Peritoneal Protein Loss With Time in Peritoneal Dialysis

Longitudinal evolution of peritoneal protein loss (PPL), a reflection of hydrostatic pressure-driven leak of plasma proteins through the large-pore pathway, is not clear. Time on PD causes loss of mesothelial cells, vasculopathy, and increased thickness of the submesothelial fibrous layer. Are these structural changes associated with progressive increase of PPL, in a parallel with the rise in the D/P creatinine? The aim of the present study was to identify longitudinal changes of PPL over time. This single-center, longitudinal study included 52 peritoneal dialysis (PD) patients with a median follow-up of 26.5 months, evaluated at two different time points with a minimum interval of 6 months. Repeated measures analysis was performed using paired sample t-test or the nonparametric Wilcoxon signed-rank test, depending on the distribution. After a median interval of 15.5 months, lower levels of residual renal function and urine volume, lower Kt/V, and creatinine clearance were found. D/P creatinine and PPL were stable, but a decrease in ultrafiltration was present. Systemic inflammation, nutrition, and volume overload showed no significant change with time on PD. Analysis of a subpopulation with over 48 months between initial and subsequential assessment (n = 11) showed again no difference in inflammation, nutritional and hydration parameters from baseline, but importantly PPL decreased after more than 4 years on PD (mean difference 1.2 g/24, p = 0.033). D/P creatinine and dip of sodium remained unchanged. The absence of deleterious effects of time on PD is reassuring, pointing to the benefit of updated PD prescription, including the standard use of more biocompatible solutions towards membrane preservation and adjusted prescription avoiding overhydration and inflammation while maintaining nutritional status. After controlling for confounders, PPL may act as a biomarker of acquired venous vasculopathy, even if small pore fluid transport rates and free water transport are preserved.

Beyond Work: The Role of "Family-Friendly" Practices in the Subjective Well-Being of Teleworkers and On-Site Workers in the COVID-19 Pandemic

During the COVID-19 pandemic, telework emerged as a pivotal strategy to mitigate the spread of the virus. However, telework's feasibility was contingent on job roles. This gave rise to two distinct groups: teleworkers and on-site workers. However, the impacts of social support and well-being extended to both groups. This study investigated the link between organisational and supervisory family support and subjective well-being, examining work engagement as a mediator. Conducted in Portugal, this cross-sectional study surveyed 515 individuals via web-based questionnaires. Data were analysed using descriptive statistics, correlation analysis, confirmatory factor analysis, and multiple-group analysis. The findings revealed a positive correlation between perceived organisational family support (POFS) and work engagement for both groups. Additionally, perceived supervisory family support (PSFS) positively correlated with work engagement for telecommuters but not on-site workers. Furthermore, work engagement was positively associated with subjective well-being for both groups. Moreover, work engagement mediated the relationship between POFS and subjective well-being. This study enriches the literature by analysing POFS, PSFS, work engagement, and subjective well-being dynamics among teleworkers and on-site employees.

Cervical muscle parameters and allodynia in migraine and cervical pain-A controlled study

BACKGROUND

Neck pain is common among individuals with migraine, but there is a lack of information of how this comorbidity can be associated with cervical muscle function. This controlled cross-sectional study aimed to compare cervical muscle function, activity, and sensitization in women with migraine, neck pain, both, and neither.

METHODS

This study included women, between 18 and 55 years old, with either episodic migraine with or without aura, without any concomitant headache diagnosis; chronic neck pain, with at least moderate intensity and mild disability; or neither headache nor neck pain. Pain pressure threshold, allodynia, muscle strength, and endurance and cervical muscles activity were evaluated.

RESULTS

One hundred subjects, with mean age of 30.4 years old, were stratified by diagnosis (n = 25 per group) and by self-reported pain during tests. Lower endurance during flexion was observed for migraine and neck pain (34s) relative to neck pain alone (45s), migraine (40s), and controls (58s) (p = 0.04). For extensor endurance, means were 142s, 166s, 215s, and 270s, respectively (p < 0.001). Endurance times were impacted by the presence of test-induced pain decreasing about 40%-53% of the performance. Diagnostic groups did not differ significantly in strength (p > 0.05), but all pain groups presented significantly higher proportion of test-induced pain, lower muscle activity during the maximal isometric voluntary contractions, and lower pressure pain thresholds.

CONCLUSION

Patients with migraine, chronic neck pain, and the association of both present altered cervical muscle function and activity. Also, test-induced pain impacts significantly on neck muscles endurance.

SIGNIFICANCE

The diagnosis of migraine and chronic neck pain is associated with altered function and activity of the cervical muscles. However, the test-induced pain had an important contribution to worse cervical muscle endurance. This suggests that the therapeutic approach should focus on de-sensitization of the trigeminal-cervical complex when dealing with the comorbidity of migraine and cervical pain.

Anticoagulation Management in V-V ECMO Patients: A Multidisciplinary Pragmatic Protocol

(1) Background: Extracorporeal membrane oxygenation (ECMO) is a complex procedure affecting both the risk of thrombosis and bleeding. High-quality data to personalize anticoagulation management in ECMO are lacking, resulting in a high variability in practice among centers. For this reason, we review coagulation methods and monitoring and share a pragmatic proposal of coagulation management, as performed in our high-volume ECMO Referral Centre; (2) Methods: We revised the anticoagulation options and monitoring methods available for coagulation management in ECMO through PubMed search based on words including "anticoagulation," "coagulation assays," "ECMO," "ELSO," and "ISTH"; (3) Results: Actual revision of the literature was described as our routine practice regarding ECMO anticoagulation and monitoring; (4) Conclusions: No coagulation test is exclusively predictive of bleeding or thrombotic risk in patients undergoing ECMO support. An approach that allows for a tailored regimen of anticoagulation (regardless of agent used) and monitoring is mandatory. To accomplish this, we propose that the titration of anticoagulation therapies should include multiple laboratory tests, including anti-Xa, aPTT, ACT, viscoelastic tests, AT levels, platelet count, fibrinogen, and FXIII levels. Anticoagulation regimens should be tailored to a specific patient and personalized based on this complex array of essays.

Analysis and applications of respiratory surface EMG: report of a round table meeting

Surface electromyography (sEMG) can be used to measure the electrical activity of the respiratory muscles. The possible applications of sEMG span from patients suffering from acute respiratory failure to patients receiving chronic home mechanical ventilation, to evaluate muscle function, titrate ventilatory support and guide treatment. However, sEMG is mainly used as a monitoring tool for research and its use in clinical practice is still limited-in part due to a lack of standardization and transparent reporting. During this round table meeting, recommendations on data acquisition, processing, interpretation, and potential clinical applications of respiratory sEMG were discussed. This paper informs the clinical researcher interested in respiratory muscle monitoring about the current state of the art on sEMG, knowledge gaps and potential future applications for patients with respiratory failure.

Effluent toxicity study using biomarkers for ciprofloxacin photoelectrocatalytic degradation by bismuth-doped titanium dioxide nanotubes

Ciprofloxacin hydrochloride (CIP) is a broad-spectrum synthetic antibiotic often found in domestic sewage and industrial waste due to the inefficiency of conventional treatments. Given the potential risk of drug accumulation, this study presents coatings of titanium dioxide nanotubes (TiO2) doped with different bismuth (Bi) concentrations to degrade CIP through photocatalytic and photoelectrochemical processes. Characterization studies revealed that bismuth (Bi) doping affected the morphology of the materials, with concentrations of 0.01 and 0.05 mol L-1, resulting in collapsed materials with a smaller active surface area. Photocatalysis tests for all the materials exhibited a similar degree of efficiency to photolysis, approximately 33%. Ecotoxicity tests using the biomarkers Lactuca sativa L., Lemna minor, and Artemia salina indicated that, although they were similar to photolysis in terms of efficiency, the effluents generated when employing the doped catalysts showed lower levels of toxicity, with the best results achieved for the material doped with 0.005 mol L-1 of Bi, with a toxicity level approximately 40% lower. Photoelectrocatalysis proved to be the most efficient CIP degradation technique. The highest degradation rate was observed for materials doped with 0.005 mol L-1 of Bi, with an efficiency of 46%, which is 1.4 times more efficient than photolysis. These results demonstrate that materials doped with low amounts of Bi can be effectively used as photoanodes for drug degradation, as their performance is superior, and the final product generated exhibits low toxicity to living organisms.

