Does third molar agenesis influence the second lower molar mineralization?

Different studies have established that the mineralization stages of the second mandibular molar can be used in forensic age estimation. Nowadays, the estimate's accuracy is an ethical concern, producing as few false positives (individuals incorrectly classified as older than a determined threshold) and false negatives (individuals incorrectly classified as younger than a determined threshold) as possible. Some have hypothesized that changes in teeth number may influence tooth mineralization, altering the age estimate process. This paper analyzes whether third molar agenesis affects the second mandibular molar mineralization time frame. To do so, 355 orthopantomograms were evaluated for third molar agenesis, and the second mandibular molar mineralization stage was assessed using the Demirjian stages. Student's t-test was used to compare the difference in the mean age at which the various stages of 37 mineralization were reached in the groups with and without third molar agenesis. The level of statistical significance was set at 5%. The results pointed to a delay in second mandibular molar mineralization in the case of agenesis, suggesting the need to consider this when estimating age using dental techniques.

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

BACKGROUND

Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA.

METHODS

This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up.

RESULTS

564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections.

CONCLUSIONS

After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

Allele frequency of muscular genetic disorders in bull-catching (vaquejada) quarter horses

Quarter horses (QH), a prominent athletic breed in Brazil, are affected by muscular genetic disorders such as myosin-heavy chain myopathy (MYHM), polysaccharide storage myopathy (PSSM1), hyperkalemic periodic paralysis (HyPP), and malignant hyperthermia (MH). Bull-catching (vaquejada), primarily involving QH, is a significant equestrian sport in Brazil. Since the allele frequencies (AF) of MYHM, PSSM1, HyPP, and MH in vaquejada QH remain unknown, this study evaluated the AF in 129 QH vaquejada athletes, specifically from the Brazilian Northeast. These variants were exclusively observed in heterozygosity. The MYHM exhibited the highest AF (0.04 ±0.01), followed by PSSM1 (0.01 ±0.01) and the HyPP variant (0.004 ±0.01), while the MH variant was not identified in this study. This study represents the first identification of these variants in vaquejada QH, emphasizing the need to implement measures to prevent the transmission of pathogenic alleles and reduce the occurrence of clinical cases of these genetic diseases.

Comprehensive look at rectal squamous cell carcinoma

Rectal squamous cell carcinoma (rSCC) is a rare cancer (0.5% of all rectal cancers). It typically presents at an advanced stage and has a poor prognosis. Recently, chemoradiotherapy with organ preservation has become an option for complete response (CR). Surveillance is essential to prompt recognition of recurrence due to its high risk. We present a case of an elderly woman with rSCC stage cT4N1aM0 who underwent a combination of chemotherapy (mitomycin and fluoropyrimidine) and radiotherapy with CR and organ preservation. The patient has been in follow-up for 2 years with digital rectal examination, tumour markers, pelvic MRI, thoracic and upper abdominal CT, proctoscopy and positron emission tomography, with no disease recurrence. This highlights the success of chemoradiotherapy for rSCC treatment, allowing organ preservation.

A Comprehensive Review on Deep Eutectic Solvents and Its Use to Extract Bioactive Compounds of Pharmaceutical Interest

The extraction of bioactive compounds of pharmaceutical interest from natural sources has been significantly explored in recent decades. However, the extraction techniques used were not very efficient in terms of time and energy consumption; additionally, the solvents used for the extraction were harmful for the environment. To improve the environmental impact of the extractions and at the same time increase the extraction yields, several new extraction techniques were developed. Among the most used ones are ultrasound-assisted extraction and microwave-assisted extraction. These extraction techniques increased the yield and selectivity of the extraction in a smaller amount of time with a decrease in energy consumption. Nevertheless, a high volume of organic solvents was still used for the extraction, causing a subsequent environmental problem. Neoteric solvents appeared as green alternatives to organic solvents. Among the neoteric solvents, deep eutectic solvents were evidenced to be one of the best alternatives to organic solvents due to their intrinsic characteristics. These solvents are considered green solvents because they are made up of natural compounds such as sugars, amino acids, and carboxylic acids having low toxicity and high degradability. In addition, they are simple to prepare, with an atomic economy of 100%, with attractive physicochemical properties. Furthermore, the huge number of compounds that can be used to synthesize these solvents make them very useful in the extraction of bioactive compounds since they can be tailored to be selective towards a specific component or class of components. The main aim of this paper is to give a comprehensive review which describes the main properties, characteristics, and production methods of deep eutectic solvents as well as its application to extract from natural sources bioactive compounds with pharmaceutical interest. Additionally, an overview of the more recent and sustainable extraction techniques is also given.

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Apple Core Unveiled: Malignant Colonic Obstruction Revealing an Unknown Rectosigmoid Neoplasm With Foreign Body Impaction

This case report highlights a rare clinical scenario of a 46-year-old male presenting with constipation and fecaloid vomiting due to an impacted chicken bone within an unidentified rectosigmoid neoplasm, leading to acute malignant colonic obstruction. Emergent exploratory laparotomy revealed an impacted chicken bone lodged in a previously unknown rectosigmoid tumor. An anatomopathological examination revealed a mucinous adenocarcinoma with clear margins and one pericolic metastatic lymph node. The postoperative period was uneventful, and the patient was proposed for adjuvant chemotherapy. The abrupt onset of symptoms allowed for an early diagnosis, emphasizing the unexpected association between foreign body impaction and incidental malignant obstruction. This case underscores the complexity of managing foreign body ingestion in the gastrointestinal tract and emphasizes the crucial role of diagnostic imaging in surgical planning. Furthermore, it draws attention to the potential occurrence of colorectal cancer in younger individuals, emphasizing the necessity for clinical vigilance and screening strategies beyond conventional age recommendations.

The impact of lung ultrasound assessment during a whole lung lavage: A paediatric case of pulmonary alveolar proteinosis

Whole lung lavage (WLL) is the first-line treatment for pulmonary alveolar proteinosis. We hypothesized that lung ultrasound (LUS) would guide flooding during treatment in a 15-year-old boy. WLL of each lung consisted of instillation of saline followed by kinesiotherapy and fluid drainage. In the first WLL, the lung was repeatedly flooded until the lavage fluid was clear on macroscopic examination. During this process, LUS was used to visualise lung aeration. In the second WLL, we used LUS signs to guide the lavage volume. The appearance of the fluid bronchogram sign showed that saline infusion could be stopped earlier than in the first lavage. In conclusion, LUS helped monitor the different stages of controlled lung de-aeration during WLL and reduce the total amount of saline used. This technique will also reduce the risk of WLL-related complications.

