Influence of Immobilization Strategies on the Antibacterial Properties of Antimicrobial Peptide-Chitosan Coatings

It is key to fight bacterial adhesion to prevent biofilm establishment on biomaterials. Surface immobilization of antimicrobial peptides (AMP) is a promising strategy to avoid bacterial colonization. This work aimed to investigate whether the direct surface immobilization of Dhvar5, an AMP with head-to-tail amphipathicity, would improve the antimicrobial activity of chitosan ultrathin coatings. The peptide was grafted by copper-catalyzed azide-alkyne cycloaddition (CuAAC) chemistry by either its C- or N- terminus to assess the influence of peptide orientation on surface properties and antimicrobial activity. These features were compared with those of coatings fabricated using previously described Dhvar5-chitosan conjugates (immobilized in bulk). The peptide was chemoselectively immobilized onto the coating by both termini. Moreover, the covalent immobilization of Dhvar5 by either terminus enhanced the antimicrobial effect of the chitosan coating by decreasing colonization by both Gram-positive (Staphylococcus aureus, Staphylococcus epidermidis) and Gram-negative (Escherichia coli, Pseudomonas aeruginosa) bacteria. Relevantly, the antimicrobial performance of the surface on Gram-positive bacteria depended on how Dhvar5-chitosan coatings were produced. An antiadhesive effect was observed when the peptide was grafted onto prefabricated chitosan coatings (film), and a bactericidal effect was exhibited when coatings were prepared from Dhvar5-chitosan conjugates (bulk). This antiadhesive effect was not due to changes in surface wettability or protein adsorption but rather depended on variations in peptide concentration, exposure, and surface roughness. Results reported in this study show that the antibacterial potency and effect of immobilized AMP vary greatly with the immobilization procedure. Overall, independently of the fabrication protocol and mechanism of action, Dhvar5-chitosan coatings are a promising strategy for the development of antimicrobial medical devices, either as an antiadhesive or contact-killing surface.

Neurocognitive and psychological comorbidities in patients with self-limited centrotemporal spike epilepsy. A case-control study

INTRODUCTION

Self-limited epilepsy with centrotemporal spikes (SeLECTS) is the most frequent self-limited focal epilepsy. This study aimed to assess the cognitive, behavioral, and other neuropsychological aspects of children with SeLECTS, and compare them with a control group.

SUBJECTS AND METHODS

A case-control study was carried out between January and May 2022. Patients with SeLECTS, aged between 6 and 18 years, and followed-up at our hospital were selected for inclusion in the study. For each case, two age-matched controls were opportunistically recruited. All the participants performed the EpiTrack Junior® test, and their parents filled out the Child Behavior Checklist (CBCL).

RESULTS

Eighteen patients were included (mean age: 8.7 ± 1.7 years). At SeLECTS' diagnosis, 83% of cases had adequate psychomotor development, and 17% had a neurodevelopmental disorder. The EpiTrack-Junior® and the Total Problems CBCL scores were not influenced by the laterality of the epileptic focus nor by the number of seizures. 61% of cases showed mild or significant impairment in the EpiTrack-Junior® test versus 44% of controls (p = 0.712), and 39% of cases vs. 14% of controls had 'clinically significant' scores on the Total Problems CBCL scale (p = 0.087).

CONCLUSIONS

Although this study did not find statistically significant differences between cases and controls, it should be noted that most patients with SeLECTS had a mild or significant disability in executive functions. A considerable percentage of cases were in the pathological range regarding emotional/behavioral problems. This study highlights the importance of screening the cognitive, behavioral, and emotional problems in all patients with SeLECTS.

Antimicrobial peptide-grafted PLGA-PEG nanoparticles to fight bacterial wound infections

Wound infection treatment with antimicrobial peptides (AMPs) is still not a reality, due to the loss of activity in vivo. Unlike the conventional strategy of encapsulating AMPs on nanoparticles (NPs) leaving activity dependent on the release profile, this work explores AMP grafting to poly(D,L-lactide-co-glycolide)-polyethylene glycol NPs (PLGA-PEG NPs), whereby AMP exposition, infection targeting and immediate action are promoted. NPs are functionalized with MSI-78(4-20), an equipotent and more selective derivative of MSI-78, grafted through a thiol-maleimide (Mal) Michael addition. NPs with different ratios of PLGA-PEG/PLGA-PEG-Mal are produced and characterized, with 40%PLGA-PEG-Mal presenting the best colloidal properties and higher amounts of AMP grafted as shown by surface charge (+8.6 ± 1.8 mV) and AMP quantification (326 μg mL^-1, corresponding to 16.3 μg of AMP per mg of polymer). NPs maintain the activity of the free AMP with a minimal inhibitory concentration (MIC) of 8-16 μg mL^-1 against Pseudomonas aeruginosa, and 16-32 μg mL^-1 against Staphylococcus aureus. Moreover, AMP grafting accelerates killing kinetics, from 1-2 h to 15 min for P. aeruginosa and from 6-8 h to 0.5-1 h for S. aureus. NP activity in a simulated wound fluid is maintained for S. aureus and decreases slightly for P. aeruginosa. Furthermore, NPs do not demonstrate signs of cytotoxicity at MIC concentrations. Overall, this promising formulation helps unleash the full potential of AMPs for the management of wound infections.