Taxonomy and systematics of the fungus-growing ant associate Escovopsis (Hypocreaceae)

Escovopsis is a symbiont of fungus-growing ant colonies. Unstandardised taxonomy prevented the evaluation of the morphological diversity of Escovopsis for more than a century. The aim of this study is to create a standardised taxonomic framework to assess the morphological and phylogenetic diversity of Escovopsis. Therefore, to set the foundation for Escovopsis taxonomy and allow interspecific comparisons within the genus, we redescribe the ex-type cultures of Escovopsis aspergilloides, E. clavata, E. lentecrescens, E. microspora, E. moelleri, E. multiformis, and E. weberi. Thus, based on the parameters adopted in this study combined with phylogenetic analyses using five molecular markers, we synonymize E. microspora with E. weberi, and introduce 13 new species isolated from attine nests collected in Argentina, Brazil, Costa Rica, Mexico, and Panama: E. breviramosa, E. chlamydosporosa, E. diminuta, E. elongatistipitata, E. gracilis, E. maculosa, E. papillata, E. peniculiformis, E. phialicopiosa, E. pseudocylindrica, E. rectangula, E. rosisimilis, and E. spicaticlavata. Our results revealed a great interspecific morphological diversity throughout Escovopsis. Notwithstanding, colony growth rates at different temperatures, as well as vesicle shape, appear to be the most outstanding features distinguishing species in the genus. This study fills an important gap in the systematics of Escovopsis that will allow future researchers to unravel the genetic and morphological diversity and species diversification of these attine ant symbionts. Taxonomic novelties: New species: Escovopsis breviramosa Q.V. Montoya, M.J.S. Martiarena & A. Rodrigues, E. chlamydosporosa Q.V. Montoya, M.J.S. Martiarena & A. Rodrigues, E. diminuta Q.V. Montoya, M.J.S. Martiarena & A. Rodrigues, E. elongatistipitata Q.V. Montoya, M.J.S. Martiarena & A. Rodrigues, E. gracilis Q.V. Montoya, M.J.S. Martiarena & A. Rodrigues, E. maculosa Q.V. Montoya, M.J.S. Martiarena & A. Rodrigues, E. papillata Q.V. Montoya, M.J.S. Martiarena & A. Rodrigues, E. peniculiformis Q.V. Montoya, M.J.S. Martiarena & A. Rodrigues, E. phialicopiosa Q.V. Montoya, M.J.S. Martiarena & A. Rodrigues, E. pseudocylindrica Q.V. Montoya, M.J.S. Martiarena & A. Rodrigues, E. rectangula Q.V. Montoya, M.J.S. Martiarena & A. Rodrigues, E. rosisimilis Q.V. Montoya, M.J.S. Martiarena & A. Rodrigues, E. spicaticlavata Q.V. Montoya, M.J.S. Martiarena & A. Rodrigues. Citation: Montoya QV, Martiarena MJS, Rodrigues A (2023). Taxonomy and systematics of the fungus-growing ant associate Escovopsis (Hypocreaceae). Studies in Mycology 106: 349-397. doi: 10.3114/sim.2023.106.06.

Comparing in-person, blended and virtual training interventions; a real-world evaluation of HIV capacity building programs in 16 countries in sub-Saharan Africa

We sought to evaluate the impact of transitioning a multi-country HIV training program from in-person to online by comparing digital training approaches implemented during the pandemic with in-person approaches employed before COVID-19. We evaluated mean changes in pre-and post-course knowledge scores and self-reported confidence scores for learners who participated in (1) in-person workshops (between October 2019 and March 2020), (2) entirely asynchronous, Virtual Workshops [VW] (between May 2021 and January 2022), and (3) a blended Online Course [OC] (between May 2021 and January 2022) across 16 SSA countries. Learning objectives and evaluation tools were the same for all three groups. Across 16 SSA countries, 3023 participants enrolled in the in-person course, 2193 learners participated in the virtual workshop, and 527 in the online course. The proportions of women who participated in the VW and OC were greater than the proportion who participated in the in-person course (60.1% and 63.6%, p<0.001). Nursing and midwives constituted the largest learner group overall (1145 [37.9%] vs. 949 [43.3%] vs. 107 [20.5%]). Across all domains of HIV knowledge and self-perceived confidence, there was a mean increase between pre- and post-course assessments, regardless of how training was delivered. The greatest percent increase in knowledge scores was among those participating in the in-person course compared to VW or OC formats (13.6% increase vs. 6.0% and 7.6%, p<0.001). Gains in self-reported confidence were greater among learners who participated in the in-person course compared to VW or OC formats, regardless of training level (p<0.001) or professional cadre (p<0.001). In this multi-country capacity HIV training program, in-person, online synchronous, and blended synchronous/asynchronous strategies were effective means of training learners from diverse clinical settings. Online learning approaches facilitated participation from more women and more diverse cadres. However, gains in knowledge and clinical confidence were greater among those participating in in-person learning programs.

COVID-19-associated Coagulopathy Characterization using Rotational Thromboelastometry in a Prospective, Observational Cohort Study: The HemoCoV Study

INTRODUCTION

COVID-19-associated coagulopathy includes systemic and endothelial inflammation with coagulation dysregulation related to immunothrombosis. The aim of this study was to characterize this complication of SARS-CoV-2 infection in patients with moderate to severe COVID-19.

METHODS

An open-label, prospective observational study conducted in patients with COVID-19 moderate to severe acute respiratory failure admitted to an intensive care unit (ICU). Coagulation testing, including thromboelastometry, biochemical analysis and clinical variables, were collected at prespecified time points during the 30 days of ICU stay.

RESULTS

The study included 145 patients, 73.8% male, with a median age of 68 years (interquartile range - IQR 55 - 74). The most prevalent comorbidities were arterial hypertension (63.4%), obesity (44.1%) and diabetes (22.1%). Simplified acute physiology score II (SAPS II) was on average 43.5 (11 - 105) and sequential organ failure assessment (SOFA) at admission was 7.5 (0 - 14). During ICU stay, 66.9% of patients underwent invasive mechanical ventilation and 18.4% extracorporeal membrane oxygenation support; thrombotic and hemorrhagic events occurred in 22.1% and 15.1% of the patients respectively; anticoagulation with heparin was present in 99.2% of patients since early ICU stay. Death occurred in 35% of patients. Longitudinal studies revealed changes in almost all coagulation tests during the ICU stay. SOFA score, lymphocyte counts, some biochemical, inflammatory and coagulation parameters, including hypercoagulability and hypofibrinolysis seen in thromboelastometry, differed significantly (p < 0.05), between ICU admission and discharge. Hypercoagulability and hypofibrinolysis persisted throughout ICU hospitalization, showing higher incidence and severity in non-survivors.

CONCLUSION

COVID-19-associated coagulopathy is characterized by hypercoagulability and hypofibrinolysis from ICU admission, and persisted throughout the clinical course in severe COVID-19. These changes were more pronounced in patients with higher disease burden and in non-survivors.

Potential of omega-3 and conjugated fatty acids to control microglia inflammatory imbalance elicited by obesogenic nutrients

High-fat diet-induced obesity detrimentally affects brain function by inducing chronic low-grade inflammation. This neuroinflammation is, at least in part, likely to be mediated by microglia, which are the main immune cell population in the brain. Microglia express a wide range of lipid-sensitive receptors and their activity can be modulated by fatty acids that cross the blood-brain barrier. Here, by combining live cell imaging and FRET technology we assessed how different fatty acids modulate microglia activity. We demonstrate that the combined action of fructose and palmitic acid induce Ikβα degradation and nuclear translocation of the p65 subunit nuclear factor kB (NF-κB) in HCM3 human microglia. Such obesogenic nutrients also lead to reactive oxygen species production and LynSrc activation (critical regulators of microglia inflammation). Importantly, short-time exposure to omega-3 (EPA and DHA), CLA and CLNA are sufficient to abolish NF-κB pathway activation, suggesting a potential neuroprotective role. Omega-3 and CLA also show an antioxidant potential by inhibiting reactive oxygen species production, and the activation of LynSrc in microglia. Furthermore, using chemical agonists (TUG-891) and antagonists (AH7614) of GPR120/FFA4, we demonstrated that omega-3, CLA and CLNA inhibition of the NF-κB pathway is mediated by this receptor, while omega-3 and CLA antioxidant potential occurs through different signaling mechanisms.

Renal Dysfunction Phenotypes in Patients Undergoing Obesity Surgery

Obesity surgery candidates are at an increased risk of kidney injury, but pre-operative evaluation usually neglects kidney function assessment. This study aimed to identify renal dysfunction in candidates for bariatric surgery. To reduce the sources of bias, subjects with diabetes, prediabetes under metformin treatment, neoplastic or inflammatory diseases were excluded. Patients' (n = 192) average body mass index was 41.7 ± 5.4 kg/m². Among these, 51% (n = 94) had creatinine clearance over 140 mL/min, 22.4% (n = 43) had proteinuria over 150 mg/day and 14.6% (n = 28) albuminuria over 30 mg/day. A creatinine clearance higher than 140 mL/min was associated with higher levels of proteinuria and albuminuria. Univariate analysis identified sex, glycated hemoglobin, uric acid, HDL and VLDL cholesterol as being associated with albuminuria, but not with proteinuria. On multivariate analysis, glycated hemoglobin and creatinine clearance as continuous variables were significantly associated with albuminuria. In summary, in our patient population prediabetes, lipid abnormalities and hyperuricemia were associated with albuminuria, but not with proteinuria, suggesting different disease mechanisms might be implicated. Data suggest that in obesity-associated kidney disease, tubulointerstitial injury precedes glomerulopathy. A significant proportion of obesity surgery candidates present clinically relevant albuminuria and proteinuria along with renal hyperfiltration, suggesting that routine pre-operative assessment of these parameters should be considered.

Fibrosis of Peritoneal Membrane, Molecular Indicators of Aging and Frailty Unveil Vulnerable Patients in Long-Term Peritoneal Dialysis

Peritoneal membrane status, clinical data and aging-related molecules were investigated as predictors of long-term peritoneal dialysis (PD) outcomes. A 5-year prospective study was conducted with the following endpoints: (a) PD failure and time until PD failure, (b) major cardiovascular event (MACE) and time until MACE. A total of 58 incident patients with peritoneal biopsy at study baseline were included. Peritoneal membrane histomorphology and aging-related indicators were assessed before the start of PD and investigated as predictors of study endpoints. Fibrosis of the peritoneal membrane was associated with MACE occurrence and earlier MACE, but not with the patient or membrane survival. Serum α-Klotho bellow 742 pg/mL was related to the submesothelial thickness of the peritoneal membrane. This cutoff stratified the patients according to the risk of MACE and time until MACE. Uremic levels of galectin-3 were associated with PD failure and time until PD failure. This work unveils peritoneal membrane fibrosis as a window to the vulnerability of the cardiovascular system, whose mechanisms and links to biological aging need to be better investigated. Galectin-3 and α-Klotho are putative tools to tailor patient management in this home-based renal replacement therapy.

Alpha-klotho and peritoneal membrane status: A hypothesis generating study

BACKGROUND

Long-term success of peritoneal dialysis relies on the integrity of the peritoneal membrane. This proof-of-concept study addressed the hypothesis that fibrosis is already present in the membrane at pre-dialysis and that the membrane status is related to the individual's uraemic fingerprint.