Subcritical Water Extraction to Valorize Grape Biomass-A Step Closer to Circular Economy

With the increase in the world population, the overexploitation of the planet's natural resources is becoming a worldwide concern. Changes in the way humankind thinks about production and consumption must be undertaken to protect our planet and our way of living. For this change to occur, sustainable development together with a circular economic approach and responsible consumption are key points. Agriculture activities are responsible for more than 10% of the greenhouse gas emissions; moreover, by 2050, it is expected that food production will increase by 60%. The valorization of food waste is therefore of high importance to decrease the environmental footprint of agricultural activities. Fruits and vegetables are wildly consumed worldwide, and grapes are one of the main producers of greenhouse gases. Grape biomass is rich in bioactive compounds that can be used for the food, pharmaceutical and cosmetic industries, and their extraction from this food residue has been the target of several studies. Among the extraction techniques used for the recovery of bioactive compounds from food waste, subcritical water extraction (SWE) has been the least explored. SWE has several advantages over other extraction techniques such as microwave and ultrasound extraction, allowing high yields with the use of only water as the solvent. Therefore, it can be considered a green extraction method following two of the principles of green chemistry: the use of less hazardous synthesis (principle number 3) and the use of safer solvents and auxiliaries (principle number 5). In addition, two of the green extraction principles for natural products are also followed: the use of alternative solvents or water (principle number 2) and the use of a reduced, robust, controlled and safe unit operation (principle number 5). This review is an overview of the extraction process using the SWE of grape biomass in a perspective of the circular economy through valorization of the bioactive compounds extracted. Future perspectives applied to the SWE are also discussed, as well as its ability to be a green extraction technique.

The Association between Childhood Obesity and Cardiovascular Changes in 10 Years Using Special Data Science Analysis

The increasing prevalence of overweight and obesity is a worldwide problem, with several well-known consequences that might start to develop early in life during childhood. The present research based on data from children that have been followed since birth in a previously established cohort study (Generation XXI, Porto, Portugal), taking advantage of State-of-the-Art (SoA) data science techniques and methods, including Neural Architecture Search (NAS), explainable Artificial Intelligence (XAI), and Deep Learning (DL), aimed to explore the hidden value of data, namely on electrocardiogram (ECG) records performed during follow-up visits. The combination of these techniques allowed us to clarify subtle cardiovascular changes already present at 10 years of age, which are evident from ECG analysis and probably induced by the presence of obesity. The proposed novel combination of new methodologies and techniques is discussed, as well as their applicability in other health domains.

Surgically Targeted Radiation Therapy (STaRT) for Brain Metastases: Initial Experience from a Prospective Multi-Institutional Registry

PURPOSE/OBJECTIVE(S)

Resection and intraoperative brachytherapy for patients with large, operable brain metastasis allows for both relief of mass effect and the delivery of radiotherapy (RT) to the resection cavity with a favorable dosimetric profile. The objective of this study was to analyze early patterns-of-care and treatment-related toxicity outcomes for brain metastasis patients treated with surgically targeted radiation therapy (STaRT) using a novel brachytherapy carrier.

MATERIALS/METHODS

Patients with brain metastasis, de novo and recurrent disease, who enrolled onto a prospective multi-institutional observational study (NCT04427384) were the subject of this analysis. Patients underwent resection and immediate implantation of bioresorbable, conformable, 20 mm x 20 mm x 4 mm collagen tile brachytherapy device(s) containing four uniform-intensity Cesium-131 sources. Toxicities were categorized using the CTCAE v5.0 adverse event (AE) criteria.

RESULTS

From 10/2020 to 01/2023, 13 participating sites enrolled and treated 48 patients with 51 metastases (13 with de novo and 35 patients with recurrent brain metastases), and 3 patients had 2 lesions implanted at the same procedure. Median age was 61 years (range: 28-80), 52% were female, and the most common primary types were lung (56%) and breast (13%). The median maximum pre-operative dimension was 3.4 cm (range: 1.7-5.7) and median pre-operative tumor volume 13.7cm3 (range: 1.7-132). 64% had received prior RT with a median time from last RT to STaRT of 14.6 months range: 3.5-57.3). Median KPS at screening was 80 (range: 50-100), and remained stable at post op visit (80, range: 50-100), and at 3-months following treatment (80, range 50-100), respectively (p>0.05). The median time for implantation was 3 minutes (range: 0.4-30). At a median follow-up of 4 months (range: <1-18), no patient experienced a radiation-attributed AE, and only 1 attributable Gr >3 AE was noted (Gr 5 intracerebral hemorrhage deemed probably related to surgery and unrelated to the implanted device).

CONCLUSION

Early results from this prospective multi-center trial demonstrate the feasibility and safety of STaRT. The lack of radiation-related AE, even with short follow-up, is intriguing given the relatively large lesion size and proportion of patients treated for recurrent, previously irradiated disease. Additional follow-up will provide data on tumor control outcomes and radiation necrosis rates using this novel technique.

The Effects of Adjuvant Chemoradiotherapy (CRT) on Myeloid-Derived Suppressor Cell (MDSC) Subsets in Glioblastoma (GBM)

PURPOSE/OBJECTIVE(S)

GBM continues to be a diagnosis with an exceedingly low survival rate despite standard therapy of resection followed by concurrent CRT. MDSC, immunosuppressive myeloid cells that aid immune system evasion by the tumor, expand during fractionated RT. To date, little is known about the effects of CRT on MDSC subsets. The goal of our pilot study is to compare peripheral blood MDSC subset frequency in patients (pts) undergoing CRT. We hypothesize that the pro-tumor, monocytic MDSC (M-MDSC) subset increases following CRT.

MATERIALS/METHODS

Pts over the age of 18 yo with a new diagnosis of GBM from a single institution participated in the study between 7/2022 -1/2023. Exclusion criteria included prior history of brain RT. Baseline peripheral blood samples were collected within one week prior to CRT start and post-CRT samples were collected within the last week of CRT. Peripheral blood mononuclear cells (PBMC) were isolated from whole blood and freshly stained for intracellular flow cytometric analyses. Total MDSC (singlet, viable, non-lymphocyte, CD11b+CD33+ HLA-DR- cells) and subsets (M-MDSC, granulocytic (G-MDSC), and early MDSC (eMDSC)) were identified. Percent frequency (%fx) of total and MDSC subsets as well as MDSC activation status (n = 3) (interleukin (IL)-10, transforming growth factor-β (TGF-β), interferon gamma (IFNγ)) was compared before and after CRT.

RESULTS

The average age of pts receiving CRT (n = 4) was 70 yo. Fractionated RT consisted of CF RT (n = 2), 6000 cGy in 30 fractions, and HF RT (n = 2), 4005 cGy in 15 fractions. All pts received concurrent chemotherapy with temozolomide. The %fx of MDSC of non-lymphocytes started at 29.2% prior to CRT and decreased to 9.9% at the end of CRT. The fold change of %fx of total MDSC in CF RT and HF RT was 0.39 and 0.29, respectively. The mean change in %fx of MDSC subsets before and after CRT are shown in Table 1. The mean %fx of TGF-β-expressing MDSC in all GBM pts increased by 3.5% after CRT. The mean IFNγ+ MDSC %fx for all GBM pts decreased after CRT from 24.2% to 16.2% with a corresponding decrease in geometric mean fluorescence intensity (GMFI). The mean %fx of IL-10+ MDSC decreased by 1.5% at the end of CRT with a decrease in GMFI from 5550 to 1806.

