system was more frequently observed in older and heavier hens. This result raises the possibility of tumors being correlated with the higher number of prior ovulatory events. The total condemnation rate was lower in hens from organic systems, followed by free-range, and differed significantly from barns and cage systems. Carcasses with ascites and peritonitis were found more commonly in hens from cages and barns and both differed significantly from organic systems. Salpingitis was statistically more prevalent in barns, presenting differences from organic and free-range systems. Monitoring condemnation causes of end-of-lay hens at slaughter provided a better understanding of health and welfare issues in different housing systems and allowed to identify potential welfare problems, which can be used to improve management and welfare on farms.

Left atrial mechanics improvement after initiation of sacubitril-valsartan

Introduction

Heart failure with reduced ejection fraction (HFrEF) is associated with significant morbidity and mortality. Recently, in the PARADIGM-HF, sacubitrilvalsartan was superior to enalapril in reducing death and hospitalization for heart failure, and there is a growing interest in determining the structural changes besides reverse left ventricular remodelling.

Purpose

To determine if, in patients treated with sacubitril-valsartan, there was a change in left atrial (LA) mechanics quantified by two-dimensional strain echocardiography (2D-STE).

Methods

A total of 38 consecutive patients with HFrEF, followed in an outpatient heart failure clinic, were recruited. Population characteristics are summarized in Table 1. 2D-STE was used to measure left atrial strain in the reservoir phase (LASr) (Figure 1) and strain rate (LA-SR) before and 3 months after initiation of sacubitril-valsartan.

Results

There was a significant improvement in LASr (11.3±6.5% vs 14.2±7.4%, p=0.006) and LA-SR (0.55±0.25 s-1 vs 0.69±0.31 s-1, p=0.008) after initiation of sacubitril-valsartan. There was also a significant reduction in N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels (1443.5 pg/ml (Interquartile range [IQR], 772–2912) vs 1112.0 pg/ml (IQR, 510–1455), p=0.016) and a tendency towards reduction in left atrial volume index (LAVI) (54.6±17.0 ml/m2 vs 51.4±18.8 ml/m2, p=0.053). The change in LASr and LA-SR was not related with the dose of sacubitril-valsartan (p=0.089).

Conclusion

In this population of HFrEF patients LA mechanics, as determined by 2D-STE, as well as NT-proBNP levels, significantly improved after treatment with sacubitril-valsartan.

Figure 1. Left atrial strain

Funding Acknowledgement

Type of funding source: None

Anthracycline Cardiotoxicity in a Patient with Diffuse Large B-Cell Lymphoma: A Case Report

Cardiotoxicity is a relevant side effect of cancer therapy that leads to increased patient morbidity and mortality. It is fundamental to understand and remember it as a cause of disease since accurate and timely diagnosis is crucial. We present the case of a patient who developed chemotherapy-associated cardiac dysfunction after receiving treatment for a diffuse large B-cell lymphoma. Clinical history, echocardiography, and differential diagnosis led us to attribute her condition to heart failure (HF) due to early doxorubicin-induced cardiomyopathy. The patient outcome was favorable. We discuss the pathogenesis and incidence of anthracycline-induced cardiotoxicity as well as strategies for its detection, prevention, and treatment.

Evaluation of gonadal macroscopic and microscopic morphometry reveals precocious puberty in Bísaro pig

Bísaro pig (BP), like many other local breeds reared in extensive non-industrial systems, faces many constraints to comply with the EU welfare regulation, particularly regarding the restrictions to surgical castration. In order to adapt an immunocastration protocol to overtake this issue, a puberty timeline is needed. Using gonadal morphometry data from 91 young male BP, this study intended to characterize testicular development, describing the prominent cell types and structures, to ultimately assess the age at puberty in male BP through a mixed prediction model. As expected, the relations between several macro and microscopic parameters and their relation with age were as described within the literature. Post-pubertal animals have larger and heavier gonads, lower Sertoli cell density/tubule, higher Leydig cell density and larger seminiferous tubules. Meiosis was firstly seen in 44-day-old animals, elongated spermatids in 70-day-old animals. Complete spermatogenesis was firstly identified in a 90-day-old animal. Spermatozoa were present in the epididymis of 23 animals, aged from 70 to 240 days old, and in the vas deferens of 14 animals (105 to 240 days old). The prediction model inferred that male Bísaro pigs reach puberty between 14 and 17 weeks (3 and 4 months old) and become sexually capable from 15 to 19 weeks (3.5 and 4.4 months old). These parameters confirm the sexual precocity of this breed.