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.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Boosting Cosmeceutical Peptides: Coupling Imidazolium-Based Ionic Liquids to Pentapeptide-4 Originates New Leads with Antimicrobial and Collagenesis-Inducing Activities

Following our previous reports on dual-action antibacterial and collagenesis-inducing hybrid peptide constructs based on "pentapeptide-4" (PP4, with amino acid sequence KTTKS), whose N-palmitoyl derivative is the well-known cosmeceutical ingredient Matrixyl, herein we disclose novel ionic liquid/PP4 conjugates (IL-KTTKS). These conjugates present potent activity against either antibiotic-susceptible strains or multidrug resistant clinical isolates of both Gram-positive and Gram-negative bacterial species belonging to the so-called "ESKAPE" group of pathogens. Noteworthy, their antibacterial activity is preserved in simulated wound fluid, which anticipates an effective action in the setting of a real wound bed. Moreover, their collagenesis-inducing effects in vitro are comparable to or stronger than those of Matrixyl. Altogether, IL-KTTKS exert a triple antibacterial, antifungal, and collagenesis-inducing action in vitro. These findings provide solid grounds for us to advance IL-KTTKS conjugates as promising leads for future development of topical treatments for complicated skin and soft tissue infections (cSSTI). Further studies are envisaged to incorporate IL-conjugates into suitable nanoformulations, to reduce toxicity and/or improve resistance to proteolytic degradation. IMPORTANCE As life expectancy increases, diseases causing chronic wound infections become more prevalent. Diabetes, peripheral vascular diseases, and bedridden patients are often associated with non-healing wounds that become infected, resulting in high morbidity and mortality. This is exacerbated by the fact that microbes are becoming increasingly resistant to antibiotics, so efforts must converge toward finding efficient therapeutic alternatives. Recently, our team identified a new type of constructs that combine (i) peptides used in cosmetics to promote collagen formation with (ii) imidazolium-based ionic liquids, which have antimicrobial and skin penetration properties. These constructs have potent wide-spectrum antimicrobial action, including against multidrug-resistant Gram-positive and Gram-negative bacteria, and fungi. Moreover, they can boost collagen formation. Hence, this is an unprecedented class of lead molecules toward development of a new topical medicine for chronically infected wounds.

Assessment of fusion pacing on exercise capacity in patients with cardiac resynchronisation therapy devices

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Local Departmental Research Funding

Background

Cardiac resynchronisation therapy (CRT) using fusion pacing requires correct timing of left ventricular pacing to right ventricular activation. The SyncAV™ algorithm, achieves this by dynamic reassessment of intrinsic atrio-ventricular (AV) conduction to adjust the paced/sensed AV delay. However, it is unclear whether AV optimisation maintains resynchronisation during exercise, or whether loss of fusion could lead to decreased exercise capacity. Cardio-pulmonary exercise testing (CPET) is the gold standard method for assessing exercise performance and can provide prognostic information in the heart failure population.

Purpose

We therefore used CPET measures of exercise capacity to compare the SyncAV™ algorithm to conventional pacing with fixed AV delays, in a double blinded, randomised crossover study (NCT03768804).

Methods

Patients at least 6 months post-CRT implant performed 2 CPET tests at least 1 week apart, with randomisation to either SyncAV™ with fusion pacing or conventional biventricular pacing with a fixed AVD of 120ms. All other programming was optimised to produce the narrowest QRS duration possible at rest in each case.

Results

Twenty patients (11 male, age 71 [65-77] years, median [interquartile range]) were recruited, with both ischaemic and non-ischaemic aetiology of heart failure. All had clinical and/or echocardiographic response to CRT. Optimised Fixed AVD and SyncAV™programming resulted in similar narrowing of QRS duration (QRSd) from intrinsic rhythm at rest (131 [103-137] vs 134 [110-137] ms for fixed AVD and SyncAV™ groups respectively, p=0.85). Overall, there was no difference in peak oxygen consumption (V̇O2peak) between programming (14.91 [12.61-18.16] vs 15.61 [12.18-19.70] ml/kg/min, p=0.19), or oxygen consumption at anaerobic threshold (VT1) (7.36 [6.93-8.94] vs 7.87 [6.77-9.24] ml/kg/min, p=0.42), or in the time to reach either V̇O2PEAK (p=0.81) or VT1 (p=0.39). The BORG rating of perceived effort was also similar between groups. CPET performance was also analysed comparing whichever programming gave the narrowest QRSd at rest (119 [96-136] vs 134 [119-142] ms, p&lt;0.01). Eight were narrower with fixed AVD, 8 with SyncAV™ and in 4 there was no difference. QRSd during exercise (p=0.03), peak O2 pulse (ml/beat, a surrogate of stroke volume, p=0.03) and cardiac efficiency (watts/ml/kg/min, p=0.04) were significantly improved when programmed to the narrowest QRS duration at rest.

Conclusion

There is no significant difference in exercise capacity or QRSd between the use of optimised fixed AVD or SyncAV™, lending reassurance to fusion pacing being adequately maintained on exercise. In addition, programming with whichever algorithm gives the narrowest QRSd at rest is associated with a narrower QRSd during exercise, higher peak stroke volume and improved cardiac efficiency. This supports the use of SyncAV™ in the 40% of patients where this gave the narrowest QRSd at rest.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Disclosure of a Promising Lead to Tackle Complicated Skin and Skin Structure Infections: Antimicrobial and Antibiofilm Actions of Peptide PP4-3.1

Efficient antibiotics are being exhausted, which compromises the treatment of infections, including complicated skin and skin structure infections (cSSTI) often associated with multidrug resistant (MDR) bacteria, methicillin-resistant S. aureus (MRSA) being the most prevalent. Antimicrobial peptides (AMP) are being increasingly regarded as the new hope for the post-antibiotic era. Thus, future management of cSSTI may include use of peptides that, on the one hand, behave as AMP and, on the other, are able to promote fast and correct skin rebuilding. As such, we combined the well-known cosmeceutical pentapeptide-4 (PP4), devoid of antimicrobial action but possessing collagenesis-boosting properties, with the AMP 3.1, to afford the chimeric peptide PP4-3.1. We further produced its N-methyl imidazole derivative, MeIm-PP4-3.1. Both peptide-based constructs were evaluated in vitro against Gram-negative bacteria, Gram-positive bacteria, and Candida spp. fungi. Additionally, the antibiofilm activity, the toxicity to human keratinocytes, and the activity against S. aureus in simulated wound fluid (SWF) were assessed. The chimeric peptide PP4-3.1 stood out for its potent activity against Gram-positive and Gram-negative bacteria, including against MDR clinical isolates (0.8 ≤ MIC ≤ 5.7 µM), both in planktonic form and in biofilm matrix. The peptide was also active against three clinically relevant species of Candida fungi, with an overall performance superior to that of fluconazole. Altogether, data reveal that PP4-3.1 is as a promising lead for the future development of new topical treatments for severe skin infections.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

P02.01 A strategy to personalize the use of radiation in patients with brain metastasis based on S100A9-mediated resistance

BACKGROUND

Finding effective treatment options for patients with brain metastasis remains an unmet need. Given the limitations imposed by the blood-brain-barrier for systemic approaches, radiotherapy offers a superior ability to access the brain. While clinical practice recently adapted the use of stereotactic radiosurgery (SRS), Whole-Brain-Radiotherapy (WBRT) continuous to be an important treatment option, since many patients present with multifocal lesions or bad performance scores, rendering them ineligible for SRS. Unfortunately, overall survival of patients remains unaffected by radiotherapy. Despite this clinical data, the molecular mechanisms that allow metastatic cells to resist radiotherapy in the brain is unknown.