CONCLUSION

In this limited dataset of pts with GBM receiving standard of care adjuvant therapy, we identified an expansion in the eMDSC and decrease in the M-MDSC subsets. These early results suggest HF RT may promote immunity that is more supportive of anti-tumor function, with a lesser increase in fold change of total MDSC after CRT. A more detailed understanding of the effect of RT on myeloid subpopulations is essential to addressing immune suppression in pts with GBM.

Sex-Specific Patterns of Cerebral Atrophy and Enlarged Perivascular Spaces in Patients with Cerebral Amyloid Angiopathy and Dementia

BACKGROUND AND PURPOSE

Cerebral amyloid angiopathy is characterized by amyloid β deposition in leptomeningeal and superficial cortical vessels. Cognitive impairment is common and may occur independent of concomitant Alzheimer disease neuropathology. It is still unknown which neuroimaging findings are associated with dementia in cerebral amyloid angiopathy and whether they are modulated by sex. This study compared MR imaging markers in patients with cerebral amyloid angiopathy with dementia or mild cognitive impairment or who are cognitively unimpaired and explored sex-specific differences.

MATERIALS AND METHODS

We studied 58 patients with cerebral amyloid angiopathy selected from the cerebrovascular and memory outpatient clinics. Clinical characteristics were collected from clinical records. Cerebral amyloid angiopathy was diagnosed on MR imaging on the basis of the Boston criteria. Visual rating scores for atrophy and other imaging features were independently assessed by 2 senior neuroradiologists.

RESULTS

Medial temporal lobe atrophy was higher for those with cerebral amyloid angiopathy with dementia versus those cognitively unimpaired (P = .015), but not for those with mild cognitive impairment. This effect was mainly driven by higher atrophy in men with dementia, compared with women with and without dementia (P = .034, P = .012; respectively) and with men without dementia (P = .012). Enlarged perivascular spaces in the centrum semiovale were more frequent in women with dementia versus men with and without dementia (P = .021, P = .011; respectively) and women without dementia (P = .011).

CONCLUSIONS

Medial temporal lobe atrophy was more prominent in men with dementia, whereas women showed a higher number of enlarged perivascular spaces in the centrum semiovale. Overall, this finding suggests differential pathophysiologic mechanisms with sex-specific neuroimaging patterns in cerebral amyloid angiopathy.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Bacterial pneumonia in horses associated with Escherichia coli infection: report of five cases

ABSTRACT Respiratory diseases have a major impact on sport horses and are often cited as the second most common reason for loss of training days and significant veterinary costs. Adult horses most commonly develop pneumonia when bacteria aspirated from the environment, nose, or oropharynx reach the lower airways and overwhelm the pulmonary defense mechanisms. This article report five cases of bacterial pneumonia in horses associated with infection by Eschericia coli. Five Quarter horses, three males and two females, with ages varying from 5 to 12 years, were examined for diagnosis of respiratory disease characterized by apathy, cough and lack of appetite. Auscultation of the thorax revealed increased harsh breath sounds dorsally, crackles, wheezes, and dullness of respiratory sounds ventrally. Manipulation of the trachea and larynx induced cough. Culture results were positive for Escherichia coli. The therapeutic protocol consisted of anti-inflammatory, antibiotic therapy, and supportive care. Flunixin meglumine was administered intravenously at 24-hour intervals over eight days. Ceftiofur sodium was prescribed intramuscularly, q.d., for 15 days. Horses were clinically monitored daily until complete remission of clinical signs. None of the animals relapsed, and all returned to routine athletic activities.

Body image shame in men: confirmatory factor analysis and psychometric properties of the Body Image Shame Scale

PURPOSE

Body image shame plays a key role in disordered eating symptoms and psychological adjustment. Nonetheless, research has been mainly focussed on women. The Body Image Shame Scale (BISS) was previously developed and tested in a nonclinical sample of women. This study examines the BISS in a sample of men comprising students and community participants.

METHODS

Participants were 420 men, who completed the BISS and self-report measures of shame, self-criticism, body weight and shape concerns, and psychopathological symptoms.

RESULTS

The previously identified structure of the BISS, with an external and internal dimension, fitted the data well. All items presented high reliability. The BISS total score and its subscales in men present high construct reliability, and convergent and discriminant validity. Correlation analyses indicated that BISS and its subscales in men present positive associations with general shame and self-criticism, body weight and shape concerns, and with indices of poorer psychological adjustment.

CONCLUSION

Findings supported that the BISS is a reliable measure to assess body shame in men.

LEVEL OF EVIDENCE

III: Evidence obtained from well-designed cohort or case-control analytic studies.

T-pattern analysis of offensive and defensive actions of youth football goalkeepers

Nowadays, football goalkeepers (GKs) play an important role in the team's organization, namely, considering the offensive and defensive processes. The purpose of our investigation focuses on the notational and T-pattern analysis of the offensive and defensive actions of elite young football GKs. The participating GKs (n = 3, mean age of 16.6 years) presented 8 years of experience in the specific position, were internationally selected for the national team of Portugal, and competed in the national U-17 championship of Portugal. Thirty football matches were observed. The observational sample consisted of defensive actions (n = 225) and offensive actions (n = 296). Two observational instruments were used to codify the actions: the observation system of defensive technical-tactical actions of GKs and the observation system of offensive technical-tactical actions of GKs. Both instruments underwent a validation process, and inter- and intra-observer reliability was tested. The codification of the actions was performed with the LINCE program, and later the data were exported to Microsoft Excel and THEME 5.0. The notational data were analyzed in SPSS, and T-pattern detection analysis was performed in THEME 5.0. The predominant actions of young observed GKs were fundamentally goal defense and participation in the team's offensive process construction through actions performed with the foot and hand. The analysis of T-patterns allowed to identify T-pattern actions in the defensive actions of goal defense and exit of the goal, as well as related to the defensive set pieces. In the offensive process, the analysis of T-patterns reinforced the participation of the GK in the team's first phase of construction and in the execution of goal kicks and actions that start as a result of the actions of the opponent. The GK's defensive actions are mostly focused on the objective of goal defense and offensive actions with the hands and feet are important for their participation in positional attack construction. Our study contributes to a better knowledge of the GK's actions in the competition and is relevant to be considered by the specific position coaches in the training process organization.

1,8-cineole Ameliorates Right Ventricle Dysfunction Associated With Pulmonary Arterial Hypertension by Restoring Connexin 43 and Mitochondrial Homeostasis

For the first time, the present study unravels a cardiospecific therapeutic approach for Pulmonary Arterial Hypertension (PAH), a disease with a very poor prognosis and high mortality rates due to right ventricle dysfunction. We first established a new in vitro model of high-pressure-induced hypertrophy that closely resembles heart defects associated with PAH and validated our in vitro findings on a preclinical in vivo model of monocrotaline (MCT)-induced PAH. Our results showed the in vitro antihypertrophic effect of 1,8-cineole, a monoterpene widely found in several essential oils. Also, a decrease in RV hypertrophy and fibrosis, and an improvement in heart function in vivo was observed, when 1,8-cineole was applied topically. Furthermore, 1,8-cineole restored gap junction protein connexin43 distribution at the intercalated discs and mitochondrial functionality, suggesting it may act by preserving cardiac cell-to-cell communication and bioenergetics. Overall, our results point out a promising therapeutic compound that can be easily applied topically, thus paving the way for the development of effective cardiac-specific therapies to greatly improve PAH outcomes.