Clinical decision-making and importance of the AAE/AAOMR position statement for CBCT examination in endodontic cases

AIM

To compare conventional radiographic and cone beam computed tomography (CBCT) findings with reference to the American Association of Endodontics and American Academy of Oral and Maxillofacial Radiology (AAE/AAOMR) joint position statement and to determine the effect of the CBCT on the initial diagnoses and treatment plans in a single-centre Postgraduate Endodontic Programme.

METHODOLOGY

The clinical CBCT scans of patients, treated at the Endodontic Department of the University of British Columbia, were reviewed for CBCT referrals by comparing them with corresponding radiographs. The features considered were periapical lesions, missed/extra canals, root fractures, complex anatomy, calcified canals and root resorption of tooth/teeth in question. Reasons for the CBCT prescriptions were assigned to 3 groups: to formulate the primary diagnosis, to confirm the diagnosis achieved by clinical examination and conventional radiographs, and to assist in treatment planning. Variables were compared statistically using chi-square and McNemar tests.

RESULTS

A total of 128 CBCT examinations were performed on 110 patients. No CBCT examination was performed more than once on the same tooth. Overall, 76% of CBCT examinations were performed on previously root filled teeth. CBCT images revealed a significantly higher incidence of periapical lesions (P = 0.002), missed canals (P < 0.001), vertical root fractures (P = 0.004) and complex anatomy (P = 0.008) than periapical radiographs. CBCT was prescribed most frequently to assist surgical treatment planning (62%) rather than for generating a diagnosis (9%) or confirming diagnoses (29%). Both the diagnosis (P = 0.001) and the treatment plan (P = 0.005) initially made by examining periapical radiographs were altered significantly by the subsequent CBCT examination by revealing information such as new periapical lesions, missed canals or involvement of buccal or lingual cortical bone.

CONCLUSION

CBCT examinations were prescribed mainly to assist treatment planning rather than for diagnosis. The majority of CBCT examinations were performed on previously root filled teeth. The additional information obtained from CBCT scans resulted in the alteration of the initial diagnoses as well as subsequent treatment plans in 59 out of 128 cases.

Invasive Pulmonary Aspergillosis in an (Apparently) Immunocompetent Patient

Invasive pulmonary aspergillosis (IPA) is an opportunistic infection that usually threatens immunocompromised patients. However, there are some reports of IPA in immunocompetent patients without the obvious classic risk factors. We present the case of an 82-year-old woman with a prior medical history of chronic obstructive pulmonary disease (COPD) and a recent short-term corticosteroid regimen for an acute exacerbation. She was admitted with dyspnoea, cough, and pleuritic pain and was diagnosed with pneumonia. Clinical deterioration occurred, and a diagnosis of IPA was made. She received treatment with voriconazole but died 14 days after admission. This case highlights the importance of considering IPA among the possible causes of infection in this population. Prompt institution of appropriate antifungal therapy is paramount for the management of this condition.

Anabolic steroids and their effects of on neuronal density in cortical areas and hippocampus of mice

Anabolic substances have been increasingly used by bodybuilders and athletes with the goal of improving performance and aesthetics. However, this practice has caused some concern to physicians and researchers because of unknowledge of consequences that the indiscriminate and illicit use of these substances can cause. Thus, this study analyzed the effects of two commercially available anabolic steroids (AS), Winstrol Depot® (Stanozolol) and Deposteron® (Testosterone Cypionate), in the neuronal density of limbic, motor and sensory regions on the cerebral cortex and in CA1, CA2, CA3 regions of the hippocampus. A total of 60 Swiss mice were used (30 males and 30 females), separated into three groups: control and two experimental groups, which received the AAS. From each brain, homotypic and semi-serial samples were taken in frontal sections from areas established for the study. The results showed that females treated with testosterone cypionate presented a reduction in all regions tested and the ones treated with Stanozolol showed a decrease in some hippocampal areas. Regarding male animals, stanozolol led to a decrease in neuron number in one hippocampal region. These data allow us to conclude that supra-physiological doses of steroids used in this study, can cause considerable damage to nervous tissue with ultrastructural and consequently behavioral impairment. These changes could interfere with the loss of physical yield and performance of athletes and non-athletes and may cause irreparable damage to individuals making irresponsible use of anabolic steroids.