METHODS

A clinical-mechanistic, transversal, single-centre study was conducted. Pre-dialysis peritoneal biopsies were scored considering the submesothelial compact zone thickness (STM), vasculopathy and inflammation. We investigated if the membrane status could be inferred from a panel of proteins (α-Klotho, Galectin-3, FGF21, FGF23, Tweak, TNFα and hsPCR) in blood.

RESULTS

A total 58 incident patients aged 56 ± 15 years old were included, 31% female, 55% hypertension, 29% diabetic and 24% obese. Person-to-person STM was found to be highly variable and 38% of patients were fibrosis positive. Both α-Klotho (Spearman r = -.7491, p < 0.001) and FGF21 (Spearman r = -.5102, p < 0.001) were negatively associated with STM. α-Klotho, but not FGF21, was able to discriminate fibrosis from nonfibrosis with/without inflammation and vasculopathy. PLS models identified α-Klotho as the protein most relevant for fibrosis. α-Klotho was independently associated with fibrosis of the peritoneal membrane (OR = .991 (.896-.997), p = 0.002).

CONCLUSION

Before the start of dialysis in incident patients, some patients already present fibrosis of the peritoneal membrane and other patients do not. Our findings suggest that α-Klotho may be implicated in fibrosis of the peritoneal membrane.

Peritoneal Dialysis Exit-Site Care Protocols in Portugal and Its Association with Catheter-Related Infections

INTRODUCTION

Exit-site infection (ESi) prevention is a key factor in lowering the risk of peritonitis. This study aimed to evaluate the associations between exit-site (ES) care protocols and the annual incidence rates of ESi and peritonitis in Portugal.

METHODS

We performed a national survey using two questionnaires: one about the incidence of catheter-related infections and the other characterizing patients' education and ES care protocols.

RESULTS

In 2017 and 2018, 14 Portuguese units followed 764 and 689 patients. ESi incidence rate was 0.41 episodes/year, and the peritonitis incidence rate was 0.37. All units monitor catheter-related infections on a yearly basis, use antibiotic prophylaxis at the time of catheter placement, and treat nasal carriage of S. aureus, although with different approaches. Screening for nasal carriage of S. aureus is performed by 12 units, and daily topical antibiotic cream is recommended by 6 out of 14 of the units. We did not find statistical differences in ESi/peritonitis, comparing these practices. The rate of ESis was lower with nonocclusive dressing immediately after catheter insertion, bathing without ES dressing, with the use of colostomy bags in beach baths and was higher with the use of bath sponge. The peritonitis rate was lower with bathing without ES dressing and if shaving of the external cuff was performed in the presence of chronic ESi.

CONCLUSIONS

We found potential proceedings associated with ESi and peritonitis. A regular national audit of peritoneal dialysis units is an important tool for clarifying the best procedures for reduction of catheter-related infections.

Analytical development for the assessment of pesticide contaminations in blood and plasma of wild birds: The case of grey partridges (Perdix perdix)

In this study, blood and plasma of grey partridges (Perdix perdix) were analyzed to assess their potential contamination by plant protection products (PPP) and especially pesticide compounds. The group of pesticides selected is composed of a huge variety of compounds. Therefore, in this study, two methods were optimized and validated to analyze 104 compounds including herbicides, insecticides, fungicides and photoprotectors or synergists. Various extraction methods found in the literature were compared and adapted for the extraction of pesticides from blood and plasma. After extraction, samples were concentrated then injected for quantification simultaneously in LC-MS/MS and ATD-GC-MS/MS with an automatic thermal desorption step (ATD). Both LC-MS/MS and ATD-GC-MS/MS analyses were performed using the MRM mode with 2 mass transitions for each compound.The two analytical methods achieved a good linearity for the calibration responses in plasma and blood. Methods allowed sensitive detection and quantification in complex biological matrices such as plasma and blood in both LC and GC. For plasma samples and considering all 104 compounds of the study, the average LOD was 0.005 ng mg^-1 in LC-MS/MS and 0.035 ng mg^-1 in ATD-GC-MS/MS and the average LOQ was 0.017 ng mg^-1 and 0.116 ng mg^-1 in LC-MS/MS and ATD-GC-MS/MS respectively. Accordingly, the average LOD for blood samples was 0.011 ng mg^-1 in LC and 0.028 ng mg^-1 in GC whereas the average LOQ was 0.038 ng mg^-1 and 0.094 ng mg^-1 in LC-MS/MS and ATD-GC-MS/MS respectively. Those analytical methods were then successfully applied to 70 blood samples and 35 plasma samples.

EQ-5D in dialysis units: a PROM with a view

Summary Chronic kidney disease (CKD) is a silent worldwide epidemic responsible for a high clinical and socioeconomic burden. Beyond disease-related outcomes, there is an urgent need for clinicians to focus on implementation of validated patient-reported outcome measures (PROMs) in routine care practice. This updated concept of high-quality renal care implies a changing paradigm, with a focus on patient experiences and health-related quality of life (HRQL) measures. This is even more crucial in end-stage renal disease, where adequate dialysis should aim at a multidimensional approach instead of only analytical targets. It is vital to emphasize interventions that positively affect the quality of life of the patient with CKD beyond improving their survival. Although the importance of using HRQL measures is well established, there has been resistance to their use in routine care. There are numerous tools to assess HRQL, but not all are easy to apply. It is essential to overcome these possible barriers and better adequate the HRQL tools to the patients. The shorter and simpler instruments are more appealing, as well as the electronic health questionnaires. The EuroQol-5 Dimensions tool (EQ5D) is a standardized measure of health status, is simple and quick, and provides information that can be used in economic assessments of healthcare.In this era of limited health resources, cost analysis and economic evaluations are becoming increasingly relevant. In dialysis units, sustainability management should include a pathway of integrated care, including home and center dialysis, that values the better adjustment of prescriptions to the individual patient. The authors advocate using the EQ5D to support this pathway of quality in dialysis units toward global health gains. The EQ5D is a PROM with a view centered on patient and sustainable health services.

Managing Transition between dialysis modalities: a call for Integrated care In Dialysis Units

Summary Patients with chronic kidney disease have three main possible groups of dialysis techniques: in-center hemodialysis, peritoneal dialysis, and home hemodialysis. Home dialysis techniques have been associated with clinical outcomes that are equivalent and sometimes superior to those of in-center hemodialysisTransitions between treatment modalities are crucial moments. Transition periods are known as periods of disruption in the patient’s life associated with major complications, greater vulnerability, greater mortality, and direct implications for quality of life. Currently, it is imperative to offer a personalized treatment adapted to the patient and adjusted over time.An integrated treatment unit with all dialysis treatments and a multidisciplinary team can improve results by establishing a life plan, promoting health education, medical and psychosocial stabilization, and the reinforcement of health self-care. These units will result in gains for the patient’s journey and will encourage home treatments and better transitions.Peritoneal dialysis as the initial treatment modality seems appropriate for many reasons and the limitations of the technique are largely overcome by the advantages (namely autonomy, preservation of veins, and preservation of residual renal function).The transition after peritoneal dialysis can (and should) be carried out with the primacy of home treatments. Assisted dialysis must be considered and countries must organize themselves to provide an assisted dialysis program with paid caregivers.The anticipation of the transition is essential to improve outcomes, although there are no predictive models that have high accuracy; this is particularly important in the transition to hemodialysis (at home or in-center) in order to plan autologous access that allows a smooth transition.

Project SELfit: training socio-emotional skills in a school environment in Porto

Issue/Problem

Mental disorders are the main cause of years lived with disability (YLD) in 5-14-year-old people around the world, in Western Europe, and particularly in Portugal. Young people who experience anxiety during childhood have a 3,5-fold likelihood of suffering from depression or anxiety during adulthood. COVID-19 has aggravated this situation, namely regarding socio-emotional competencies.

Description of the problem

SELfit, a project based on the Socio-emotional learning (SEL) methodology, aims promoting mental health, by training teachers and community nurses to develop socio-emotional skills in students from primary schools. The project includes a theoretical and a practical/training session, and monthly supervision sessions by a team that includes a psychologist, a public health doctor and public health nurses. The period of implementation is between February to July 2022.

Results

A total of 8 community nurses and 13 teachers from 3 primary schools in Porto enrolled in this project, which corresponds to a total around 272 students from 5 to 8-year-old. Knowledge of nurses and teachers regarding mental health literacy, and social emotional learning was assessed, before and after the theoretical session. The mean percentage of correct answers before was 49% (54% regarding nurses and 45% teachers) compared to 84% (92% regarding nurses and 78% teachers) after. Concerning socio-emotional skills of the primary school students, possible improvement will be evaluated at the end of the project (July 2022).

Lessons

Mental health literacy and social emotional learning knowledge increased 35%, which highlights the importance of these theoretical sessions promoting mental health literacy. By the end of this project, it is expected to exist an improvement on socio-emotional skills of the primary school students. This is a very important project, expected to be implement and replicated in other schools in Porto and in Portugal.

Key messages

• Mental disorders are the main cause of years lost due to disability (YLD) in primary school students in Portugal; hence, it was chosen for this mental health promotion project.

• This is a pioneer project in Porto, involving both community nurses and primary teachers, in which all are involved in training and promoting social-emotional learning in a school context.

Flow-status and survival in severe aortic stenosis treated with TAVI – is flow rate superior to stroke volume index?

Background

Low-flow status, currently defined as a stroke volume index (SVi) &lt;35 mL/m2, is an important prognostic predictor for mortality after Transcatheter Aortic Valve Implantation (TAVI) for severe aortic stenosis (SAS). However, transaortic flow rate (FR) – defined as stroke volume divided by left ventricle ejection time - has recently been suggested to be superior to SVi in defining low-flow states, as it reflects more closely valvular resistance, while being independent of body surface area. Low FR is most consistently defined as FR&lt;200 mL/s.