MATERIAL AND METHODS

We have applied WBRT to experimental brain metastasis from lung and breast adenocarcinoma and validated their resistance in vivo.

RESULTS

An unbiased search to identify potential mediators of resistance identified the S100A9-RAGE-NFκB-JunB pathway. Targeting this pathway genetically reverts the resistance to radiotherapy and increases therapeutic benefits in vivo. In two independent cohorts of brain metastasis from lung and breast adenocarcinoma patients, levels of S100A9 correlate with the response to radiotherapy, offering a novel approach to stratify patients according to their expected benefit. In order to make this biomarker also available for brain metastasis patients receiving palliative WBRT without preceding surgery, we complemented our tumor-specimen based approach with the less invasive detection of S100A9 from liquid biopsies. Here, serum S100A9 also correlated with a worse response to WBRT in brain metastasis patients. Furthermore, we have validated the use of a blood-brain-barrier permeable RAGE inhibitor to restore radio-sensitivity in experimental brain metastasis models in vivo and in patient-derived organotypic cultures of radio-resistant brain metastasis ex vivo.

CONCLUSION

We identified S100A9 as a major mediator of radio-resistance in brain metastasis and offer the molecular framework to personalize radiotherapy by exploiting it as a biomarker and as a therapeutic target, thus maximizing the benefits for the patient.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Assessment of the SyncAV fusion pacing algorithm on exercise capacity in patients with cardiac resynchronisation therapy device

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation (BHF) and Local Departmental Research Funding

Background

Fusion pacing as part of cardiac resynchronization therapy (CRT) requires correct timing of left ventricular pacing to right ventricular activation.  The SyncAV algorithm, available in Quadra Allure and Assura CRT devices, is designed to allow optimal fusion pacing by dynamic reassessment of intrinsic atrio-ventricular (AV) conduction to adjust the paced/sensed AV delay. However, it is unclear whether AV optimisation continues to maintain resynchronisation during exercise, or whether potential loss of fusion pacing with changes in intrinsic AV conduction could lead to decreased exercise capacity. Cardio-pulmonary exercise testing (CPET) is the gold standard method for assessing exercise performance.

Purpose

To assess exercise capacity using the SyncAV algorithm for fusion pacing, compared with conventional biventricular pacing with fixed AV delays (AVD) for CRT.

Methods

 Patients at least 6 months post-CRT implant were recruited in a prospective single-centre randomized single-blind crossover study.  Patients performed 2 CPET tests at least 1 week apart, with randomization to either SyncAV with fusion pacing or conventional biventricular pacing with a fixed AVD of 120ms. All other programming was optimised to produce the narrowest QRS duration possible at rest in each case.

Results

Nine patients (5 male, age 70 ± 10 years, mean ± standard deviation) were recruited, with both ischaemic and non-ischaemic aetiology of heart failure.  All had clinical or echocardiographic response to CRT.  There was no difference in peak oxygen consumption (V̇O2max) between programming (1.47 ± 0.57 vs 1.50 ± 0.65 l/min for fixed AVD and SyncAV groups respectively, p = 0.59), or oxygen consumption at anaerobic threshold (VT1) (0.72 ± 0.20 vs 0.74 ± 0.25 l/min, p = 0.57). There was no difference in oxygen pulse (V̇O2/heart rate - a surrogate of stroke volume) at peak (12.3 ± 3.8 vs 13 ± 5.0 ml/beat , p = 0.28) or VT1 (8.4 ± 2.2 vs 8.7 ± 2.1 ml/beat, p = 0.67) and also no change in time to V̇O2max (1400 ± 491 vs 1367 ± 543 seconds, p = 0.38) or VT1 (518 ± 211 vs 534 ± 200 seconds, p = 0.75).  Average heart rate at the median stage of exercise showed no difference between programming (96 ± 18 vs 93 ± 15 bpm respectively, p = 0.32).  There was no difference in BORG Rating of Perceived Exertion (BORG-RPE) score at either peak exercise (median 19 [interquartile range (IQR) 2] vs 17 [IQR 2], p = 0.23) or at the median stage of exercise (median 13 [IQR 1] vs 13 [IQR 2], p = 0.30). 

Conclusion

Fusion pacing using the SyncAV algorithm does not appear to improve exercise capacity compared to optimised conventional biventricular pacing with fixed AVD.

Periprocedural safety and efficacy after left atrial appendage closure in a large UK tertiary centre: 10-year experience

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left atrial appendage (LAA) thrombus is responsible for up 90% of atrial fibrillation (AF) related ischaemic strokes. Mechanical closure of the LAA is an alternative stroke prevention strategy in patients with non-valvular AF who are at a high risk of bleeding. LAA morphology is highly variable which may affect acute procedural success rates.

Purpose

This study sought to examine the periprocedural safety and efficacy, and short-term outcomes in patients undergoing left atrial appendage occlusion (LAAO) device implantation in a large UK tertiary centre.

Methods

This retrospective study included all patients listed for a LAAO device in our institution from January 2010 to December 2020. Medical notes, procedural and imaging reports were reviewed and adverse event rates were calculated at discharge, 30 and 90 days. A Cox regression model was used for multivariable analysis with pre-specified covariates to assess outcomes at 90 days.