P1393Prolonged atrial electrical conduction as a predictor of atrial fibrillation after atrioventricular nodal reentrant tachycardia ablation

BACKGROUND

Patients (pts) with atrioventricular nodal reentrant tachycardia (AVNRT) have a higher incidence of atrial fibrillation (AF) during follow-up. Conventional risk factors can play a role in AF development, however atrial electrical conduction properties may be implicated in AF pathogenesis.

AIMS

to evaluate atrial conduction times and assess its effect on AF development during follow-up.

METHODS

We studied AVNRT pts who performed EPS and catheter ablation of the slow pathway between 2013 and 2016 in a single center. Pts with AF or valvular disease were excluded. We evaluated duration of symptoms due to AVNRT, conventional risk factors for AF (age, gender, obesity, hypertension, diabetes and structural heart disease (SHD)), left atrium (LA) enlargement and electrophysiologic study (EPS) time intervals related with atrial electrical conduction properties. We measured the time interval between: (1) the beginning of the P wave on the ECG to the A deflection in His-bundle electrogram (P-AHis); (2) the beginning of the P wave to the mid-distal coronary sinus (CS) atrial electrogram (P-CS) and (3) the beginning of the P wave to the H deflection in His-bundle electrogram (P-HHis).

RESULTS

Fifty-two pts were evaluated during a median follow-up of 63 months (IQR 51-69): 22% male, median age 55 years (IQR 42-67). AF occurred in 9 patients (17%) (39 cases per 1000 person-years). Patients with AF were older (67 vs 53 years, p= 0.005) and had more frequently LA enlargement (33% vs 7%, p= 0.024) but they did not differ in hypertension, obesity, diabetes, SHD and duration of symptoms. EPS measured intervals P-AHis and P-HHis interval were not different between the groups (26.0 vs 22.8 ms, p = 0.89 and 151 vs 106 ms, p= 0.56, respectively) but P-CS were prolonged in patients with AF (70 vs 55 ms, p = 0.02) (figure 1). Univariate logistic analysis for AF is presented in table 1. There was no interaction between P-CS and LA enlargement (p = 0.87). In multiavariate analysis, only P-CS was independently associated with AF (table).

CONCLUSIONS

In this group of patients with AVNRT, P-CS, but not other atrial conduction intervals, was independently associated with AF development. The possible role of LA electrical conduction impairment in AVNRT pts for AF development needs further studies.

Univariate and multivariate analysis Univariate analysis Multivariate analysis OR 95% CI p-value OR 95% CI p-value Age (years) 1.10 1.02-1.19 0.016 1.10 1.00-1.21 0.051 LA enlargement 7.00 1.10-44.71 0.040 3.42 0.41-28.03 0.255 P-CS 1.07 1.021.14 0.013 1.06 1.01-1.12 0.044 OR Odds ratio. CI: confidence interval

Abstract Figure. Box-plot for the studied intervals

235Anatomic guided ablation of the right ganglionated plexus is enough for cardiac autonomic denervation in patients with significant bradyarrhythmias

Background

In patients with significant bradyarrhytmias, cardiac denervation is an alternative therapeutic approach. Previous reports proposed different methods (as high frequency ednocardial stimulation of ganglionated plexus and specific atrial electrogram identification) and targets (right and left atrial ganglionated plexus) for adequate denervation. There is no consensus on the best way to perform these procedures, in spite the right atrial ganglia plexus (GP) ablation seeming to be the most contributive to its success.

Purpose

To assess the results of a purely anatomic approach for ablation of just the right atrial plexus in patients with severe vagal bradyarrhytmias.