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

Funding Acknowledgements

Type of funding sources: None.

Background

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

Methods

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

Results

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

Conclusions

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

Postpartum headache after epidural anaesthesia: Who to blame?

INTRODUCTION

Epidural analgesia is considered the preferred analgesic choice during labour. Post dural puncture headache (PDPH) is considered a potential complication of this analgesic technique and is a frequently hypothesis for any headache occurring after delivery. It is essential that anaesthetists and obstetricians are familiar with other possible differential diagnosis for postpartum headache (PPH).

CASE DESCRIPTION

37-year-old female presented after delivery with intense occipital pulsatile headache associated with neck radiation, nausea and vomiting, hemodynamically stable and normal neurologic physical examination. Abnormalities in thyroid hormone levels were found. CT-scan findings suggested pituitary apoplexy.

DISCUSSION

There are many differential diagnoses for PPH and some are rarely considered, such as pituitary apoplexy. It is essential to differentiate signs and symptoms of each diagnosis, since many of them overlap.

CONCLUSION

Not all postpartum headaches are PDPH and the first suspected diagnosis may not always be accurate.

Outcomes of radiofrequency catheter ablation for persistent and long-standing persistent atrial fibrillation

Introduction

Catheter ablation has become the first-line treatment for symptomatic patients with atrial fibrillation (AF). Several approaches of substrate ablation have been used for persistent and long-standing persistent AF and the best protocol procedure is yet to be established. The purpose of this study was to evaluate the outcomes of patients submitted to catheter ablation of persistent and long-standing persistent AF adding extra-pulmonary substrate approaches to pulmonary vein isolation.

Methods

We retrospectively studied 67 consecutive patients referred for the first procedure of catheter ablation of persistent or long-standing persistent AF from May 2016 to October 2018. The first 27 patients were subjected to pulmonary vein isolation and complex fractionated atrial electrograms (CFAE) ablation (group 1) and the last 40 patients were subjected to a tailored approach guided by voltage map areas and CFAE (group 2). Patient characteristics, procedure details and follow-up were assessed, and predictors of recurrence were determined.

Results

Mean age was 59±11 years with 58% being male. During a mean follow-up of 16±6 months 27% of the patients showed AF recurrence. There were no differences in baseline characteristics of group 1 and 2. A higher recurrence rate was found in group 1 by comparison with group 2 (40.7% vs 17.5%, Log Rank X2 = 5.076, P=0.024) (Figure 1). Also, recurrence was associated with a longer AF duration, an increased baseline Brain Natriuretic Peptide (BNP), an increased left atrium (LA) volume, the presence of hyperthyroidism, the absence of sinus rhythm after procedure, the inducibility of AF post-ablation and the absence of an antiarrhythmic drug at hospital discharge. After adjustment for other confounders, the patient group (HR 5.16 [1.23–21.71] P=0.025), a long-standing AF (HR 9.09 [1.41–58.82] P=0.020), the BNP value at admission (HR 1.03 [1.01–1.05] P=0.033) and the LA volume index (HR 1.13 [1.02–1.25] P=0.017) were the only independent predictors of recurrence.

Conclusion

Ablation of persistent and long-standing persistent AF is feasible with good results when a substrate approach is added to pulmonary vein isolation. A tailored approach seems to be more efficient, showing best outcomes in mid-term follow-up. A long-standing AF, higher BNP value and the LA enlargement are important predictors of recurrence and should be used to better select patients and to manage follow-up.

Funding Acknowledgement

Type of funding sources: None.

Metabolic reprogramming in pulmonary arterial hypertension: is it a cancer-like disease?

Background

Idiopathic pulmonary arterial hypertension (iPAH) is a rare and chronic disease associated with poor outcomes. Previously considered a disease restricted to the pulmonary circulation, PAH is now being recognized as a systemic disorder that is associated with metabolic dysfunction. The aim of this study is to analyze the metabolic reprogramming in the lung and peripheral blood mononuclear cell (PBMCs) of iPAH patients and explore their potential roles in PAH pathophysiology.

Methods

Five independent datasets, containing transcriptomic data of human PBMCs (GSE22356 and GSE33463) and lung (GSE48149 GSE113439 and GSE117261) samples, from 139 iPAH patients and 96 healthy controls, were downloaded at the GEO database. In each dataset, the samples were normalized and a pair-wise comparison between control and iPAH samples was performed using limma package, for the R programming language. Genes with a p-value lower than 0.05 were considered differentially expressed between the two groups. A subset of metabolism related genes was selected, and their expression was compared across the datasets.

Results

Among the 13 genes with differential expression identified, only 10 had a coherent expression across all datasets (Figure 1). Firstly, we report an association with insulin resistance through impairment of PI3K signaling in iPAH patients, by expressing lower levels of the heterodimer PIK3CD and regulatory PIK3IP1 and PIKR1 subunits in PBMCs, and by expressing higher levels of its downstream targets in the lung (TBC1D4). However, more extensive metabolic dysfunction was observed. A significant glycolytic shift in the lung and PBMCs was present, as a consequence of deregulation in genes involved in aerobic glycolysis and decreased fatty acid oxidation, namely increased expression of PD1K and lower levels of expression of LDHB. The findings of decreased SLC25A1 protein in both PBMCs and lung suggest impairment of the tricarboxylic acid (TCA) cycle flux in PAH. Additionally, SLC1A5 highlights the involvement of glutamine metabolism and glutaminolysis derangements in PAH. Conversely, SREBP1 is involved in sterol biosynthesis and lower levels in PMBCs results in impaired resolution of inflammatory responses. Finally, although the role of autophagy in iPAH is complex, higher levels of expression of ATG13 in PBMCs and lower levels in the lung confirm autophagy deregulation in iPAH. Interestingly, all the metabolic pathways identified (Figure 2) are hallmarks of the metabolic reprogramming seen in cancer cells, a finding already suggested by the clonal proliferation of pulmonary artery smooth muscle cells described in plexiform lesions.

Conclusion

Our results provide novel insights into the metabolic regulation in iPAH. Molecularly, these cells exhibit many features common to cancer cells, suggesting the opportunity to exploit therapeutic strategies used in cancer to treat iPAH.

Funding Acknowledgement

Type of funding sources: None.

Interventional cardiology in times of COVID-19: impact on a terciary centre

Introduction

Cardiovascular diseases are the leading cause of death worldwide and the pandemic caused by coronavirus disease 2019 (COVID-19) has forced profound changes in the care of patients with cardiac conditions. In Portugal, an increase in mortality beyond that attributed solely to COVID-19 was observed. We aimed to realize how COVID-19 has changed the activity of our Interventional Cardiology Unit.

Methods

We retrospectively assessed all patients submitted to any interventional procedure in 2019 and 2020 in our hospital. A total of 7621 patients and 9163 procedures were evaluated. The mean weekly numbers of coronarography, angioplasty, right heart catheterization and structural heart intervention during 2019 were assessed and were compared with the first COVID-19 wave (comprising March and April 2020) and the second COVID-19 wave (including the time period from October to end of December 2020).