Results

Of 237 patients listed for a LAAO device, 8 (3.4%) had a LAA thrombus and the procedure was abandoned (4 had a successful implant at a later date). In 225 (94.9%) patients a LAAO device was implanted and 4 (1.7%) had unsuitable anatomy precluding device deployment. Seventy-two percent were male, age 74 ± 8 years, BMI 27 ± 6 kg/m2, CHA2DS2-VASc score 4.4 ± 1.2, HASBLED score 3.2 ± 0.8 and at high risk of stroke (98 ischaemic strokes and 129 haemorrhagic strokes) and bleeding (151 major or life-threatening bleeding episodes).  The mean procedural and fluoroscopy time were 52.5 ± 30.5 and 8.0 ± 5.9 minutes, respectively. Three different LAAO devices were used (136 Watchman, 54 Watchman FLX and 35 Amplatzer Cardiac Plug) with no significant difference in acute procedural success (97.8%, 98.2% and 94.4%, p = 0.41, respectively). Complete seal was achieved in 202 (92%) patients with only 1 (0.4%) moderate leak. Procedure-related mortality was 1.3% and non-fatal serious adverse events occurred in 5 (2.1%) patients. At 90 days, 28 patients experienced an adverse event (KM 12.5%; 95% CI, 8%-16.1%) and 16 patients suffered a serious adverse event (KM 7.1%; 95% CI, 3.7%-10.4%). In a covariate-adjusted Cox model, CHA2DS2-VASc score less than 4 had hazard ratio of 0.21 (95% CI, 0.06 -0.71, p = 0.01) for serious events at 90 days.

Conclusion

The acute procedural success rate was high (97%) with a low number of periprocedural complications. Serious adverse events at both 30 and 90-days were low in keeping with other published registries. Abstract Figure.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Right ventricular morphology and function analysis in moderately preterm-born young adults

Background

Previous studies have shown that prematurity leads to altered right ventricular (RV) geometry and performance with persistent impairments in RV systolic function in young adulthood. It is unknown to what extent pulmonary physiology impacts these findings.

Purpose

To better quantify known alterations in RV morphology and function in preterm-born young adults and to determine to what extent these changes are influenced by the pulmonary circulation.

Methods

A total of 101 normotensive preterm-born (n=47, mean gestational age 32.8±3.2 weeks) and term-born (n=54) young adults were recruited. Echocardiography and cardiovascular magnetic resonance (CMR) imaging were performed to characterise RV morphology, RV function, pulmonary hemodynamics and RV-pulmonary arterial vascular (PA) coupling. CMR cine images were used to create a 3D computational atlas of the RV geometry and principal component analysis was undertaken to identify the key modes of shape variation. Spirometry was performed to assess lung function.

Results

RV CMR revealed a higher absolute and indexed RV mass (P&lt;0.05) and lower ejection fraction (54.90±5.17 versus 57.48±4.39%, P=0.008) in young adults born preterm. RV end-diastolic areas and volumes for CMR and echocardiography were lower in preterm-born compared to term-born young adults (P≤0.001). Principal component analysis of the computational atlas defined the anatomical modes of the RV geometry, with mode 1 accounting for 25.3% of the population variance. Preterm and term cohorts showed significant differences (P&lt;0.001) in mode 1, which represented a smaller and shorter RV cavity in the preterm group (Figure 1). Measurements of RV function by echocardiography, including RV fractional area of change (FAC) and tricuspid annular plane systolic excursion (TAPSE), were lower in preterm-born compared to term-born adults (P&lt;0.05). Despite lower pulmonary artery acceleration times (PAAT) in those born preterm (141.1±15.1 versus 159.2±21.6msec, P&lt;0.001), indicating increased pulmonary vascular resistance, the RV remained coupled to its pulmonary circulation (TAPSE/PAAT: 0.13±0.02 versus 0.14±0.03m/sec, P=0.153). Reduced RV performance in preterm-born individuals remained significant when adjusting for pulmonary function parameters (P&lt;0.05).

Conclusions

Multimodality cardiac imaging demonstrated that moderately preterm-born young adults exhibit structural and functional RV alterations, independent of lung physiology. Their RV remains hemodynamically coupled to its pulmonary circulation despite higher RV afterload, lower RV function and altered morphology.

Figure 1. Statistical shape model of the RV

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation

Food industry influence on public health policy, research and practice in Latin America

One of the key barriers to the development of public health policies, such as restrictions on marketing of unhealthy foods to children, is the influence of corporations, also known as corporate political activity' (CPA). This project aimed to identify the CPA of the food industry in Brazil, Colombia and Chile, over a 2-year period.

This research consisted of a document analysis of publicly available information triangulated with interviews. It contributed to, and was based on methods developed by INFORMAS (International Network for Food and Obesity / non-communicable Diseases Research, Monitoring and Action Support), which aims to monitor food environments.

In all three countries, the food industry lobbied against public health policies and had direct access to high ranking officials and policy makers. It also shifted the blame away from its products in the obesity and non-communicable diseases epidemic onto individuals and their lack of education. In Brazil, the food industry was active against a new front-of-pack labeling, setting up its own website to promote an alternative model and self-regulation. In Colombia, the food industry captured the media and had strong ties with the government, including through nutrition programmes. Public health advocates felt unsafe when speaking against the industry or its products. In Chile, despite advances with the introduction of public health policies to limit the sales and marketing of unhealthy products, the food industry, including the sweeteners industry, which was not affected by the recent legislation, was still influencing policy, research and practice.

Food industry actors, including local companies and transnationals, used several CPA strategies in Latin America to try and influence public health policy, research and practice. It is urgent that policy makers, academics and other individuals in public health are aware of these practices and equipped with solutions to address undue influence by the food industry

Key messages

In Latin America, the food industry used several CPA practices, which collectively could have a negative influence on public health policy, research and practice. These practices could delay efforts to protect and promote public health in the region.

Hearing Screening in Preschool Children of a Rural Community in Portugal - A 10-year Experience

Introduction Preschool hearing screening programmes would identify later onset or progressive hearing losses and conductive hearing loss, due to the high prevalence of otitis media with effusion in childhood. Hearing loss associated with otitis media with effusion can have a great impact on reading, writing, central auditory processing and balance.