Methods

We enrolled patients referred for ablation of cardiac parasympathetic ganglia, with or without atrial fibrillation ablation.  We performed eletroanatomic mapping of the right and left atria and used an irrigated tip catheter for ablation, aiming at the anterior right GP at the right pulmonary veins antrum along with ablation at the superior vena cava junction and the inferior right GP at the posterior aspect of the right inferior pulmonary vein along with ablation of the right aspect of the interatrial septum, between the posterior wall and coronary sinus ostium (Figure 1). We assessed the PW and Wenckenback cycle lengths (CL) pre and post procedure in patients with sinus arrest or AV block, respectively, and the patients had new 24h holter readings at least 30 days from the index procedure.

Results

We enrolled 12 patients: 9 males (75%), median age of 49,5 years (IQR 36-61,75). All patients had structurally normal hearts. 7 patients had only ablation of the parasympathetic ganglia and 5 patients had simultaneous pulmonary vein isolation for previously documented atrial fibrillation. 7 patients (58,3%) had sinus bradycardia (2 patients had sinus arrest with pauses of 8 and 13 seconds), 2 patients with cardioinhibitory syncope (with pauses of 23 and 28 seconds) and 3 patients had transient high degree AV block. The ablation procedure led to a median sinus rate acceleration of 15 bpm (IQR 3-29), a median decrease of 320 ms in PW (IQR 23,75-609,5) in patients with sinus arrest and a decrease of 80 ms in wenckenback CL (IQR 60-200) in patients with AV block. With a median follow up of 133,50 days (IQR 36-61,75), no patient had recurrence of symptoms or conduction disturbances.

Conclusions

In selected patients with severe functional paroxysmal bradyarrhytmias, cardiac denervation using an ablation strategy purely based on anatomic aspects and targeting only the right GP, seems to be an effective therapeutic approach.

Abstract Figure 1: Abl of right ganglionated plex

P518Inappropriate shocks in atrial fibrillation patients: are they really deleterious?

Introduction

Data suggest inappropriate defibrillator shocks are associated with a higher risk of all-cause mortality, particularly those delivered for atrial fibrillation (AF). However, the impact of inappropriate shocks has not been studied specifically in a population with AF.

Aims

to determine if AF-triggered inappropriate shocks are associated with long- term mortality in patients with AF and defibrillators implanted for primary prevention.

Methods

Retrospective single-center study. We analyzed all patients with defibrillators implanted for primary prevention in whom AF was diagnosed until the end of 2017. The cause of inappropriate shocks was evaluated by analysis of the stored intracardiac electrogram. Basal characteristics, cardiovascular risk factors, left ventricle ejection fraction, heart failure etiology (ischemic and non-ischemic), kidney function (creatinine) and medication were evaluated. Death was assessed during the follow-up.

Results

We studied 177 patients [median age 66 years (IQR 59-71); 82% male], with defibrillators and AF. AF was diagnosed before defibrillator implantation in 131 patients (74%) and after the implantation in the remaining 46 (26%). Inappropriate shocks occurred in 31 patients and 24 (14%) were caused by AF with rapid ventricular response: 13 patients with previously diagnosed AF and 11 with new-onset AF. During a median follow-up of 65 (IQR: 36-104) months, 74 patients died. Multivariate Cox-regression analysis demonstrated inappropriate shocks caused by AF were not independently related with death (adjusted HR 0.53; CI 0.23-1.23, p = 0.14). Kaplan-Meier survival curve demonstrated patients with AF-triggered inappropriate shocks had a better survival comparing to those with AF but without inappropriate shocks (logrank, p = 0.03) (figure).

Conclusions

In this group of AF patients, inappropriate shocks caused by AF did not increase the risk of death. Instead, these patients had a better survival comparing to those with AF but no shocks, probably due to a re-evaluation of the patient´s status and subsequent closer medical monitoring, strictly control of symptoms and optimization of drug treatment. These results demonstrate that inappropriate shocks are probably not deleterious per si through a direct mechanism.