Purpose

Determine the prognostic impact of FR and SVi before TAVI in survival after intervention for SAS.

Methods

A single-centre retrospective database of all TAVI performed between 2011 and 2019 was analyzed, and cases with pre-intervention echocardiograms available were included. Low-flow patients were identified according to basal FR (&lt;200 mL/s) or SVi (&lt;35 mL/m2), and compared with normal-flow cases. The primary endpoint was defined as time to all-cause death or last follow-up. The impact of flow-status (using FR or SVi) in survival was assessed using Kaplan-Meier curves and log-rank test, as well as Cox proportional hazard model adjusted for EuroSCORE II, using FR or SVi either as categorical or continuous variables. A subanalysis further compared patients with preserved and reduced ejection fraction (EF, &lt;52%). p&lt;0.05 was considered statistically significant.

Results

From 657 TAVI performed, 490 (74.6%) cases were included, with a median follow-up of 43 months. From those, 59.6% were defined as low-flow according to FR, and 43.3% using SVi. Low-flow patients, using each parameter, were of higher surgical risk (EuroSCORE II and STS scores), had more advanced NYHA classes, worse estimated creatinine clearance, and suffered more frequently from coronary artery disease. Low-FR patients were also older, and more predominantly female. Atrial fibrillation was more prevalent among low SVi cases. Functional aortic valve area was lower in low-flow patients using both assessments, but low-SVi was also associated with lower transaortic gradients, as well as lower EF before and after TAVI. Regarding all-cause mortality, low-SVi was associated with worse survival [p=0.02, hazard ratio (HR) 1.43 (1.05–1.94)], but not low-FR (p=0.4). However, low-SVi, when adjusted for EuroScore II, was no longer a predictor of all-cause mortality (p=0.08). When considering FR and SVi as continuous variables, a higher SVi (but not FR) was associated with better survival (HR 0.98, p=0.047) in multivariable analysis adjusted for EuroSCORE II. When stratifying according to preserved and reduced EF, both FR and SVi did not predict all-cause mortality.

Conclusions

Low-flow states are common in SAS population treated with TAVI, being frequently associated with worse symptoms and higher procedural risk. Low-SVi, but not low-FR, negatively impacts survival after intervention, representing a marker for prognosis after TAVI.

Funding Acknowledgement

Type of funding sources: None.

Predictors of AF recurrence in patients with paroxysmal AF undergoing catheter ablation: new predictors coming?

Introduction

Recurrence of atrial fibrillation (AF) after catheter ablation (CA) is estimated to be between 20% and 45% and the prediction of recurrence AF in patients (pts) with paroxysmal AF undergoing CA remains challenging.

Purpose

To determine the clinical and procedural predictors of recurrence AF after CA in pts with paroxysmal AF.

Methods

Single-centre retrospective study that included all pts with paroxysmal AF who underwent AF CA between 2017 and 2019. Ablation procedures included radiofrequency and second-generation cryoballoon CA. All pts underwent cardiac computed tomography prior the procedure. AF recurrence was defined as any recurrence of AF, atrial flutter or atrial tachycardia &gt;30 seconds (recorded in 12-lead electrocardiogram or Holter) after 90 days of CA. The independent association between clinical and procedural variables and AF recurrence was evaluated with Cox regression analysis.

Results

We included 351 pts, 63,5% male and with a mean age of 57,1±11,4 years. CHADSVASCscore ≥2 points were present in 43,7% of the pts, median duration of AF prior the intervention was 3 years (IQR 1–6) and most pts were treated with some antiarrhythmic drug at the time of CA (56,9%). Overall, median follow-up was 27 months (IQR 19–39).

AF recurrence was present in 96 pts (27,4%), on average, 15,2±10,4 months after CA.

Univariate logistic regression identified female gender, thyroid disease, left atrium (LA) enlargement (defined as LA indexed volume &gt;34 mL/m2 or LA diameter &gt;38mm for female or &gt;40mm for male), coronary calcium score &gt;100, epicardial adipose tissue volume, number of previous electric cardioversions, treatment with antiarrhythmic drugs prior CA and the extent of CA (only pulmonary vein isolation (PVI) or PVI and ablation of other lesions) as predictors of recurrence AF after CA in pts with paroxysmal AF (p&lt;0,05 for all).

Cox regression analysis identified female gender (OR 1,615, 95% CI 1,005–2,597; p=0,008), LA enlargement (OR 2,084, 95% CI 1,207–3,596; p=0,008) and coronary calcium score &gt;100 (OR 1,958, 95% CI 1,133–3,385; p=0,016) as independent predictors of AF recurrence.

Conclusions

In our cohort, AF recurrence was significantly higher in pts with LA enlargement, with coronary calcium score &gt;100 and female gender pts.

Funding Acknowledgement

Type of funding sources: None.

Predictors for NYHA recovery and 1-year mortality after mitral TEER

Background

Mitral regurgitation (MR) is the second-most frequent valvular heart disease in Europe and frequently aggravates heart failure (HF) symptoms. Mitral transcatheter-edge-to-edge repair (TEER) can be considered in eligible patients, for both primary (in inoperable cases) or secondary severe MR. However, intervention is not advised in severe comorbid patients in whom it is not expected to prolong survival for over 1 year.

Purpose

Evaluate characteristics associated with HF New York Heart Association (NYHA) class recovery, and one-year all-cause mortality after mitral TEER for severe MR.

Methods

All mitral TEER procedures for primary and secondary MR conducted in a single-centre between 2014 and 2020 were retrospectively analyzed. The primary endpoint was defined as a reduction of at least one NYHA class in the first month after intervention, and a secondary endpoint considered a recovery of at least two NYHA classes. Survival status 12 months after mitral TEER was also consulted. Clinical, echocardiographic and blood-analysis data were explored as characteristics associated with the endpoints defined, using Pearson's Chi-squared test, Wilcoxon rank sum test and Fisher's exact test, as appropriate. A p&lt;0.05 was considered statistically significant.

Results

From 103 mitral TEER procedures, 86 (83%) had full information about pre- and post-intervention NYHA class, as well as survival status at 12 months. There was a higher proportion of primary MR among NYHA non-responders (47% versus 25%, p=0.034), but no differences for secondary MR. Higher surgical risk patients (EuroSCORE II) tended to have exhibit more NYHA recovery, though not reaching statistical significance (p=0.068). Both a more advanced NYHA class at baseline and lower N-terminal pro-brain natriuretic peptide (NTproBNP) levels were linked to a higher symptomatic recovery (2048 versus 5676pg/ml, p&lt;0.001). Also, persisting MR after TEER of at least grade 3/4 was more frequent in non-NYHA responders. Regarding NYHA improvement of at least two classes, it was observed in 13% patients, and these also had a more advanced NYHA class at baseline and lower NTproBNP basal levels, and exhibited a lower estimated systolic pulmonary artery pressure and inferior vena cava (IVC) diameter. Finally, 10 (11.6%) of mitral TEER patients died in the first 12 months, and no statistically significant associations were found regarding pre-intervention characteristics and survival.

Conclusions

This study suggests that three-fifths of severe MR improve their NYHA class after TEER, but only one-fourth for primary MR. Earlier intervention – with lower NTproBNP levels, less severe pulmonary hypertension, and lower IVC diameters – is associated with more symptomatic HF improvement. All-cause mortality in the first year is still significant, exposing a need for better patient selection. However, these findings represent exploratory deductions of a relatively low number, single-centre, patients.

Funding Acknowledgement

Type of funding sources: None.

Burnout: personal and work factors in volunteer and career firefighters

Purpose

Firefighters are daily confronted with adverse, unpredictable and demanding situations. It is a dangerous profession that puts firefighters at risk of developing burnout. Although the literature has already identified personal and work-related factors of burnout, the examination of specific factors explaining burnout among volunteer and career firefighters is still needed. The purpose of this study is to investigate the explaining role of personal and work-related factors on volunteer and career firefighters’ burnout.

Design/methodology/approach

A nonrandom convenience sample of 250 firefighters (67% volunteer; Mage = 31.88) completed a sociodemographic questionnaire, the Oldenburg Burnout Inventory, the Proactive Coping Scale and a standard of living subscale item. Hierarchical multiple linear regression models were tested. Fisher’s criterion was considered, with p-values lower than 0.05 interpreted as statistically significant.

Findings

Personal and work-related factors accounted for 18% of volunteer and 31% of career firefighters’ variations in burnout. Personal factors offered a greater contribution explaining volunteer and career firefighters’ burnout. Still, variations in the role played by age, family responsibilities, proactive coping and satisfaction with standard of living on burnout were found among volunteer and career firefighters. Taking the work-related factors into account, working in rotative shifts constituted a risk factor for career firefighters’ burnout.

Research limitations/implications

This study advances the understanding about the role of personal and work-related factors in volunteer and career firefighters’ burnout.

Originality/value

This study adds information about specific factors explaining burnout among voluntary and career firefighters. It deepens existing knowledge on variations in the role played by age, family responsibilities, work conditions, proactive coping and satisfaction with standard of living on the burnout of volunteer and career firefighters.

Protein Loss in Peritoneal Effluent: Different Meaning for 24-h versus PET Samples

INTRODUCTION

Quantification of peritoneal protein loss (PPL) may be expressed according to a timely collection (24-h measurement or 4-h PET assessment) and as a concentration. The aim of this study was to compare the quantification methods of 24-h and 4-h collections.

METHODS

This study included 81 prevalent peritoneal dialysis patients. Demographics and clinical and bioelectrical impedance features were registered. PPL was measured (4-h PET and 24-h results) and peritoneal protein clearance was calculated. A linear regression model was performed.