Results

Mean age was 65.2±16.6 years with 72% being male. In the first COVID-19 wave there was a significant reduction in the mean weekly numbers of all procedures, with a 64% decline in coronarographies (30.9±29.3 vs 87.2±12.9, P<0.001), 48% in angiographies (15.7±10.9 vs 30.2±5.7, P=0.004), 51% in right heart catheterizations (5.3±5.9 vs 10.9±4.5, P=0.002) and 57% in structural heart interventions (1.1±1.9 vs 2.6±2, P=0.044). Although there was an evident recovery in activity (figure 1), comparing to 2019, the second wave also showed a significant lower number of procedures, with 24% fewer coronarographies (66.6±20.6 vs 87.2±12.9, P=0.003) and 13% fewer angiographies (26.4±7.6 vs 30.2±5.7, P=0.004). Contrariwise, in the second wave there was no difference in the number of right heart catheterizations (7.3±6.1 vs 10.9±4.5, P=0.055) or structural heart interventions (1.6±1.6 vs 2.6±2, P=0.106).

Conclusions

In our Interventional Cardiology Unit, COVID-19 led to a significant reduction of procedures in the first and second pandemic waves. The effect on the increase in morbidity and mortality has yet to be determined. Health authorities should focus attention in defining measures to amend the consequences of this documented activity reduction.

Funding Acknowledgement

Type of funding sources: None.

Heart failure with reduced ejection fraction: predicting exercise intolerance with echocardiography

Introduction

Cardiopulmonary exercise testing (CPET) is routinely used in the prognostic evaluation of patients with heart failure with reduced ejection fraction (HFrEF). Left ventricular ejection fraction (LVEF) is a strong prognostic marker but have shown a bad correlation with exercise capacity. The aim of this study is to assess the relationship between echocardiographic parameters and exercise capacity in HFrEF patients.

Methods

We retrospectively assessed all patients with HFrEF submitted to CPET and echocardiography between March and September of 2019. 73 patients were eligible for analysis. ANOVA test was used to compare Weber class groups regarding echocardiographic parameters. Multivariate linear regression with a stepwise approach was used to assess independent predictors of peak VO2 uptake. ROC curves were compared to assess the best parameter to discriminate a peak VO2 &lt;10 ml/kg/min (Weber class D).

Results

Mean age was 53.4±11.7 years with 72.6% being male. Mean LVEF was 29.2±7.7% and mean peak VO2 was 13.4±3.8 ml/kg/min. Between the Weber class groups, significant differences were found in left (LV) and right ventricular (RV) longitudinal strain (P&lt;0.001 and P=0.005 respectively), in the left and right atrial reservoir strain (P=0.009 and P&lt;0.001 respectively), in pulmonary velocity acceleration time (P=0.002) and in maximal tricuspid regurgitation velocity (TRmax) (P=0.014). Left ventricular ejection fraction, tricuspid annular plane systolic excursion, and ratio E/e' were not significantly different among exercise capacity groups. Additionally, only RV longitudinal strain (r2=0.225, P=0.008) and TRmax (r2=0.073, P=0.030) were independent predictors of peak VO2. RV longitudinal strain showed the best accuracy in discriminating a Weber class of D (AUC=0.731, 95% CI: 0.613–0.848, P=0.005) with a calculated cut of −8.6% and with a negative predictive value of 95%.

Conclusion

RV longitudinal strain and TRmax seem to be the best echocardiographic predictors of exercise intolerance in patients with HFrEF. Since CPET is not widely available, these echocardiographic parameters can be clinically useful as a surrogate prognostic factor.

Funding Acknowledgement

Type of funding sources: None.

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

Cardiopulmonary exercise testing; do circulatory and ventilatory power predict cardiovascular outcomes in patients with heart failure

Background

Cardiopulmonary exercise testing (CPET) has an important role in mortality prediction in heart failure (HF) and patient selection for heart transplant. New indices as circulatory power (CP) and ventilatory power (VP) have been proposed as predictors of cardiac events. In addition, VP predicts mean pulmonary artery pressure (mPAP) in patients with pulmonary arterial hypertension.

Purpose

We aimed to analyse the prognostic value of classic and new CPET variables in patients with HF.

Methods

We retrospectively assessed consecutive patients with HF who underwent CPET in a single-centre between 2013 and 2017. New CPET variables were collected: CP was defined as the product of peak O2 uptake and peak systolic blood pressure (SBP), while VP was defined as peak SBP divided by the minute ventilation–CO2 production (VE/VCO2) slope. The primary endpoint was a composite of all-cause mortality, heart transplant, or HF hospitalization. Survival analysis was performed using Kaplan-Meier curves and multivariable Cox regression.

Results

Overall, 216 patients (mean age 55.4±10.9, 77.3% male) were included, 38.4% with ischemic HF, and mean left ventricle ejection fraction (LVEF) 30±14%. Most patients were evaluated through the modified Naughton (76.3%), the original Naughton (19.0%), and Bruce protocols (4.7%). Regarding classic CPET variables: mean pVO2 16.8±6.0 mL O2 kg–1 min–1, mean percent-predicted pVO2 62.6±23.9%, median VE/VCO2 slope 37.3 [32.6–44.5], exercise oscillatory ventilation (EOV) present in 13.9%, resting partial pressure of end-tidal carbon dioxide (PETCO2) ≥33 mmHg with an increase of 3–8 mmhg during exercise in 17.1%, and mean peak SBP 128.8±27.2 mmHg. Median circulatory power was 1927 [1404–2694] mmHg·min/mL/kg and mean ventilatory power 3.47±1.32 mmHg. After a median follow-up of 5 [4–6] years, the primary endpoint occurred in 66.2% of patients (rehospitalization, heart transplant, and all-cause death occurred in 57.0%, 25.9%, and 32.4%, respectively). In Cox regression multivariate analysis, the primary endpoint was predicted by pVO2 (HR 0.90, 95% CI: 0.87–0.93), percent-predicted pVO2 (HR 0.97, 95% CI: 0.96–0.98), VE/VCO2 slope (HR 1.04, 95% CI: 1.03–1.06), VP (HR 0.62, 95% CI: 0.52–0.73) but not CP (HR 0.99, 95% CI: 0.98–1.01). Kaplan-Meier curves according to the LVEF are depicted in Fig. 1A. ROC analysis (Fig. 1B) revealed that VP (AUC 0.768) has higher discriminative power for the primary endpoint, compared to pVO2 (AUC 0.741). One hundred and twenty-seven patients also underwent right heart catheterization: mean mPAP was 30.6±12.9 and it was not correlated with VP (r=−0.06, p=0.47).

Conclusion

CPET variables are good predictors of all-cause mortality, heart transplant, or HF hospitalization. Ventilatory power (but not circulatory power) is an additional useful variable in event prediction. On the other hand, VP is not correlated with mPAP in patients with HF.

Funding Acknowledgement

Type of funding sources: None.