Objectives The present study aims at characterising the audiological alterations found in preschool children screened in a rural community in Portugal, and the correlation between audiological findings and otoscopy.

Methodology This is an observational study using the results obtained in a ten year audiological and otological screening of preschool children. Otoscopy, Tympanometry and Audiometry (1, 2 and 4 KHz presented at 40 and 20 dB intensity) were performed at the first stage of the screening and the results were classified as “pass” or “refer”. Every non-normal result of any category would imply a second stage consisting of observation by an ENT specialist at the site and the establishing of a follow-up plan. Written Informed Consent was obtained from the parents prior to initiating the study.

Results 595 children aged 5 and 6 years were screened between 2007 and 2017, of whom 192 (32.3%) required referral to the second stage. The most frequent alteration was found in the tympanogram. The tympanograms showed a significant correlation with the otoscopy performed by the ENT doctor, mainly type B tympanograms. The pass/refer audiometry also showed a statistically significant correlation with the medical otoscopy, although weak in all frequencies studied.

Conclusion It’s extremely important to perform a hearing screening in the age range of 5-6 years (with a high predisposition to middle ear problems), with the main objective of identifying and referring for treatment children who present alterations in order to reduce the consequences of the hearing impairment.

P214 Clinical audit of in-patient echocardiography in acute heart failure: real world data from a tertiary hospital

Background

Over the last ten years, an increase in admission rates for acute heart failure (HF) has been noted in England and Wales, with one year mortality rates varying between 30% and 60%. Transthoracic echocardiography (TTE) is recommended within 48 hours of admission for suspected acute heart failure, so to guide treatment accordingly.

Our centre has a specialist team who assesses patients with suspected HF on admission, and refers them for urgent in-patient TTE, using two priority in-patient echo slots per day. Patients are initially referred for HF assessment by general medics and geriatricians, across non-specialist medical wards. We audited the referrals and results of those who received TTE in this context.

Methods and results

We screened the medical notes of 252 patients admitted with suspected HF between January and December 2017, and reviewed the echocardiography results of those who received it during their admission.

50% of these patients were female and 59% were elderly (over 80 years old). 245 of these patients (97.2%) had in-patient echocardiography performed during their hospital stay. The mean wait for echocardiography was 0.58 days, with 92% of the scans being performed within 24 hours. The mean admission duration was 8.6 days (SD 10.9). 17.9% of patients were readmitted with suspected heart failure within six months, 69% of which were elderly.

The majority of this cohort presented with heart failure with preserved ejection fraction (HFpEF), 50%), followed by heart failure with reduced ejection fraction (HFrEF, 29%) and heart failure with mid-range ejection fraction (HFmrEF, 16%). 41% of the patients who received an echocardiogram were in atrial fibrillation, 51% of which were diagnosed with HFpEF.

All patients had their HF medical treatment optimised post-echocardiography and only 18.4% were readmitted within 6 months of the first admission. The majority of these patients was elderly (68.9%). 38.8% of patients who received echocardiography were referred for specialist clinic follow-up, with HFrEF patients more likely to be seen in this setting (42%).

Six-month mortality occurred in 19.8% of patients; cause of death (COD) was undocumented in 25.8% of cases. In those where a post-mortem was conducted, the main COD was HF (16.7%), followed by sepsis (13.6%), cardiac (6.1%) and respiratory arrest (6.1%). 66% of the deceased patients were elderly and 48% presented with HFpEF.

Conclusion

Our cohort is an accurate representation of the current HF statistics seen nationwide. Appropriate treatment was offered to the large majority of patients who received in-patient echocardiography within the first 24 hours of their admission, with low six-month readmission rates. This approach also allowed for the inclusion of these patients on a systematic review plan, including specialist cardiology follow-up. Our numbers are consistent with the higher awareness about HFpEF currently seen in the medical community.

P374 Prediction of an adverse cardiovascular response to physical exercise from resting echocardiography imaging in young adults with suboptimal blood pressure

Funding Acknowledgements

British Heart Foundation (BHF) grants (PG/13/58/30397)

Background

Young adults with mildly elevated blood pressure are less likely to engage with physical activity. This may be because early hypertension alters myocardial response to moderate exercise, leading to greater perceived exertion and lower levels of enjoyment. As atrial and ventricular function are closely coupled we investigated whether subclinical atrial changes at rest may identify this myocardial response.

Purpose

To identify whether subclinical changes in left atrial function at rest predict response to exercise by performing left atrial deep-phenotyping in a cohort of young adults with a range of blood pressures.

Methods

Seventy-one full-term born young adults (25.25 ± 5.13 years) were enrolled in the Young Adult Cardiovascular Health sTudy (YACHT) to undergo baseline clinical and cardiovascular phenotyping including detailed blood pressure measurement. Cardiopulmonary exercise testing combined with echocardiography imaging was performed to assess the myocardial response to physical exercise at 40%, 60% and 80% of peak exercise load for all participants. Left ventricular ejection fraction and global longitudinal strain were measured from an apical four chamber view at each exercise load, and resting left atrial phasic function was assessed by conventional and speckle tracking echocardiography from apical four and two chamber views (figure 1).

Results

In this young cohort with a range of blood pressure (120.9 ± 12.96/70.85 ± 9.78 mmHg), resting left atrial reservoir and conduit function, but not left atrial structural measures, showed good correlation with left ventricular ejection fraction and global longitudinal strain during 40%, 60% and 80% of peak exercise. The association between resting left atrial conduit with left ventricular deformation at 60% of peak exercise intensity remained significant when adjusted for age, sex and mean arterial pressure (P = 0.007).

Conclusion

Left atrial phasic function at rest predicts left ventricular responses to physical exercise in this cohort of young adults, which may relate to early subclinical left atrial remodelling in early hypertension. These findings require validation in other cohorts and investigation of whether this exercise limitation can be overcome in young hypertensives.