RESULTS

Age and continuous ambulatory peritoneal dialysis (compared to cycler) were positively associated with greater PPL on 24-h collections. Neither cardiovascular disease, hypertension, diabetes nor the comorbidity Charlson Index was significantly associated with PPL. There was a consistent univariable relationship with D/P creatinine, whichever sampling method was used. Only 24-h measurements of PPL correlated with body composition variables. In multiple linear regression analysis, D/P creatinine association with PPL stands out. On the other hand, 24-h determinations (in grams or clearance) were associated with overhydration. PET protein quantification was associated with peritoneal creatinine clearance.

DISCUSSION/CONCLUSION

Different methods sign different pathophysiological pathways. PET protein loss quantification should be regarded as a marker of peritoneal membrane intrinsic permeability. Measurements of a 24-h sample might be closer to patients' clinical status and prognosis, signalizing opportunities for therapy intervention.

Peritoneal Protein Loss, Inflammation, and Nutrition: Refuting Myths

Peritoneal protein loss (PPL) has been correlated with mortality, malnutrition and inflammation. More recently overhydration was brought to the equation. This study aims to review classic and recent factors associated with PPL. Prevalent and incident peritoneal dialysis (PD) patients were included. Dialysate and serum IL-6 was obtained during PET. Hydration and nutritional status were assessed by bio-impedance. Linear regression and Cox regression were performed. The 78 included patients presented median values of PPL 4.8 g/24 h, serum IL-6: 5.1 pg/mL, and IL-6 appearance rate 153.5 pg/min. Mean extracellular water excess (EWexc) was 0.88 ± 0.94 L, and lean body mass index (LBMI) 17.3 ± 2.4 kg/m2. After mean follow-up of 33.9 ± 29.3 months, 12 patients died. Linear univariable analysis showed positive associations between PPL and small solute transport, body composition (LBMI and EWexc), comorbidities and performing CAPD (vs. cycler). PPL correlated positively with dialysate appearance rate of IL-6, but not with serum IL-6. Linear multivariable analysis confirmed positive association between PPL and EWexc (p = 0.012; 95%CI: 4.162–31.854), LBMI (p = 0.008; 95%CI: 1.720–11.219) and performing CAPD (p = 0.023; 95%CI: 4.375–54.190). In survival analysis, no relationship was found between mortality and PPL. Multivariable Cox regression showed Charlson Comorbidity Index (HR: 1.896, 95%CI: 1.235–2.913), overhydration (HR: 10.034, 95%CI: 1.426–70.587) and lower PPL (HR: 0.576, 95%CI: 0.339–0.978) were predictors for mortality. Overhydration, was a strong predictor of PPL, overpowering variables previously reported as determinants of PPL, namely clinical correlates of endothelial dysfunction or local inflammation. PPL were not associated with malnutrition or higher mortality, emphasizing the importance of volume overload control in PD patients.

Peritoneal Protein Loss, Inflammation, and Nutrition: Refuting Myths

Peritoneal protein loss (PPL) has been correlated with mortality, malnutrition and inflammation. More recently overhydration was brought to the equation. This study aims to review classic and recent factors associated with PPL. Prevalent and incident peritoneal dialysis (PD) patients were included. Dialysate and serum IL-6 was obtained during PET. Hydration and nutritional status were assessed by bio-impedance. Linear regression and Cox regression were performed. The 78 included patients presented median values of PPL 4.8 g/24 h, serum IL-6: 5.1 pg/mL, and IL-6 appearance rate 153.5 pg/min. Mean extracellular water excess (EWexc) was 0.88 ± 0.94 L, and lean body mass index (LBMI) 17.3 ± 2.4 kg/m2. After mean follow-up of 33.9 ± 29.3 months, 12 patients died. Linear univariable analysis showed positive associations between PPL and small solute transport, body composition (LBMI and EWexc), comorbidities and performing CAPD (vs. cycler). PPL correlated positively with dialysate appearance rate of IL-6, but not with serum IL-6. Linear multivariable analysis confirmed positive association between PPL and EWexc (p = 0.012; 95%CI: 4.162-31.854), LBMI (p = 0.008; 95%CI: 1.720-11.219) and performing CAPD (p = 0.023; 95%CI: 4.375-54.190). In survival analysis, no relationship was found between mortality and PPL. Multivariable Cox regression showed Charlson Comorbidity Index (HR: 1.896, 95%CI: 1.235-2.913), overhydration (HR: 10.034, 95%CI: 1.426-70.587) and lower PPL (HR: 0.576, 95%CI: 0.339-0.978) were predictors for mortality. Overhydration, was a strong predictor of PPL, overpowering variables previously reported as determinants of PPL, namely clinical correlates of endothelial dysfunction or local inflammation. PPL were not associated with malnutrition or higher mortality, emphasizing the importance of volume overload control in PD patients.

MO697: FGF-21 Correlates with Overhydration: Is There a Role for Peritoneal GLUT-1?

BACKGROUND AND AIMS

FGF-21 is a hepatokine that stimulates glucose uptake through GLUT-1. The presence of this glucose transporter in peritoneal fibroblasts is driven by peritoneal glucose exposure and is related to impaired ultrafiltration, predisposing to overhydration. The study was designed to determine FGF-21 levels in peritoneal effluent and serum, and its possible association with overhydration.

METHOD

Prevalent and incident peritoneal dialysis (PD) patients without diabetes were included. FGF-21 (dialysate and serum) was obtained during a 3.86% glucose peritoneal equilibration test. Peritoneal glucose load was calculated. The presence or absence of local peritoneal production was assessed by comparing the dialysate to plasma (D/P) ratio of FGF-21 (MW 32 kD) with that of albumin (MW 67 kD). Hydration status was assessed by bioimpedance. Spearman's correlations were performed.

RESULTS

A total of 58 patients (38 incident, 20 prevalent) were included, mean age 54 years, 67% males, PD duration from 1 to 75 months, mean 10.4. Residual GFR was 6.4 ± 3.5 mL/min/1.73 m2 and D/P creatinine 0.65 ± 0.12. Peritoneal glucose load was 110.5 g/day (range 40.8–226.9). Dialysate FGF-21 was 42.5 ± 47.0 pg/mL and serum FGF-21 943.9 ± 1164.8 pg/mL, giving a D/P ratio of 0.07. D/P albumin was 0.009, indicating that dialysate FGF-21 concentrations can be explained by transport from the circulation, without local peritoneal production. Serum FGF-21 was positively correlated with dialysate FGF-21, extracellular water excess and total peritoneal glucose load (all P &lt; 0.01). Some association was present with PD duration (P &lt; 0.05). No relationship was found between plasma FGF-21 and plasma insulin, D/P creatinine, or residual kidney function.

CONCLUSION

FGF-21 in peritoneal effluent is likely not locally produced, but caused by transport from the circulation. The associations between plasma FGF-21 levels with PD duration, peritoneal glucose load and overhydration, all indicate an effect of peritoneal glucose absorption from the peritoneal cavity into the interstitium with an insulin-independent storage into interstitial adipocytes, where it may stimulate the expression of GLUT-1.

MO688: Peritoneal Protein Clearance, Inflammation, Nutrition and Overhydration in PD Patients: Looking for the Culprit

BACKGROUND AND AIMS

Peritoneal protein loss has been for many years seen as a detrimental consequence of peritoneal dialysis (PD). Many studies correlated this leakage with mortality, malnutrition and inflammation. More recent knowledge has brought overhydration to this equation. This study aims to review classic and recent factors associated with peritoneal protein clearance and its consequences on overall mortality.

METHOD

Prevalent and incident PD patients were included. Interleukin 6 (IL-6; dialysate and serum) was obtained during a 3.86% glucose peritoneal equilibration test. Hydration and nutritional status was assessed by bioimpedance. Linear and Cox regression were performed.

RESULTS

A total of 78 patients were included (54 incident, 24 prevalent), the mean age was 54.6 ± 18.1 years, 65% were males, and the mean follow-up was 33.9 ± 29.3 months. The mean Charlson comorbidity index (CCI) was 4.4 ± 2.4. The residual GFR was 6.7 ± 3.6 mL/min/1.73 m2 and the D/P creatinine 0.65 ± 0.12. The IL-6 concentration in the dialysate was 24.9 ± 30.8 pg/mL and in serum was 37.3 ± 5.1 pg/mL. The phase angle was 5.4 ± 1.1°, overhydration 0.88 ± 0.94 L and peritoneal protein clearance 85.6 ± 54.7 mL/24 h. Overall, eight patients died.

Linear univariable analysis showed positive associations between peritoneal protein clearance and (i) small solute transport, as measured by D/P creatinine, (ii) body composition, as measured by phase angle and overhydration and (iii) CCI. The peritoneal protein clearance also correlated positively with dialysate IL-6, but not with serum IL-6. By linear multivariable analysis, using the backward method, a significant positive association between peritoneal protein and overhydration (P &lt; 0.001; IC:26.665–71.694) and also phase angle (P = 0.032; IC: 1.845–39.330) were validated.

In the exploratory survival analysis, no relationship was found between mortality and peritoneal protein clearance. A univariable positive association was shown with serum IL-6 concentration, overhydration and CCI. A higher phase angle was associated with lower mortality. No relationship with dialysate IL-6 or D/P creatinine was found. In this early-stage PD population, with globally preserved residual kidney function, an effect of this variable on mortality was not evident.

Cox regression, conditional backward method, showed CCI (OR: 1.896, IC: 1.235–2.913, P = 0.003), overhydration (OR: 10.034, IC: 1.426–70.587, P = 0.021) and peritoneal protein clearance (OR: 0.576, IC: 0.339–0.978, P = 0.041) were predictors for mortality.