Biliary tract anatomical variance - the value of MRCP

Duplication of the common bile duct (CBD) is a rare congenital anomaly of the bile ducts that should be diagnosed prior to surgery in order to optimise management and prevent complications. We report a case of a patient presenting with choledocholithiasis and type Va duplicated extrahepatic bile duct that was missed on ultrasonography. The atypical course prompted further imaging with magnetic resonance cholangiopancreatography (MRCP), which identified the aberrant bile duct and assisted in safe preoperative and operative management. This case highlights the importance of accurate pre-interventional imaging and agrees with the reclassification of duplications of the CBD.

Intestinal perforation on an incarcerated incisional hernia secondary to an ingested foreign body. Report of a rare case

Ingestion of foreign bodies (FBs) is common and rarely has consequences for the patient, but sometimes it can originate gastrointestinal perforation and lead to devastating consequences if unrecognized. Therefore, whenever present, bowel perforation demands immediate surgical treatment.

An 89-year-old woman with an incarcerated incisional hernia, whose imaging study was consistent with intestinal occlusion and perforation within the hernia sac was treated at our hospital. A segmental enterectomy and direct correction of the hernial defect were performed. A perforation in the mesenteric border due to a FB, which seemed to be a toothpick, was identified in the surgical specimen. Nine months after surgery, the patient was without complaints, with adequate healing, and without evidence of hernial recurrence.

To the best of our knowledge, this is the first case of intestinal perforation on an incarcerated incisional hernia, due to an ingested FB, reported in the literature.

Impact of SARS-CoV-2 pandemic on ST-elevation myocardial infarction admissions and outcomes in a Portuguese primary percutaneous coronary intervention center: Preliminary Data

INTRODUCTION

Coronavirus disease (COVID-19) has led to significant changes in healthcare systems and its impact on the treatment of cardiovascular conditions, such as ST-elevation myocardial infarction (STEMI), is unknown in countries where the healthcare systems were not saturated, as was the case in Portugal. As such, we aimed to assess the effect on STEMI admissions and outcomes in Portuguese centers.

METHODS

We conducted a single-center, observational, retrospective study including all patients admitted to our hospital due to STEMI between the date of the first SARS-CoV-2 case diagnosed in Portugal and the end of the state of emergency (March and April 2020). Patient characteristics and outcomes were assessed and compared with the same period of 2019.

RESULTS

A total of 104 STEMI patients were assessed, 55 in 2019 and 49 in 2020 (-11%). There were no significant differences between groups regarding age (62±12 vs. 65±14 years, p=0.308), gender (84.8% vs. 77.6% males, p=0.295) or comorbidities. In the 2020 group, there was a significant decrease in the proportion of patients transported to the hospital in pre-hospital emergency medical transportation (38.2% vs. 20.4%, p=0.038), an increase in system delay (49 [30-110.25] vs. 140 [90-180] minutes, p=0.019), a higher Killip-Kimball class, with a decrease in class I (74.5% vs. 51%) and an increase in class III (1.8% vs. 8.2%) and IV (5.5% vs. 18.4%) (p=0.038), a greater incidence of vasoactive support (3.7% vs. 26.5%, p=0.001), invasive mechanic ventilation usage (3.6% vs. 14.3%, p=0.056), and an increase in severe left ventricular dysfunction at hospital discharge (3.6% vs. 16.3%, p=0.03). In-hospital mortality was 14.3% in the 2020 group and 7.3% in the 2019 group p=0.200).

CONCLUSION

Despite a lack of significant variation in the absolute number of STEMI admissions, there was an increase in STEMI clinical severity and significantly worse outcomes during the SARS-CoV-2 pandemic. An increase in system delay, impaired pre-hospital care and patient fear of in-hospital infection can partially justify these results and should be the target of future actions in further waves of the pandemic.

Impact of SARS-CoV-2 pandemic on ST-elevation myocardial infarction admissions and outcomes in a Portuguese primary percutaneous coronary intervention center: Preliminary Data

INTRODUCTION

Coronavirus disease (COVID-19) has led to significant changes in healthcare systems and its impact on the treatment of cardiovascular conditions, such as ST-elevation myocardial infarction (STEMI), is unknown in countries where the healthcare systems were not saturated, as was the case in Portugal. As such, we aimed to assess the effect on STEMI admissions and outcomes in Portuguese centers.

METHODS

We conducted a single-center, observational, retrospective study including all patients admitted to our hospital due to STEMI between the date of the first SARS-CoV-2 case diagnosed in Portugal and the end of the state of emergency (March and April 2020). Patient characteristics and outcomes were assessed and compared with the same period of 2019.

RESULTS

A total of 104 STEMI patients were assessed, 55 in 2019 and 49 in 2020 (-11%). There were no significant differences between groups regarding age (62±12 vs. 65±14 years, p=0.308), gender (84.8% vs. 77.6% males, p=0.295) or comorbidities. In the 2020 group, there was a significant decrease in the proportion of patients transported to the hospital in pre-hospital emergency medical transportation (38.2% vs. 20.4%, p=0.038), an increase in system delay (49 [30-110.25] vs. 140 [90-180] minutes, p=0.019), a higher Killip-Kimball class, with a decrease in class I (74.5% vs. 51%) and an increase in class III (1.8% vs. 8.2%) and IV (5.5% vs. 18.4%) (p=0.038), a greater incidence of vasoactive support (3.7% vs. 26.5%, p=0.001), invasive mechanic ventilation usage (3.6% vs. 14.3%, p=0.056), and an increase in severe left ventricular dysfunction at hospital discharge (3.6% vs. 16.3%, p=0.03). In-hospital mortality was 14.3% in the 2020 group and 7.3% in the 2019 group p=0.200).

CONCLUSION

Despite a lack of significant variation in the absolute number of STEMI admissions, there was an increase in STEMI clinical severity and significantly worse outcomes during the SARS-CoV-2 pandemic. An increase in system delay, impaired pre-hospital care and patient fear of in-hospital infection can partially justify these results and should be the target of future actions in further waves of the pandemic.

Portuguese version of Parent-reported Drug Hypersensitivity Quality of Life Questionnaire (P-DrHy-Q): assessment of reliability and validity

Summary

Background. Drug hypersensitivity in children impacts the quality of life of the patients and their caregivers. The parent-reported drug hypersensitivity quality of life questionnaire (P-DrHy-Q), the first disease-specific quality-of-life questionnaire for caregivers who have children with drug hypersensitivity, was recently developed. The aim of this study was to assess the validity and reliability of the portuguese version of the P-DrHy-Q. Methods. A translation of the Parent-reported Drug Hypersensitivity Quality of Life Questionnaire (P-DrHy-Q) to the Portuguese population was performed, assessing its applicability in 74 caregivers from two allergy departments. The analyses included internal consistency (Cronbach's alpha) and test-retest reliability: 14 caregivers completed the P-DrHy-Q without any intervention one week after answering the first questionnaire. Results. The 12-item scale assessed the mental health and social activity. The internal consistency of the scale was good (Cronbach's alpha = 0.884) and the test-retest associations were excelent (Intra-class correlation coefficient = 0.985; p less than 0.001). The mean value of the questionnaire was (37.01 SD; 18.57) with Mental Health being more affected than Social Activity. Employed caregivers had a significant higher score (p less than 0.001). No other factor was statistically significant. Conclusions. The Portuguese version of the P-DrHy-Q is valid for evaluating quality of life impairment in Portuguese caregivers of children with drug hypersensitivity. Its application might be relevant for future research and provide clinicians and researchers with a tool to define which psychosocial support is required to provide more comprehensive care in drug hypersensitivity.