Abstract Figure. Kaplan-Meier survival curve

P3563The influence of circadian patterand obstructive sleep apnean of blood pressure in nocturnal arrhythmias in hypertensive patients

Introduction

There is growing evidence suggesting hypertension is related to the occurrence of arrhythmias. When occurring predominantly during the night, two potential entities commonly present in hypertensive patients could be related with increased arrhythmogenesis: (1) the lack of normal nocturnal dipping of blood pressure (BP) (non-dipping pattern of hypertension) or (2) obstructive sleep apnea (OSA). Thus, nocturnal arrhythmias (NAs) can identify hypertensive patients with OSA and/or non-dipping pattern, both related with adverse outcomes.

Aims

To determine if NAs are related with non-dipping hypertension, OSA or both.

Methods

We studied hypertensive patients who performed ambulatory blood pressure monitoring (ABPM) and also polysomnography and 24-hour Holter monitoring. Non-dipping pattern was considered when nocturnal BP reduction was inferior to 10%. Based on Holter monitoring, NAs were present when atrial fibrillation, frequent premature atrial contractions (PACs) (>30 PACs/hour), runs of >4 consecutive PACs, frequent premature ventricular contractions (PVCs) (>30PVCs/hour) or runs of >4 consecutive PVCs were present predominantly during sleeping hours. During polyssonography, apnoea/hypopnoea index (AHI) and oxygen saturation (SaO2) were analysed. Moderate to severe OSA was considered when AHI >15.

Results

We studied 104 patients [median age 62 (54–70) years, 65% male): 42 (40%) had moderate to severe OSA (median AHI=11 (6–26), mean SaO2=94% (92–95)] and 64 (61%) were non-dippers. NAs occurred in 18 patients (17%) and they were independently associated with AHI (Odds Ratio (OR) for a one unit increase 1.04, 95% confidence interval (CI) 1.01–1.07, p=0.03) but not with SaO2 (OR 0.96, CI 0.78–1.19, p=0.73) nor non-dipping pattern (OR 1.23, CI 0.38–3.98, p=0.72). No interaction was found between OSA and non-dipping hypertension (p=0.35). In patients with dipping pattern (n=40), AHI was higher in NAs patients comparing with no NAs patients (median AHI 29 versus 10, p=0.04), while in those with non-dipping pattern (n=64), AHI was not statistically different between patients with and without NAs (21 versus 11, p=0.12) (figure).

Figure 1

Conclusion

In this population of hypertensive patients, the presence of NAs was associated with OSA severity (i.e AHI), but not with the non-dipping pattern of hypertension. The importance of obstructive events in arrhythmogenesis seemed to be more pronounced in dipping patients, suggesting the abnormal high blood pressure during the night may also have some impact on NAs in non-dipping patients. Overall, our results suggest that OSA screening should be considered when nocturnal arrhythmias are detected in hypertensive patients, but ABPM should not be forgotten since multiple mechanisms can be involved in nocturnal arrhythmogenesis.

P6560Delayed ablation of atrioventricular nodal reentry tachycardia as a risk factor for future atrial fibrillation

Introduction

Atrioventricular nodal reentry tachycardia (AVNRT) is the most common type of supraventricular tachycardia. Most of the patients experience recurrent symptoms for years before electrocardiographic documentation and AVNRT ablation. The effects of these ongoing episodes of AVNRT on atrial structure and function, and their influence on new-onset atrial fibrillation (AF) in patients with delayed AVNRT ablation are unknown.

Purpose

To assess if delayed ablation of AVNRT was associated with the development of AF.

Methods

We retrospectively evaluated patients subjected to AVNRT ablation between 2009 and 2016. Patients with history of AF previous to ablation were excluded. We evaluated age at the time of AVNRT ablation, the presence of cardiovascular risk factors, left atrial (LA) dilatation and the presence of frequent premature atrial contractions (PACs) (by 24-hour holter monitoring, defined as >30/h). During follow-up we assessed the occurrence of sustained AF episodes and age at the time of the first AF episode.