Abstract P374 Figure 1

Semen quality is affected by HLA class I alleles together with sexually transmitted diseases

BACKGROUND

The human leukocyte antigen (HLA) locus includes several genes with key roles in antigen presentation and immune response, some of them inclusively found to be associated with non-obstructive azoospermia. Still, HLA connections to other infertility phenotypes such as semen hyperviscosity (SHV), asthenozoospermia (AST), and oligozoospermia (OLI) have been often neglected.

OBJECTIVES

In this work, we aimed to evaluate the association of HLA class I and II genes with SHV, AST, and OLI phenotypes while exploring a possible role in an adaptive immune response to sexually transmitted diseases (STD).

MATERIALS AND METHODS

Whole-exome sequencing was performed in a Portuguese cohort of 71 infertility cases and 68 controls, followed by HLA typing using a specific software-HLA*PRG:LA tool. Molecular screenings of seven STD were carried out in a subset of 72 samples (30 cases and 42 controls).

RESULTS

Statistical tests uncovered three protective alleles: HLA-A*11:01, associated with all forms of male infertility (p = 0.0006); HLA-DQB1*03:02 with SHV and OLI (P_SHV   = 0.0303, P_OLI   = 0.0153); and HLA-A*29:02 with OLI (p = 0.0355), which was found to interfere in sperm number together with HPV (p = 0.0313). Five risk alleles were also identified: two linked with SHV (HLA-B*50:01, p = 0.0278; and HLA-C*06:02, p = 0.0461), another one with both SHV and OLI (HLA-DQA1*05:01, P_SHV   = 0.0444 and P_OLI =0.0265), and two with OLI (HLA-C*03:03, p = 0.0480; and HLA-DQB1*03:01, p = 0.0499). Here, HLA-C*03:03 carriers tend to be HPV infected.

CONCLUSIONS

The application of HLA*PRG:LA tool to the study of male infertility provided novel insights for an HLA correlation with semen quality, namely among SHV and OLI phenotypes. The discovery of an HLA-A*29:02/HPV crosstalk, together with former reports of HLA alleles conferring resistance-susceptibility to diverse human pathogens, raises the hypothesis of a mechanistic link between male infertility, HLA polymorphism, and host response to STD.

Aspergillus species collected from environmental air samples in Portugal-molecular identification, antifungal susceptibility and sequencing of cyp51A gene on A. fumigatus sensu stricto itraconazole resistant

AIMS

Aspergillus sp. are ubiquitous saprophytic fungi and their conidia easily inhaled. This is particularly important in immunocompromised patients, more susceptible to developing invasive aspergillosis. In addition to A. fumigatus sensu stricto, cryptic species, many resistant to antifungal drugs, have been associated with invasive infections, making it important to assess their presence and diversity in different environments. Therefore, the aim of this study was to assess the presence, diversity and susceptibility to antifungal drugs of airborne fungi. Moreover, in azole-resistant A. fumigatus sensu stricto isolates the presence of underlying molecular mechanisms of resistance was investigated.

METHODS AND RESULTS

Eighty-four Aspergillus isolates were collected from the environment air in hospitals and the Water Treatment Plant. The use of molecular tools allowed to detect 12 different cryptic species, showing a prevalence of 21·4%. The majority of isolates (69·0%) belonged to A. fumigatus complex and 65·4% were A. fumigatus sensu stricto. Among these, 21·8% were resistant to itraconazole (ITZ), 38·2% to posaconazole and 87·3% to isavuconazole; none of them were resistant to voriconazole or amphotericin B. Sequencing of the cyp51A gene on the 12 A. fumigatus sensu stricto ITZ-resistant isolates revealed the presence of mutations.

CONCLUSION

Our study reports a large number of environmental-resistant Aspergillus species, including A. fumigatus sensu stricto that display an important role in invasive fungal infections. None of the environmental isolates showed mutations on cyp51A gene related to azole resistance.

SIGNIFICANT AND IMPACT OF THE STUDY

This study is the first assessment of molecular resistance mechanisms in A. fumigatus sensu stricto environmental isolates, in Portugal. Since TR34/L98H and TR46/Y121F/T289A cyp51A mutations were already reported in the clinical setting in Portugal (Monteiro et al. J Glob Antimicron Resist 13: 190-191, 2018; Pinto et al. Front Microbiol 9: 1656, 2018), and have been linked to environmental route, it is utmost importance to perform surveillance network for azole-resistant A. fumigatus.

Blockade of dopamine D2 receptors disrupts intrahippocampal connectivity and enhances pain-related working memory deficits in neuropathic pain rats

BACKGROUND

Dopamine (DA) is thought to be important to local hippocampal networks integrity during spatial working memory (sWM) processing. Chronic pain may contribute to deficient dopaminergic signalling, which may in turn affect cognition. However, the neural mechanisms that determine this impairment are poorly understood. Here, we evaluated whether the sWM impairment characteristic of animal models of chronic pain is dependent on DA D2 receptor (D2r) activity.

METHODS

To address this issue, we implanted multichannel arrays of electrodes in the dorsal and ventral hippocampal CA1 field (dvCA1) of rats and recorded the neuronal activity during a classical delayed food-reinforced T-maze sWM task. Within-subject behavioural performance and patterns of dorsoventral neural activity were assessed before and after the onset of persistent neuropathic pain using the spared nerve injury (SNI) model.

RESULTS

Our results show that the peripheral nerve lesion caused a disruption in sWM and hippocampus spike activity and that disruption was maximized by the systemic administration of the D2r antagonist raclopride. These deficits are strictly correlated with a selective disruption of hippocampal theta-oscillations. Particularly, we found a significant decrease in intrahippocampal CA1 field connectivity level.

CONCLUSIONS

Together, these results suggest that disruption of the dopaminergic balance in the intrahippocampal networks may be important for the development of cognitive deficits experienced during painful conditions.

SIGNIFICANCE

This study provides new insights into the role of D2r in the manifestation of pain-related sWM deficits. Our findings support that selective blockade of D2r produces a significant decrease in intrahippocampal connectivity mediated by theta-oscillations, and amplifies pain-related sWM deficits. These results suggest that further characterization of intrahippocampal dopaminergic modulation may be clinically relevant for the understanding of cognitive impairments that accompanies nociceptive stressful conditions.