Prognostic Value of Isolated Elevated Troponin I Levels in Patients without Acute Coronary Syndrome Admitted to the Emergency Department

Fundamento:

Embora a elevação não isquêmica da troponina seja frequentemente observada em pacientes admitidos no pronto-socorro (PS), não há consenso quanto ao seu manejo.

Objetivos:

Este estudo teve como objetivo caracterizar os pacientes admitidos no PS com elevação da troponina não-isquêmica e identificar potenciais preditores de mortalidade nessa população.

Métodos:

Este estudo observacional retrospectivo incluiu pacientes do PS com resultado positivo no teste da troponina entre junho e julho de 2015. Pacientes com diagnóstico clínico de síndrome coronariana aguda (SCA) foram excluídos. Os dados demográficos dos pacientes e as variáveis clínicas e laboratoriais foram extraídos dos prontuários médicos. Os dados do seguimento foram obtidos por 16 meses ou até a ocorrência de morte. O nível de significância estatística foi de 5%.

Resultados:

A elevação da troponina sem SCA foi encontrada em 153 pacientes no PS. A mediana (IIQ) de idade dos pacientes foi de 78 (19) anos, 80 (52,3%) eram do sexo feminino e 59 (38,6%) morreram durante o seguimento. A mediana do período de seguimento (IIQ) foi de 477 (316) dias. Os sobreviventes eram significativamente mais jovens 76 (24) vs. 84 (13) anos; p=0,004) e apresentaram uma maior proporção de elevação da troponina isolada (sem elevação da creatina quinase ou mioglobina) em duas avaliações consecutivas: 48 (53,9%) vs. 8 (17,4%), p<0,001. Os sobreviventes também apresentaram menor taxa de tratamento antiplaquetário e internação no mesmo dia. Na regressão logística multivariada com ajuste para variáveis significativas na análise univariada, a elevação isolada da troponina em duas avaliações consecutivas mostrou hazard ratio = 0,43 (IC95% 0,17–0,96, p=0,039); hospitalização, tratamento antiplaquetário anterior e idade permaneceram independentemente associados à mortalidade.

Conclusões:

A elevação isolada da troponina em duas medidas consecutivas foi um forte preditor de sobrevida em pacientes no PS com elevação da troponina, mas sem SCA.

Do not underestimate the blood urea nitrogen-to-creatinine ratio in heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

The blood urea nitrogen-to-creatinine ratio (BUN/SCr) has been proposed as a prognostic marker in heart failure (HF). We aimed to evaluate whether BUN/SCr predicts mortality outcomes in a real-world Southern European population with decompensated chronic HF.

Methods

We retrospectively studied 1057 patients with chronic HF admitted to our emergency department between November 2016 and December 2017 with acute decompensation. We excluded patients with a GFR &lt;15mL/min/m2 or on dialysis. The incidence of cardiovascular (CV) and all-cause death was evaluated through multivariable logistic regression models and by Kaplan-Meyer survival curves.

Results

1025 patients were included, median age 80 years (IQR 73-85), 52.4% male, mean LVEF 42.8 ± 12.7%, and mean GFR 57.2 ± 23.9 mL/min/m2. Mean BUN/SCr was 24.9 ± 8.2 and mean SBP was 139 ± 29mmHg (r=-0.17, p &lt; 0.001). After a median follow-up of 5 months (IQR 3-11 months), CV and all-cause death occurred in 8.0% and 21.6%, respectively. Mean BUN/SCr was higher in patients with fatal outcomes both for CV (31.3 vs. 24.3, p &lt; 0.001) and all-cause death (28.6 vs. 23.8, p &lt; 0.001). BUN/Scr was grouped by terciles: T1 (&lt;20.78), T2 (20.78-27.15), T3 (&gt;27.15). In the T3 group, the multivariable-adjusted  OR for CV and all-cause death was 5.43 (95% CI 2.20-13.37) and 2.72 (95% CI 1.66-4.46), respectively, compared to the T1 group. No significant differences between T1 and T2 groups.

Conclusions

BUN/SCr at admission predicts CV and all-cause death in patients with chronic HF after an episode of decompensation. BUN/SCr, as an easy-to-use tool, helps to identify those patients who benefit from tight monitoring both during hospitalization and after discharge.

Abstract Figure_1

Does lipoprotein(a) predict cardiovascular events in a long-term follow-up?

Funding Acknowledgements

Type of funding sources: None.

Background

Elevated plasma lipoprotein(a) [Lp(a)] concentrations are associated with an increased risk of atherosclerotic cardiovascular disease and its role in risk categorizing was recognized in the new ESC guidelines for the management of dyslipidaemias. We investigated 1) the association between baseline Lp(a) levels and incident long-term cardiovascular (CV) events and 2) its relationship with type 2 diabetes mellitus (T2DM) in a Southern European population.

Methods

We retrospectively assessed baseline Lp(a) concentrations in a total of 499 patients of a primary prevention cohort followed at the Lipidology Clinic of our hospital, with a median follow-up time of 15 (IQR 12-17) years. Lp(a) was analysed as a continuous variable, as a categorical variable with a 180mg/dL cut-off and by quartiles. We collected data on major CV events (CV death, myocardial infarction, stroke) as a composite outcome. Cox proportional hazard regression analyses were used to estimate hazard ratios (HR) and 95% confidence interval (CI).

Results

Mean age was 48.30 ± 14.41 years and 61.70% were male (n = 499). Median Lp(a) was 36.60 (IQR 0-396) mg/dL and 12.4% of patients had very high Lp(a) (≥180mg/dL); T2DM prevalence was 13.60%. The composite outcome incidence was 10%. At the baseline, individuals with T2DM had lower Lp(a) levels (11.85 IQR 3-330 mg/dL vs. 46.40 IQR 0-396, p &lt; 0.01 mg/dL). There was a moderate inverse correlation between Lp(a) and HbA1c (r = -0.67, p &lt; 0.01) but no significant correlations with lipid profile (total, LDL or HDL), risk scores (SCORE or the ACC pooled cohort equation), age nor gender. We found no relationship between baseline Lp(a) quartiles and composite outcome’s incidence (age-, sex-, and diabetes-adjusted HR: 1.15, 95%CI: 0.71-1.87, p = 0.57) (Figure 1), neither with the individual CV endpoints. Exploratory analysis showed that patients on aspirin had lower Lp(a) levels (29.55 IQR 0-264 mg/dL vs. 63.60 IQR 1-396 mg/dL, p &lt; 0.01).

Conclusion

In a single centre cohort of a primary prevention southern European population, we did not find an association between Lp(a) levels and incident CV events in a 15-year median follow-up time.

Myocardial infarction in young adults: are the risk profile and mortality outcomes different from older patients?

Funding Acknowledgements

Type of funding sources: None.