Results

We studied 130 patients that underwent AVNRT ablation. Mean follow-up time was 75±27 months and seventeen patients (13%) had new-onset AF during follow-up. Patients who developed AF were more often males (35% vs. 22%, p=0,015), older at the time of AVNRT ablation (60±16 vs. 50±15, p=0,01), had a higher prevalence of hypertension (64% vs. 35%, p=0,03), diabetes mellitus (35% vs. 6%, p=0,02), LA dilation (41% vs. 7%, p=0,01) and frequent PACs (24% vs. 2%, p=0,03). In Univariable Cox regression analysis all these available variables were associated with AF occurrence during follow-up. However, in Multivariable Cox regression analysis, only age at the time of the ablation procedure was independently associated with AF occurrence (Table 1).

Multivariable Analysis HR 95% CI P value Age at ablation 8.762 3.308–23.20 <0.001 Age at the time of the first AF episode 0.113 0.043–0.302 <0.001 LA dilation 0.408 0.113–1.472 0.171 Frequent PACs 1.016 0.156–6.611 0.987

Conclusion

In this group of patients the occurrence of new-onset AF during follow-up was independently associated with delayed AVNRT ablation. These findings suggest that longer atrial exposure to AVNRT episodes before ablation may be associated with LA structural and functional changes leading to higher occurrence of AF.

P3795Should we also screen for obstructive sleep apnea in patients presenting with excessive supraventricular ectopic activity?

Background

It is recommended to consider obstructive sleep apnoea (OSA) screening in atrial fibrillation (AF) patients with risk factors, due to the strong evidence of an association between these two entities. Excessive supraventricular ectopic activity (ESVEA) has been proposed to be a risk factor for AF. However, strong evidence between ESVEA and OSA has not been established.

Objective

We aimed to determine if ESVEA is associated with moderate to severe OSA since its treatment may prevent AF.

Methods

We studied patients who performed polysomnography and 24-hour Holter monitoring. Patients with atrial fibrillation were excluded. ESVEA was defined as more than 30 PACs per hour (frequent PACs) or runs of >4 consecutive PACs. The circadian pattern of PACs was also evaluated. Sleeping hours were used to define “nocturnal”. Moderate to severe OSA was defined when polyssonography demonstrated a apnoea/hypopnoea index (AHI) >15. We examined the association between ESVEA and moderate to severe OSA during wakefulness and sleep.

Results

We studied 290 patients [median age 65 (55–72) years, 62% males, body mass index (BMI) 30 (27–34)]. 112 (38%) had moderate to severe OSA. Median AHI was 11 (5–24) and mean oxygen saturation was 94% (92–95). Median PACs was 35 (9–117) and 29 patients (10%) had frequent PACs. Runs of >4PACs occurred in 114 patients (39%). Forty-three patients (15%) had predominant nocturnal PACs and 42 (14%) had nocturnal runs of PACs. Multivariate logistic regression analysis demonstrated only nocturnal PACs were associated with moderate to severe OSA (p=0.027) (table 1).

Multivariate logistic regression Odds Ratio 95% Confidence Interval p-value Male gender 4.49 2.48–8.17 <0.001 Body mass index (kg/m2) 1.09 1.03–1.15 0.002 Nocturnal PACs 4.12 1.17–14.46 0.027 Variables not included in the model: age, number of PACs/h, frequent PACs (>30 PAcs/hour), runs of PACs (>4 consecutive PACs), nocturnal frequent PACs and nocturnal runs of PACs.

Conclusion

OSA screening in patients presenting with nocturnal PACs should be routinely considered, especially in male and obese. Treating moderate to severe OSA patients with CPAP has a potential benefit in preventing ESVEA and consequently AF.

Influence of different housing systems on prevalence of keel bone lesions in laying hens

The present study aimed to investigate the effect of three housing systems (furnished cages - FC, barns - B, and free-range - FR) on the prevalence and severity of keel bone protrusion and deformations. These health and welfare indicators were measured at the slaughterhouse, using a 4-point scale (0 = absence, 1 = slight, 2 = moderate and 3 = severe). Keel bone deformation was also categorized in relation to the presence of compression over the ventral surface, deviation from a 2D straight plane and deviation from the transverse (C-shaped) or median sagittal (S-shaped) plane. The housing system had a significant effect on prevalence of keel bone deformation (χ² = 45.465, df = 6, P < 0.001). In FR systems 60.4% of hens presented keel bone deformation, followed by 54.2% in FC and 53.5% in B; however, higher scores for keel bone deformations were more frequent in B systems. Although keel bone protrusion was observed in all laying hen systems, the majority of hens only presented a slight degree (score 1) of protrusion. A positive correlation was obtained for keel bone protrusion and emaciation. The results could be used to initiate detailed investigations into problematic issues that occur during the laying period to improve the health and welfare conditions on farms.