CONCLUSION

A better nutrition status and overhydration are the major determinants of peritoneal protein clearance. The survival analysis showed that mortality is higher in overhydrated patients, with higher CCI, but not with higher peritoneal protein clearance. Inflammation, local or systemic, as assessed by IL-6 concentration, did not reveal to be such a strong prognosis predictor as overhydration in these PD patients.

Metabolomics as a tool for the early diagnosis and prognosis of diabetic kidney disease

Diabetic kidney disease (DKD) is one of the most prevalent comorbidities of diabetes mellitus and the leading cause of the end-stage renal disease (ESRD). DKD results from chronic exposure to hyperglycemia, leading to progressive alterations in kidney structure and function. The early development of DKD is clinically silent and when albuminuria is detected the lesions are often at advanced stages, leading to rapid kidney function decline towards ESRD. DKD progression can be arrested or substantially delayed if detected and addressed at early stages. A major limitation of current methods is the absence of albuminuria in non-albuminuric phenotypes of diabetic nephropathy, which becomes increasingly prevalent and lacks focused therapy. Metabolomics is an ever-evolving omics technology that enables the study of metabolites, downstream products of every biochemical event that occurs in an organism. Metabolomics disclosures complex metabolic networks and provide knowledge of the very foundation of several physiological or pathophysiological processes, ultimately leading to the identification of diseases' unique metabolic signatures. In this sense, metabolomics is a promising tool not only for the diagnosis but also for the identification of pre-disease states which would confer a rapid and personalized clinical practice. Herein, the use of metabolomics as a tool to identify the DKD metabolic signature of tubule interstitial lesions to diagnose or predict the time-course of DKD will be discussed. In addition, the proficiency and limitations of the currently available high-throughput metabolomic techniques will be discussed.

Transfusion Practices in Gastrointestinal Bleeding - a Tertiary Care Single-Centre Analysis

Acute upper or lower Gastrointestinal bleeding (GIB) is a clinical emergency in which transfusion can be lifesaving. An individualized and restrictive transfusion strategy is recommended. This study aims to analyze and evaluate GIB transfusion practices during one year in a large tertiary hospital in Lisbon, Portugal. All patients with GIB and transfusion support during 2014 were identified and clinical data collected and statistically treated. There were 1005 GIB transfusion episodes, in a total of 494 patients. Upper GIB was more common. The median haemoglobin concentration that triggered RBC transfusion was 7,6 g/dL with a median of 2 RBC per episode. In 21,9% of episodes, RBC were used in combination with other therapies, in 70,8%, only RBC were administered and in 7,3% RBC were not used at all. In the subgroup of patients receiving FC and/or PCC there were higher median of blood products transfused: RBC (3 17 units), FFP (3 units), PC (1 unit). In a large percentage of the transfusion episodes for GIB, only RBC were used whereas only 7,3% of the GIB didn't require RBC transfusion. Patients requiring FC and/or PCC, needed more allogenic components. We observed, in accordance with the latest clinical practice guidelines and the published literature, a restrictive transfusion approach in our clinical practice.

Predictors of early and late recurrence of atrial fibrillation after catheter ablation: two sides of the same coin?

Background

Recurrence of atrial fibrillation (AF) after catheter ablation (CA) is estimated to be between 20% and 45%. Recurrent AF early after ablation is generally classified as benign as a part of a blanking period, but recently has been associated with later recurrent AF. The prediction of early and late AF recurrence after CA remains challenging as well as the predictive value of early AF recurrence in the blanking period.

Purpose

We aimed to determine the clinical and procedural factors associated with early and late recurrence of AF after CA.

Methods

Single-centre retrospective study that included all patients who underwent AF CA between January 2017 and October 2019. Ablation procedures included radiofrequency and second-generation cryoballoon CA. Early recurrence of AF (ERAF) was defined as any recurrence of AF &gt;30 seconds within 90 days after CA and late recurrence (LR) was defined as any recurrence of AF &gt;30 seconds after 90 days of CA. The independent association between clinical and procedural variables and AF recurrence was evaluated with logistic regression analysis.

Results

We included 399 patients, 64,7% male, with a mean age of 56,8±11,6 years, most of them had paroxysmal AF with a mean duration until CA of 3,5±3,4 years.

Early recurrence of AF occurred in 51 patients (12,8%). After multivariate logistic regression, we identify left atrium (LA) diameter [odds ratio (OR) 1,1, 95% confidence interval (CI) 1,03–1,18; p=0,007] as the only independent predictor associated with recurrent AF.

Late recurrence of AF was observed in 104 patients (26,1%), on average, 12,8±8,7 months after CA. After multivariable adjustment, LA diameter (OR 1,1, 95% CI 1,01–1,12; p=0,032) and intraprocedural electric cardioversion (OR 1,8, 95% CI 1,03–3,12; p=0,040) were independently associated with recurrent AF.

Regarding patients with ERAF, most of them also had late recurrent AF (64,7%), whereas in patients without ERAF, only 20,4% had LR (p&lt;0,001). After including ERAF in the multivariate logistic regression, we identify ERAF as the only independent predictor of late recurrence of AF (OR 5,23, 95% CI 2,56–10,72; p&lt;0,001).

Conclusions

In our cohort, late recurrence of AF after catheter ablation was significantly higher in patients with recurrence within the blanking period, which was the only independent predictor of AF late recurrence.

Funding Acknowledgement

Type of funding sources: None.

The impact of mitral regurgitation grade on exercise capacity following cardiac rehabilitation program after transcatheter aortic valve implantation

Introduction

Severe aortic stenosis (AS) and mitral regurgitation (MR) often coexist. Transcatheter aortic valve implantation (TAVI) is becoming widely used for the treatment of patients (pts) with symptomatic severe AS. However, conflicting data reside concerning the impact of MR on outcomes after TAVI. Also, very few data exist regarding the benefits of a cardiac rehabilitation program (CRP) following TAVI in pts with MR.

Purpose

To evaluate the effect of a CRP in functional parameters after TAVI, particularly in pts with MR grade ≥ II.

Methods

Retrospective study which included all pts submitted to TAVI between 2014 and 2020 that completed a CRP following the procedure. Cardiopulmonary exercise tests (CPET) were performed after TAVI at baseline (pre-CRP) and post-CRP. We evaluated pre- and post-CRP peak oxygen consumption (pVO2), pVO2 at the anaerobic threshold (AT), respiratory exchange ratio (RER), VE/VCO2 and CPET duration. The exercise protocol included low/medium intensity exercises and consisted of sessions 3 times per week carried over 3 months. MR grading severity was assessed with transthoracic echocardiography performed after TAVI and was divided into 2 groups (grade &lt; II vs grade ≥ II).

Results

Fifty-two pts were included, 59,6% were male, mean age of 78,6±8,6 years-old. Mean Society of Thoracic Surgery (STS) risk score was 4,9. Mean pre-TAVI aortic valve area was 0,68 cm2, with a mean gradient of 45,5 mmHg and a mean ejection fraction (EF) of 51%. The majority of pts implanted a self-expandable prosthesis (55,8%).

Twenty-seven (51,9%) pts had MR grade ≥ II. Baseline characteristics were similar between pts with MR grade &lt; II vs MR grade ≥ II, with the exception of the prevalence of coronary artery disease which was higher in MR grade ≥ II (p=0,036). Patients with MR grade &lt; II had higher maximum and median aortic gradients before TAVI (p&lt;0,05 for all). The mean number of cardiac rehabilitation sessions was 21±7, without differences between both groups. In pts with MR grade ≥ II, there was an improvement in CPET duration after CRP (HF protocol from 03:57 min to 05:02 min; p=0,017 and modified Bruce protocol from 06:03 min to 06:41 min; p=0,049) but without significant changes in pVO2 (14,7 mL/kg/min to 14,9 mL/kg/min; p=0,990), RER or VEVCO2/VO2 ratio. Patients with MR grade &lt; II significantly improved pVO2 (13,8 mL/kg/min to 14,7 mL/kg/min; p=0,015), and CPET duration with HF protocol from 05:04 min to 06:23 min; p=0,006 after CRP. There was also an improvement in VEVCO2/VO2 ratio, although not statically significant.

Conclusions

Patients with MR grade &lt; II after TAVI who underwent a CRP significantly improved pVO2 and CPET duration. Although pts with MR grade ≥ II did not improved pVO2 after a CRP, an improvement in CPET duration may translate into a clinical benefit in these pts. These results highlight the importance of further research and personalization among this potentially higher risk subset of pts.

Funding Acknowledgement

Type of funding sources: None.

Single stenting versus double stenting technique in true bifurcation coronary lesions

Introduction

The ideal treatment technique for coronary bifurcation lesions remains unknown. Although single-stenting strategy has been recommended by default, little evidence exists regarding clinical outcomes between single versus double-stenting in current practice.

Purpose

To compare procedural details and clinical outcomes between single vs double-stenting techniques in true bifurcation coronary lesions.

Methods

Retrospective study of all patients (pts) referred for percutaneous coronary intervention (PCI) of true bifurcation lesions between June 2018 and June 2020. Only Medina X,X,1 lesions were included. Pts were split in 2 groups: group 1 (single-stenting) and group 2 (double-stenting). Procedural details and clinical outcomes were assessed. Acute and long-term adverse events included procedural complications (a composite outcome of side branch occlusion, coronary iatrogenic dissection and type 4 acute myocardial infarction (AMI)) and a composite of cardiovascular death, AMI, stroke, re-restenosis and reintervention, respectively.

Results

A total of 118 pts were included, 74,6% male, mean age of 66,4±11 years.

Ninety-five pts (80,5%) were treated with single-stenting (G1) and 23 pts (19,5%) with double-stenting technique (G2). Both groups were well matched regarding baseline characteristics and clinical presentation. T and protrusion (TAP) and minicrush were the most frequent double-stenting techniques (43,5% and 21,7%).