Preservação da Fertilidade em Mulheres Jovens com Carcinoma do Endométrio: A Propósito de um Caso Clínico

Nos últimos anos, um número crescente de mulheres adia o seu projeto reprodutivo para idades mais avançadas, sendo por isso cada vez mais importante que se avalie a possibilidade e a segurança de tratamentos conservadores que preservem a fertilidade em pacientes jovens com carcinoma do endométrio. O tratamento recomendado para o carcinoma do endométrio é a histerectomia total com salpingo-ooforectomia, o que interfere, como é óbvio, na fertilidade da mulher, não sendo por isso recomendável em mulheres que pretendem preservar a sua função reprodutora.Em alternativa, o tratamento conservador pode ser uma opção de exceção em casos bem selecionados.Contudo, a decisão de efetuar tratamento conservador não está isenta de riscos, nomeadamente os riscos de estadiar e/ou tratar inadequadamente o carcinoma do endométrio e os riscos de não diagnosticar tumores ováricos síncronos ou metastáticos. Além disso, não há consenso quanto ao tratamento ideal por quanto tempo deve ser prolongado, como efetuar a vigilância destas doentes e qual o resultado oncológico a longo prazo.O caso presente, no conhecimento dos autores, é o primeiro documentado em Portugal de gravidez após tratamento conservador de carcinoma do endométrio, numa mulher jovem. Recebido: 02/05/2017 - Aceite: 04/09/2017

Current and future treatment of amyloid diseases

There are more than 30 human proteins whose aggregation appears to cause degenerative maladies referred to as amyloid diseases or amyloidoses. These disorders are named after the characteristic cross-β-sheet amyloid fibrils that accumulate systemically or are localized to specific organs. In most cases, current treatment is limited to symptomatic approaches and thus disease-modifying therapies are needed. Alzheimer's disease is a neurodegenerative disorder with extracellular amyloid β-peptide (Aβ) fibrils and intracellular tau neurofibrillary tangles as pathological hallmarks. Numerous clinical trials have been conducted with passive and active immunotherapy, and small molecules to inhibit Aβ formation and aggregation or to enhance Aβ clearance; so far such clinical trials have been unsuccessful. Novel strategies are therefore required and here we will discuss the possibility of utilizing the chaperone BRICHOS to prevent Aβ aggregation and toxicity. Type 2 diabetes mellitus is symptomatically treated with insulin. However, the underlying pathology is linked to the aggregation and progressive accumulation of islet amyloid polypeptide as fibrils and oligomers, which are cytotoxic. Several compounds have been shown to inhibit islet amyloid aggregation and cytotoxicity in vitro. Future animal studies and clinical trials have to be conducted to determine their efficacy in vivo. The transthyretin (TTR) amyloidoses are a group of systemic degenerative diseases compromising multiple organ systems, caused by TTR aggregation. Liver transplantation decreases the generation of misfolded TTR and improves the quality of life for a subgroup of this patient population. Compounds that stabilize the natively folded, nonamyloidogenic, tetrameric conformation of TTR have been developed and the drug tafamidis is available as a promising treatment.

Overview: Bellagio Conference on Program and Policy Options for Preventing Obesity in the Low- and Middle-Income Countries

The Bellagio 'Conference on Program and Policy Options for Preventing Obesity in the Low- and Middle-Income Countries' (LMICs) was organized to pull together the current. We need not reiterate the importance of this topic or the speed of change in eating, drinking and moving facing us across the globe. The conference emerges from need to significantly step up the policies and programs to reduce obesity by learning from some current examples of best practice and strengthening the role of the academic and civil society players in translating global evidence and experience into action at the national level. There is also a need to empower the younger generation of scholars and activists in these countries to carry on this effort. The meeting was also timely because a number of funding agencies in the United States, Canada and the UK, at least, are beginning to focus attention on this topic. This set of papers provides not only examples of existing best practice but also a road map ahead for LMICs in the various areas of action needed to reduce obesity across LMICs. The meeting highlighted critical barriers to implementation that have blocked many initiatives.

Monitoring policy and actions on food environments: rationale and outline of the INFORMAS policy engagement and communication strategies

The International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support (INFORMAS) proposes to collect performance indicators on food policies, actions and environments related to obesity and non-communicable diseases. This paper reviews existing communications strategies used for performance indicators and proposes the approach to be taken for INFORMAS. Twenty-seven scoring and rating tools were identified in various fields of public health including alcohol, tobacco, physical activity, infant feeding and food environments. These were compared based on the types of indicators used and how they were quantified, scoring methods, presentation and the communication and reporting strategies used. There are several implications of these analyses for INFORMAS: the ratings/benchmarking approach is very commonly used, presumably because it is an effective way to communicate progress and stimulate action, although this has not been formally evaluated; the tools used must be trustworthy, pragmatic and policy-relevant; multiple channels of communication will be needed; communications need to be tailored and targeted to decision-makers; data and methods should be freely accessible. The proposed communications strategy for INFORMAS has been built around these lessons to ensure that INFORMAS's outputs have the greatest chance of being used to improve food environments.

Monitoring the health-related labelling of foods and non-alcoholic beverages in retail settings

Food labelling on food packaging has the potential to have both positive and negative effects on diets. Monitoring different aspects of food labelling would help to identify priority policy options to help people make healthier food choices. A taxonomy of the elements of health-related food labelling is proposed. A systematic review of studies that assessed the nature and extent of health-related food labelling has been conducted to identify approaches to monitoring food labelling. A step-wise approach has been developed for independently assessing the nature and extent of health-related food labelling in different countries and over time. Procedures for sampling the food supply, and collecting and analysing data are proposed, as well as quantifiable measurement indicators and benchmarks for health-related food labelling.