Huffmanela lusitana sp. n. (Nematoda: Trichosomoididae) infecting pouting, Trisopterus luscus (Teleostei: Gadidae) off the Atlantic coast of Portugal

Some pouting caught off the Atlantic coast of Portugal are discarded as unmarketable due to a dark discolouration of the skin and muscle. This study investigates the cause of this condition, describes the new parasite species responsible, and highlights the importance of educating those in charge of premarket inspection of food fish in order to reduce likelihood that consumers will eat infected fish. Macroscopically, infected fish showed considerable heterogeneity in darkening of the skin and hypaxial and epaxial muscles. Microscopical observation revealed bipolar nematode eggs in varying stages of development arranged in a linear pattern along muscle fibers. Histopathology confirmed the presence of eggs of a nematode of the genus Huffmanela Moravec, 1987 as the cause of muscle darkening and established a relationship between infection intensity and consequent darkened appearance of the tissues. The eggs are oval or barrel-shaped, with a smooth surface and polar plugs at opposite ends. The thin outer vitelline membrane is smooth and lacks ornamentation. Under light microscopy, the main eggshell of older eggs exhibits the outermost delicate and smooth vitelline membrane, and a thicker layer, correspondent to chitinous and chondroitin proteoglycan layers. Scanning electron microscopy of eggs confirmed light microscopic studies, namely the presence of a smooth vitelline membrane surrounding the egg. Microscopic and ultrastructural characteristics of eggs, and a new host family in a new geographic area, all suggest that a new species, herein named Huffmanela lusitana sp. n. is involved.

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Huffmanela lusitana sp. n in Trisopterus luscus.

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Dark muscle due to Huffmanela eggs.

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H. lusitana sp. n as the cause of disgusting aspect of infected fish meat.

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H. lusitana sp. n as a zoonotical potential infection to consumers.

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H. lusitana sp. n. as a constraint factor of healthy wildlife stocks.

Efficacy of LISTEX P100 at Different Concentrations for Reduction of Listeria monocytogenes Inoculated in Sashimi

Sushi restaurants have become quite popular in Europe, with an increase in the consumption of the sashimi speciality. Pathogenic bacteria such as Listeria monocytogenes, Staphylococcus aureus, and Bacillus cereus have been reported in this kind of food. Controlling the presence and multiplication of L. monocytogenes is a challenge for food safety management systems owing to its ubiquitous presence and psychrotrophic growth. Bacteriophages have been used as pathogenic biocide agents for decades. The bacteriophage P100, present in LISTEX P100, was used in this study to understand the possibility of implementing a new critical control point for L. monocytogenes in sashimi preparation and sale. Different concentrations of LISTEX P100 were used for reduction of L. monocytogenes in inoculated samples at 3 and 22°C. The reduction in initial counts of 2 log CFU/g was effective in the first 24 h with the 8-log PFU/g inoculation. Promising results were obtained in assays with the 6-log CFU/g initial counts and the 8-log PFU/g inoculation, at 22°C, achieving a maximum reduction of 4.44 log CFU/g, compared with the control group. These results seem to confirm that bacteriophages can be an option in reducing the population of the L. monocytogenes pathogenic bacteria in sashimi, mainly in takeaway sales.

An Itchy Problem: A Clinical Case of Crusted Scabies

Scabies is an infestation of the skin by the mite Sarcoptes scabiei. A more severe form called crusted or Norwegian scabies may occur in immunosuppressed patients and the elderly. Crusted scabies mostly differs from normal scabies by the exuberance of its lesions, body distribution and high contagiousness, and requires different and more prolonged treatment. Early recognition of the lesions and isolation precautions are crucial for disease control and prevention of transmission. The authors describe a clinical case of crusted scabies with pruritus and exuberant cutaneous lesions.