G2 lesions mainly involved the left main (LM) and proximal left anterior descendent artery (LAD) (52,2%) and in G1 mid LAD (34,7%). LM lesions were more common in G2 (26,1% vs 8,4%; p=0,030). G1 had more lesions Medina 1,1,1 (75,8% vs 52,2%; p=0,025) and less Medina 0,1,1 (9,5% vs 30,4%; p=0,015). Proximal optimization technique and kissing balloon occurred more in G2 (p&lt;0,05). G2 had more intravascular ultrasound guided PCI (p=0,046). Femoral access, heparin, contrast and radiation dose, and fluoroscopy time were higher in G2 (p&lt;0,05). Acute adverse composite outcome was similar in both groups (G1 13% vs G2 14,3%; p=0,855).

Median follow-up was similar (G1 16,8±7,9 and G2 19,7±8,8 months; p=0,127). G1 had less occurrence of long-term adverse composite outcome (7,4% vs 26,3%; p=0,032). Excluding interventions in LM, G2 had more significant incidence of acute events (20% vs 2,6%; p=0,028), and higher rate of long-term adverse events (20% vs 4,2%; p=0,056). In interventions of the LM only, no differences were noticed in acute and long-term composite events between groups.

Conclusions

Double-stenting techniques in true coronary bifurcation lesions included more often LM lesions and were complex procedures requiring frequently intracoronary imaging. Although acute adverse events were similar to those of single-stenting, long-term adverse outcomes were more frequent in double-stent group, except for LM lesions.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of coronary artery disease severity and revascularization in TAVI patients

Background

Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis. In patients who undergo surgical aortic valve replacement, the presence of CAD and the need for CABG adversely influences short- and long-term outcomes. However, the impact of concomitant CAD and its revascularization in patients undergoing transcatheter aortic valve implantation (TAVI) is still a matter of debate.

Purpose

The aim of this study was to evaluate the prognostic impact of CAD severity in 1-year all-cause mortality of patients undergoing TAVI and whether prior complete or incomplete reasonable revascularization can improve prognosis after TAVI.

Methods and results

Retrospective analysis of a total of 575 patients (51,3% female, mean age 79,7±7,7 years) who underwent TAVI from August 2007 to November 2018. 50,3% of patients had significant CAD (at least one stenosis &gt;50%) which 54,2% of these had history of prior revascularization (64,8% complete or incomplete reasonable revascularization and 35,2% incomplete revascularization).

Pre-TAVI CAD severity was defined by the SYNTAX Score (SS) and reasonable revascularization by the residual SYNTAX Score (rSS). Patients without history of revascularization were stratified into 3 groups: no CAD (SS=0); nonsevere CAD (SS between 1 and 22); and severe CAD (SS ≥23); Patients who had undergone revascularization prior to TAVI were separated into 2 categories based on their residual SS: complete or incomplete reasonable revascularization (rSS&lt;8) and incomplete revascularization (rSS≥8). The primary end point was an all-cause mortality. 1 year, patients with severe CAD had significantly higher rates of mortality (no CAD: 9,8%, nonsevere CAD: 12,6%, severe CAD: 38,9%; P=0.001) without significant differences between patients with no CAD and nonsevere CAD (p=1,00). Patients with high rSS had significantly higher rates of mortality comparing to no CAD or rSS&lt;8 (no CAD: 9,8%, rSS&lt;8: 8,6%; rSS≥8: 28,0%, p=0.001).

Conclusions

In our study, only the presence of severe CAD (SS≥23) prior to TAVI was associated with increased 1-year all-cause mortality. In patients with previous history of revascularization, a complete/reasonable revascularization (lower rSS) was associated with lower long-term mortality, which may attenuate the association of severe CAD and mortality and therefore improve the prognosis of these patients.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Vila Nova de Gaia / Espinho Figure 1. Prognostic Impact of CAD severityFigure 2. Prognostic Impact of Revascularization

Feasibility of coronary angiography after TAVR

Background

The prevalence of coronary artery disease (CAD) is high among patients with severe aortic stenosis who undergo transcatheter aortic valve replacement (TAVR).

Indications for TAVR are now expanding to younger and lower risk patients. During their lifetime, these patients will be at risk of developing CAD and it is expected an increase in coronary angiography and percutaneous coronary intervention (PCI). Aortic prosthesis, particularly if in supra-annular position, may pose important technical difficulties in coronary re-engagement after TAVR.

Purpose

To evaluate the feasibility to reengage the coronary ostia after TAVR, describe complications and compare technical differences between coronary procedures performed before and after TAVR.

Methods

Retrospective analysis of 714 patients submitted to TAVR from August 2007 to December 2019. Patients who needed coronary angiography after TAVR were selected.

The primary endpoint was the rate of successful coronary ostia cannulation after TAVR, defined by the possibility to selectively cannulate and inject both coronary ostia.

Secondary endpoint was complications associated with coronary catheterization after TAVR.

Results

Among 714 patients, 25 (3.5%) patients were submitted to a total of 28 coronary angiography after TAVR. 14 patients were male (56%), mean age 78.2±6.2 years and 9 (36%) had history of previous coronary revascularization.

From the 28 coronary angiographies (balloon-expandable Edwards-Sapien n=11, 44%; self-expandable CoreValve n=10, 40%; Portico n=2, 8%; Symetis n=2, 8%), 25 (89%) met the primary endpoint. Only three was semiselective (Symetis, CoreValve Evolut R and CoreValve TAVR in TAVR), with impossibility to cannulate both coronary arteries, right coronary artery and left coronary artery, respectively. 13 (46%) patients had also indication for PCI and all were successfully performed (Edwards-Sapien n=4, 31%; CoreValve n=6, 46%; Portico n=2, 15%; Symetis n=1, 8%). The main indications for coronary angiography was chronic coronary syndrome (n=12, 43%) and acute coronary syndrome without ST segment elevation (n=7, 25%). Circumflex artery was the most frequently treated vessel (n=6), followed by left anterior descending artery (n=4), right coronary artery (n=3) and left main (n=2).

There were no complications reported during or post-procedure. Comparing coronary angiographies before and after TAVR, there were no significant differences regarding arterial access site, catheter diameter, fluoroscopy time and quantity of contrast used in coronary angiography.

Conclusion

Although the need for coronary angiography was rare in patients after TAVR, selective diagnostic coronary angiographies were possible in 89% (25/28) and PCI was feasible in all patients in whom it was indicated, without any reported complications.

Further prospective studies are needed to confirm the great feasibility of performing coronary angiography after TAVR.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Vila Nova de Gaia / Espinho

[A socio-anthropological survey to support communication on Covid-19 in West Africa]

The population's adherence to preventive measures is crucial for the success of the fight against the Covid-19 epidemic, whether it is a question of respecting barrier gestures or vaccination. We conducted a socio-anthropological survey in five countries of the Economic Community of West African States (Burkina Faso, Cape Verde, Côte d'Ivoire, Guinea Bissau, and Sierra Leone) on the representations of Covid-19 that may influence this adherence. Our results showed that raising the awareness of barrier gestures was extremely well-received by the population and is perfectly understood, but that a substantial part of the population denies the presence of Covid-19 in their country, that the transmission of SARS-CoV2 by asymptomatic persons is mostly ignored, that the risk factors of severe forms of the disease are insufficiently known and that a majority of the respondents fear contracting Covid-19 when visiting a health center. The "infodemia" circulating on social networks does not seem to contribute to the various misconceptions we have highlighted, which are the product of the interviewees' observations and interpretation. We propose a reorientation of communication about Covid-19 based on the results of our survey.

The role of phage therapy in burn wound infection management: advantages and pitfalls

Burn wound infections are often the source of bacteria responsible for systemic infections, including bloodstream infections and pneumonia that ultimately can result in multisystem organ failure and death. Any rapid change in the burn wound appearance or the clinical condition of the burn patient may herald burn wound infection or sepsis. The revival of phage therapy, either in single mode or in combination with conventional antibiotics may represent a valuable alternative, to treat specific bacterial infections such as burn wound infections, including those caused by multidrug resistant organisms. This systematic review addresses the: a) general characteristics of bacteriophages; b) activity of bacteriophages versus conventional antibiotics; c) activity of bacteriophages against biofilms; d) bacteriophage administration; and e) use of bacteriophages in burn wound infections. Although several scientific organizations/societies recognized that phage therapy could be of key value in modern wound care, specific aspects are critical for a burn surgeon and might represent pitfalls discouraging phage therapy adoption in burn wound management; in particular, the unavailability of consensual therapeutic guidelines/regulatory policies and the lack of laboratorial support that might be predictive of its efficacy. The availability of a product/formulation convenient to use, with adequate stability and shelf half-life is also a key condition.

PERCUTANEOUS TRANSAXILLARY TRANSCATHETER AORTIC VALVE IMPLANTATION

The transaxillary (TAX) approach for transcatheter aortic valve implantation (TAVI) results in comparable short and long-term clinical results compared to the transfemoral (TF) approach. However, adequate closure of the axillary artery is the most critical issue when performing the percutaneous approach. Compared to surgical transaxillary approach, the percutaneous approach was used only in selected cases due to this closure limitation. In the present paper, we aim to demonstrate the feasibility of implanting the CoreValve Evolut Pro transcatheter heart valve via percutaneous transaxillary approach and make a literature review of procedure particularities and outcome. We describe the case of a patient with severe aortic stenosis in the presence of small calibre and severely calcified femoral arteries. A CoreValve Evolut Pro 26 was successfully implanted percutaneously through the left axillary artery. Percutaneous transaxillary transcatheter aortic valve implantation is a feasible and safe alternative in patients who have suboptimal iliofemoral vessels.