Monitoring food and non-alcoholic beverage promotions to children

Food and non-alcoholic beverage marketing is recognized as an important factor influencing food choices related to non-communicable diseases. The monitoring of populations' exposure to food and non-alcoholic beverage promotions, and the content of these promotions, is necessary to generate evidence to understand the extent of the problem, and to determine appropriate and effective policy responses. A review of studies measuring the nature and extent of exposure to food promotions was conducted to identify approaches to monitoring food promotions via dominant media platforms. A step-wise approach, comprising 'minimal', 'expanded' and 'optimal' monitoring activities, was designed. This approach can be used to assess the frequency and level of exposure of population groups (especially children) to food promotions, the persuasive power of techniques used in promotional communications (power of promotions) and the nutritional composition of promoted food products. Detailed procedures for data sampling, data collection and data analysis for a range of media types are presented, as well as quantifiable measurement indicators for assessing exposure to and power of food and non-alcoholic beverage promotions. The proposed framework supports the development of a consistent system for monitoring food and non-alcoholic beverage promotions for comparison between countries and over time.

Monitoring the levels of important nutrients in the food supply

A food supply that delivers energy-dense products with high levels of salt, saturated fats and trans fats, in large portion sizes, is a major cause of non-communicable diseases (NCDs). The highly processed foods produced by large food corporations are primary drivers of increases in consumption of these adverse nutrients. The objective of this paper is to present an approach to monitoring food composition that can both document the extent of the problem and underpin novel actions to address it. The monitoring approach seeks to systematically collect information on high-level contextual factors influencing food composition and assess the energy density, salt, saturated fat, trans fats and portion sizes of highly processed foods for sale in retail outlets (with a focus on supermarkets and quick-service restaurants). Regular surveys of food composition are proposed across geographies and over time using a pragmatic, standardized methodology. Surveys have already been undertaken in several high- and middle-income countries, and the trends have been valuable in informing policy approaches. The purpose of collecting data is not to exhaustively document the composition of all foods in the food supply in each country, but rather to provide information to support governments, industry and communities to develop and enact strategies to curb food-related NCDs.

Monitoring foods and beverages provided and sold in public sector settings

This paper outlines a step-wise framework for monitoring foods and beverages provided or sold in publicly funded institutions. The focus is on foods in schools, but the framework can also be applied to foods provided or sold in other publicly funded institutions. Data collection and evaluation within this monitoring framework will consist of two components. In component I, information on existing food or nutrition policies and/or programmes within settings would be compiled. Currently, nutrition standards and voluntary guidelines associated with such policies/programmes vary widely globally. This paper, which provides a comprehensive review of such standards and guidelines, will facilitate institutional learnings for those jurisdictions that have not yet established them or are undergoing review of existing ones. In component II, the quality of foods provided or sold in public sector settings is evaluated relative to existing national or sub-national nutrition standards or voluntary guidelines. Where there are no (or only poor) standards or guidelines available, the nutritional quality of foods can be evaluated relative to standards of a similar jurisdiction or other appropriate standards. Measurement indicators are proposed (within 'minimal', 'expanded' and 'optimal' approaches) that can be used to monitor progress over time in meeting policy objectives, and facilitate comparisons between countries.

Monitoring the impacts of trade agreements on food environments

The liberalization of international trade and foreign direct investment through multilateral, regional and bilateral agreements has had profound implications for the structure and nature of food systems, and therefore, for the availability, nutritional quality, accessibility, price and promotion of foods in different locations. Public health attention has only relatively recently turned to the links between trade and investment agreements, diets and health, and there is currently no systematic monitoring of this area. This paper reviews the available evidence on the links between trade agreements, food environments and diets from an obesity and non-communicable disease (NCD) perspective. Based on the key issues identified through the review, the paper outlines an approach for monitoring the potential impact of trade agreements on food environments and obesity/NCD risks. The proposed monitoring approach encompasses a set of guiding principles, recommended procedures for data collection and analysis, and quantifiable 'minimal', 'expanded' and 'optimal' measurement indicators to be tailored to national priorities, capacity and resources. Formal risk assessment processes of existing and evolving trade and investment agreements, which focus on their impacts on food environments will help inform the development of healthy trade policy, strengthen domestic nutrition and health policy space and ultimately protect population nutrition.

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support): overview and key principles

Non-communicable diseases (NCDs) dominate disease burdens globally and poor nutrition increasingly contributes to this global burden. Comprehensive monitoring of food environments, and evaluation of the impact of public and private sector policies on food environments is needed to strengthen accountability systems to reduce NCDs. The International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) is a global network of public-interest organizations and researchers that aims to monitor, benchmark and support public and private sector actions to create healthy food environments and reduce obesity, NCDs and their related inequalities. The INFORMAS framework includes two 'process' modules, that monitor the policies and actions of the public and private sectors, seven 'impact' modules that monitor the key characteristics of food environments and three 'outcome' modules that monitor dietary quality, risk factors and NCD morbidity and mortality. Monitoring frameworks and indicators have been developed for 10 modules to provide consistency, but allowing for stepwise approaches ('minimal', 'expanded', 'optimal') to data collection and analysis. INFORMAS data will enable benchmarking of food environments between countries, and monitoring of progress over time within countries. Through monitoring and benchmarking, INFORMAS will strengthen the accountability systems needed to help reduce the burden of obesity, NCDs and their related inequalities.

Monitoring and benchmarking population diet quality globally: a step-wise approach

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support) aims to monitor and benchmark the healthiness of food environments globally. In order to assess the impact of food environments on population diets, it is necessary to monitor population diet quality between countries and over time. This paper reviews existing data sources suitable for monitoring population diet quality, and assesses their strengths and limitations. A step-wise framework is then proposed for monitoring population diet quality. Food balance sheets (FBaS), household budget and expenditure surveys (HBES) and food intake surveys are all suitable methods for assessing population diet quality. In the proposed 'minimal' approach, national trends of food and energy availability can be explored using FBaS. In the 'expanded' and 'optimal' approaches, the dietary share of ultra-processed products is measured as an indicator of energy-dense, nutrient-poor diets using HBES and food intake surveys, respectively. In addition, it is proposed that pre-defined diet quality indices are used to score diets, and some of those have been designed for application within all three monitoring approaches. However, in order to enhance the value of global efforts to monitor diet quality, data collection methods and diet quality indicators need further development work.