Introduction

The incidence of acute myocardial infarction (AMI) among young patients is increasing. The YOUNG-MI Registry reported that those under 40 years had similar risk profiles and outcomes compared to those aged 41 to 50. We aimed to evaluate cardiovascular risk factors and mortality outcomes in two age cohorts from southern European.

Methods

We retrospectively evaluated 4758 patients admitted to our coronary intensive care unit between 2004 and 2017 with AMI. We only included patients &lt;60 years in two subgroups: cohort A &lt; 50 years and cohort B 50-60 years. 

Results

From the 1233 patients included (mean age 50.5 ± 6.5 years, 82.2% male), 53% had STEMI. Cohort B had higher rates of hypertension (59.8 vs. 42.9%, p &lt; 0.001), diabetes (41.8 vs. 28.9%, p &lt; 0.001), and dyslipidemia (59.4 vs. 46.4%, p &lt; 0.001), while cohort A had higher rates of familial premature coronary artery disease (20.9 vs. 13.2%, p &lt; 0.001) and smoking habits (54.4 vs. 40.0%, p &lt; 0.001). Regarding coronary angiography, cohort B had higher rates of obstructive disease in each epicardial artery, except for left main involvement and non-obstructive disease (Fig. 1). Cohort A had lower all-cause mortality rates at the index hospitalization (1.3 vs. 3.2%, p = 0.045), 6-months (2.9 vs.5.4, p = 0.038), 1-year (3.1 vs. 6.3%, p = 0.014), and 3-years (3.6 vs 8.4, p = 0.001). After multivariable adjustment, we found no relationship between age cohorts and all-cause mortality for any follow-up timing: HR 1.57 (95% CI 0.56-4.37), 1.37 (95% CI 0.50-3.74), and 0.92 (95% CI 0.35-2.39) at 6-months, 1-year, and 3-years, respectively.

Conclusion

Among patients who suffer AMI, those under 50 years old have a different risk profile, compared to the 50-60 years cohort. However, there is no significant difference in all-cause mortality.

Abstract Figure.

Perianal Paget's disease: one century later and still a challenge

Perianal Paget disease (PPD) is a rare neoplastic condition defined by the presence of atypical Paget cells in the perianal skin, the aetiology of which remains largely unknown. It can be divided in primary forms, arising as an intraepithelial disease or manifestation of an underlying skin adenocarcinoma or secondary forms resulting from epidermotropic spread or metastasis of a concealed carcinoma. Indeed, because of its rarity, clear options regarding the treatment of these patients are yet to be clarified. A high level of suspicion is needed whenever dealing with any unhealed perianal skin lesions and, therefore, the need for close long-term follow-up must be highlighted. Herein, two cases of PPD, one primary and another secondary, treated at the same institution, are presented in an attempt to document the involved complexity and to bring further insight into the understanding of this entity.

RHOBTB2 p.Arg511Trp Mutation in Early Infantile Epileptic Encephalopathy-64: Review and Case Report

Early infantile epileptic encephalopathy-64 (EIEE 64), also called RHOBTB2-related developmental and epileptic encephalopathy (DEE), is caused by heterozygous pathogenic variants (EIEE 64; MIM#618004) in the Rho-related BTB domain-containing protein 2 (RHOBTB2) gene. To date, only 13 cases with RHOBTB2-related DEE have been reported. We add to the literature the 14th case of EIEE 64, identified by whole exome sequencing, caused by a heterozygous pathogenic variant in RHOBTB2 (c.1531C > T), p.Arg511Trp. This additional case supports the main features of RHOBTB2-related DEE: infantile-onset seizures, severe intellectual disability, impaired motor functions, postnatal microcephaly, recurrent status epilepticus, and hemiparesis after seizures.

Postpartum headache after epidural anaesthesia: Who to blame?

INTRODUCTION

Epidural analgesia is considered the preferred analgesic choice during labour. Post dural puncture headache (PDPH) is considered a potential complication of this analgesic technique and is a frequently hypothesis for any headache occurring after delivery. It is essential that anaesthetists and obstetricians are familiar with other possible differential diagnosis for postpartum headache (PPH).

CASE DESCRIPTION

37-year-old female presented after delivery with intense occipital pulsatile headache associated with neck radiation, nausea and vomiting, hemodynamically stable and normal neurologic physical examination. Abnormalities in thyroid hormone levels were found. CT-scan findings suggested pituitary apoplexy.

DISCUSSION

There are many differential diagnoses for PPH and some are rarely considered, such as pituitary apoplexy. It is essential to differentiate signs and symptoms of each diagnosis, since many of them overlap.

CONCLUSION

Not all postpartum headaches are PDPH and the first suspected diagnosis may not always be accurate.

Biliary tract anatomical variance - the value of MRCP

SUMMARY Duplication of the common bile duct (CBD) is a rare congenital anomaly of the bile ducts that should be diagnosed prior to surgery in order to optimise management and prevent complications. We report a case of a patient presenting with choledocholithiasis and type Va duplicated extrahepatic bile duct that was missed on ultrasonography. The atypical course prompted further imaging with magnetic resonance cholangiopancreatography (MRCP), which identified the aberrant bile duct and assisted in safe preoperative and operative management. This case highlights the importance of accurate pre-interventional imaging and agrees with the reclassification of duplications of the CBD. Keywords: bile duct, extrahepatic, anomaly, duplicated, injury

Physiological and physical effect on U-12 and U-15 football players, with the manipulation of task constraints: field size and goalkeeper in small-sided games of 4x4 players. [Efecto fisiológico y físico en los jugadores de fútbol Sub-12 y Sub-15, con la manipulación de las restricciones de tareas: tamaño de campo y portero en juegos reducidos de jugadores 4x4]

Our study aimed to verify whether the manipulation of task constraints has different effects according to age group. Another objective was to verify the physiological and physical responses in the different formats of small-sided games (SSG). Each team in the SSGs was composed of 4 players (4x4). The participants in the research are young football players U-12 (n=8) and U-15 (n=8), affiliated with a club certified as a training entity, and competed in the regional football championship of 7 and 9 players and the national championship of Portugal, respectively. The internal and external load data were collected in 5 formats of SSGs with three field size and in 2 used goalkeepers. We used the WIMU PROTM inertial device for data collection. The registration of the internal charge, using heart rate (HR), was performed with the use by the players of Garmin bands, which send the data to WIMU PROTM devices, through of Ant+ technology. The variance analysis (ANOVA) was used to verify the differences between SSGs and the effect size was determined by calculating partial eta-square). Comparisons between the two age groups were evaluated using standardized differences with combined variance (Cohen’s d). The results show that the manipulation of the playing areas and the use of goalkeepers promoted different effects in the two age groups in terms of distance, explosive distance, accelerations/decelerations and maximum sprint. As for the comparison between SSGs we found differences in the level of external load (distance, accelerations/decelerations and maximum sprint). At the level of internal load, the effects were more evident with field areas above 100m2. We can conclude that the manipulation of the task conditions, playing area and goalkeeper, promote different physical and physiological responses, and the coach should consider this fact, as well as the effects promoted in the age groups.