Overhydration May Be the Missing Link between Peritoneal Protein Clearance and Mortality

INTRODUCTION

Peritoneal protein loss (PPL) has been associated with mortality. Inflammation was assumed a putative cause with malnutrition as a consequence. Hydrostatic convection is a major drive for microvascular protein transport, but most studies in peritoneal dialysis (PD) patients overlooked this mechanism. An association between peritoneal protein clearance (PPCl) and venous congestion has been reported recently. The aim of this study was to explore the importance of fluid overload in PPCl in PD.

METHODS

Sixty-seven prevalent PD patients were assessed with peritoneal equilibration test and multifrequency bioelectrical impedance assessment (BIA). PPL and PPCl were calculated from simultaneously obtained 24-h peritoneal effluent.

RESULTS

PPL averaged 5.2 g/24 h. It was higher in patients on continuous treatment than in those without a long dwell. Significant associations between PPCl and BIA parameters of overhydration were found in both univariable and multivariable analyses. Lean mass index, partly dependent on hydration status, was associated with PPCl in univariable but not in multivariable analysis. A multiple linear model identified extracellular water excess and higher D/P creatinine as predictors of higher PPCl, independent of PD duration, type of PD, age, gender, albumin, cardiovascular disease, C-reactive protein, or lean mass index.

CONCLUSIONS

The uni- and multivariable strong associations between fluid overload and PPCl support the importance of hydrostatic pressure-induced convection for PPCl. Also, peritoneal small solute transport was associated with PPCl. Both are amenable by adjusted dialysis prescription, especially focused on fluid status and avoidance of overhydration. The assumption of an association with inflammation and malnutrition was not confirmed.

Prevalence and predictor factors of persistent pulmonary vein isolation in redo AF ablation procedure

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial fibrillation (AF) catheter ablation is a well-established procedure for the treatment of AF. The cornerstone of AF ablation is the complete isolation of pulmonary veins (PV). However, persistent PV isolation (PVI) is difficult to accomplish, with PV reconnection rates of &gt; 70%. The factors associated with persistent PVI are still uncertain.

Purpose

To assess the PVI status in patients (pts) undergoing a redo ablation and to determinate the predictors associated with persistent PVI.

Methods

Consecutive pts who underwent a redo ablation between 2016 and 2020 were identified in a single-centre retrospective study. PVI status was assessed during electrophysiologic study with electroanatomic mapping system. Index procedures included second generation cryoballoon (CB), conventional radiofrequency (RF) before 2018 and CLOSE protocol guided RF ablation after 2018. Persistent PVI was defined by the absence of reconnection of all pulmonary veins.

Results

We included 83 pts with a mean age of 55,9 ± 11,9 years; 71,1% (n = 59) were male with a mean CHA2DS2-VASc score of 1,14 ±1,0. Seventy-five percent had paroxysmal AF and undergone a redo 35,0 months (±30,9) after the index PVI.

Seventeen pts (20,5%) had persistent PVI whereas 66 pts (79,5%) had at least one PV reconnected after the index procedure, with a reconnection rate of 51,8% for right superior and inferior PV, 47,0% for left superior PV and 36,1% for left inferior PV.

No statistically significant differences were noticed between pts with persistent and non-persistent PVI in baseline (clinical and echocardiographic) characteristics.

Regarding index ablation procedure, persistent PVI occurred more frequently in patients who underwent a "CLOSE" protocol-guided index PVI compared to RF pre-2018 and CB (45,5% vs 16,7%; p = 0,043).

Twenty-nine percent of pts with persistent PVI had a "CLOSE" protocol-guided index PVI whereas only 9,1% of non-persistent PVI pts had a "CLOSE" protocol-guided index PVI (p = 0,043).

In this cohort, "CLOSE" protocol-guided index PVI was the only predictor of persistent PVI (odds ratio 4.2, 95% confidence interval 1.1-15.9; p = 0.037).

Conclusions

In patients undergoing redo AF ablation procedures, only 20,5% had persistent PVI. "CLOSE" protocol-guided index PVI presented significantly higher rates of persistent PVI.  "CLOSE" protocol-guided index PVI was the only predictor for persistent PVI in patients with AF recurrence requiring a redo procedure.

Redo ablation for atrial fibrillation recurrence post radiofrequency or cryoballoon ablation: a high volume single-centre experience

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial fibrillation (AF) ablation is a well-established procedure for the treatment of AF. The cornerstone of AF ablation is the complete and durable isolation of pulmonary veins (PV) through radiofrequency (RF) or cryoballoon (CB) ablation. However, PVI durability between RF or CB was not yet established, as reablation strategy and outcomes in patients (pt) undergoing a redo ablation.

Purpose

To compare RF versus CB regarding PVI status, reablation procedure and outcomes in pts undergoing a second procedure.

Methods

Single-centre retrospective study of consecutive pts who underwent a redo between 2016 and 2020. PVI status was assessed during electrophysiologic study with electroanatomic mapping system. Index procedures included second generation CB, conventional RF before 2018 and CLOSE protocol guided RF ablation after 2018. We assessed time-to-redo, number and location of reconnected PVs, procedural characteristics, acute and long-term outcomes between RF and CB index PVI.

Results

Seventy-four (55 RF and 19 CB) pts were included, 68,9% were male, most pts had paroxysmal AF (71,6%) and a mean CHA2DS2-VASc score of 1,14 ± 1,0.

No statistically significant differences were noticed in clinical and echocardiographic characteristics between pts within RF or CB cohorts.

Median time to reablation was significantly longer in the RF cohort (38,6 months ±33,6) compared to CB (17,0 months ±9,5) (p = 0,014). The number of reconnected PV was higher in CB than the RF cohort, although not significant (2,37 ±1,2 vs 1,75 ±1,4;p = 0,080). Right inferior PV was significantly more reconnected in pts within the CB compared to RF group (73,7% vs 45,6%;p = 0,034), without differences in the other PV reconnection rates.

Regarding reablation procedure, all pts were submitted to RF-redo. Fluoroscopy time was shorter for CB than RF cohort (7,4 ±2,9 vs 13,3 ±8,4;p = 0,002). There were no significant differences between the type of reablation (PVI only vs PVI plus other lesions or cavotricuspid isthmus ablation), with no difference in overall acute success.

After the redo procedure, no differences were observed in recurrence rate in the blanking period and after 91 days from reablation. Nevertheless, time-to-recurrence (&gt;91 days) was longer for RF than CB group (13,4 months ±10,7 vs 4,3 months ±1,5;p = 0,016). There were 2 pts in the RF group that were submitted to a third ablation procedure (p = 0,725). There were no differences between groups in the composite of adverse cardiovascular (CV) outcomes (stroke/transient ischemic attack, emergency room visit for AF, hospitalization for AF or CV death); p = 0,715.

Conclusions

After the index procedure, reablation occur later in RF than CB cohort.  Although the number of reconnected PV were similar between groups, right inferior PV was significantly more reconnected in pts originally treated with CB. After redo, time-to-recurrence was shorter for CB cohort. Recurrence and composite of adverse CV outcomes were similar.

Lymphogranuloma venereum: a retrospective analysis of an emerging sexually transmitted disease in a Lisbon Tertiary Center

BACKGROUND

Lymphogranuloma venereum (LGV) is a sexual transmitted infection (STI), currently endemic within the population of men who have sex with men (MSM) of Western Countries. L2B variant has been reported as the predominant strain in the current LGV epidemics, although a shift towards L2-434 has been observed in some European countries.

OBJECTIVES

To evaluate and characterize the population with LGV infection diagnosed in Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.

METHODS

A retrospective analysis of all LGV diagnoses between 2016 and 2019 was performed. The diagnosis was established through ompA-genotyping of samples yielding a positive result to Chlamydia trachomatis (CT). All considered samples were retrieved from the clinician activity, through swabbing and urine analysis and CT infection diagnosis was obtained using real-time PCR.

RESULTS

During the period studied 16 279 CT diagnostics tests were employed, with a striking increase from 2016 (n = 467) to 2019 (n = 9362). A total of 1602 diagnoses of CT were established, from which 168 (10.5%) corresponded to LGV, with both infections showing a rising evolution, between 2016 and 2019, of 2.9 and 2.7 times, respectively. The majority of the LGV strains were genotyped as L2/434 (67.3%; n = 113). LGV predominantly affected MSM and men who have sex with men and women (97.0%; n = 163). Anorectal infection was the most prevalent one (90.5%; n = 152), being proctitis the main clinical presentation (76.2%; n = 128). Absence of symptoms was reported in almost 15% of the cases (n = 24). The presence of concomitant infection with human immunodeficiency virus was dominant (73.2%; n = 123) and the prevalence of one or more STI co-infections was about 60.1% (n = 99).

CONCLUSIONS

An increasing evolution of CT and LGV testing and diagnosing was observable throughout the studied period. Characteristics of the population are similar with those described within LGV epidemics. In accordance with recent European studies, predominance towards L2 genotype was identified.

COVID-19 infection in patients with intestinal failure: UK experience

BACKGROUND

The direct effect of the coronavirus disease 2019 (COVID-19) pandemic on patients with intestinal failure (IF) has not been described.

METHODS

We conducted a nationwide study of UK IF centers to evaluate the infection rates, presentations, and outcomes in patients with types 2 and 3 IF.

RESULTS

A total of 45 patients with IF contracted COVID-19 between March and August 2020; this included 26 of 2191 (1.2%) home parenteral nutrition (HPN)-dependent adults and 19 of 298 (6.4%) adults hospitalized with type 2 IF. The proportion of patients receiving nursing care for HPN administration was higher in those with community-acquired COVID-19 (66.7%) than the proportion in the entire HPN cohort (26.1%; P < .01). Two HPN-dependent and 1 hospitalized patient with type 2 IF died as a direct consequence of the virus (6.7% of 45 patients with types 2 or 3 infected).

CONCLUSION

This is the first study to describe the outcomes of COVID-19 in a large cohort of patients requiring long-term PN. Methods to reduce hospital and community nosocomial spread would likely be beneficial.