The impact of post-mastectomy radiation timing on overall outcomes of autologous free-flap breast reconstruction

BACKGROUND

The optimal timing of post-mastectomy radiation therapy (PMRT) in autologous breast reconstruction is controversial. Our study compares overall reconstructive outcomes in patients who received post-mastectomy radiation therapy either before or after the autologous flap.

METHODS

A single-center retrospective review was performed for patients who underwent free flap breast reconstruction and post-mastectomy radiation from January 2004 through January 2021. Demographic, intraoperative, and post-operative variables were recorded.

RESULTS

A total of 452 free flaps were identified, and 82 underwent PMRT. 59.8% were radiated with an expander prior to free flap surgery (PreFlap), and 40.2% flaps underwent PMRT (PostFlap). PostFlap patients were significantly younger (43.0 vs. 47.9 years, p = .016). There were no significant differences in free flap outcomes between the two cohorts including thrombosis, venous congestion, flap loss, takebacks, fat necrosis, seroma, or infection. Mastectomy skin flap necrosis was significantly higher in the PostFlap cohort (9.1% vs. 0%, p = .032), but nipple necrosis rates did not differ. There were no significant differences in number or need for revision surgeries, fat necrosis, or fat grafting between groups. However, there were significantly more total reconstructive complications, including infection and wound breakdown, experienced by the PreFlap cohort (46.9% vs. 24.2%, p = .038).

CONCLUSIONS

Timing of PMRT did not impact free flap outcomes, but those who had the expander radiated experienced significantly more complications overall. For the 34.7% of patients in the preFlap group who planned for autologous reconstruction form initial consultation, radiation after the flap may have improved their overall outcomes. As added complications cause delays in cancer therapy and final reconstruction, our results suggest that PMRT of the flap when possible may improve the overall experience for breast cancer patients.

Adaptations to water stress and pastoralism in the Turkana of northwest Kenya

The Turkana people inhabit arid regions of east Africa-where temperatures are high and water is scarce-and they practice subsistence pastoralism, such that their diet is primarily composed of animal products. Working with Turkana communities, we sequenced 367 genomes and identified 8 regions putatively involved in adaptation to water stress and pastoralism. One of these regions includes a putative enhancer for STC1-a kidney-expressed gene involved in the response to dehydration and the metabolism of purine-rich foods such as red meat. We show that STC1 is induced by antidiuretic hormone in humans, is associated with urea levels in the Turkana themselves, and is under strong selection in this population (s∼0.041). This work highlights that partnerships with subsistence-level groups can lead to new models of human physiology with biomedical relevance.

Physical activity and heart failure: a forgotten indicator

Introduction

Low physical activity may be associated with comorbidities, sedentary lifestyle or clinical worsening in heart failure (HF) patients. Cardiovascular implantable electronic devices (CIEDs) detect and analyse physical activity data that is often integrated in multifactorial algorithms for predicting HF decompensations, but its potential is probably underestimated.

Purpose

We hypothesized that low physical-activity levels, obtained from remote monitoring of CIEDs, help predict clinical outcomes in HF patients, independently from multifactorial algorithms.

Methods

We retrospectively evaluated consecutive patients with HF and CIEDs through clinical assessments and remote monitoring (two monitoring systems were used). Low activity was defined as <1 hour/day of physical activity and two groups of patients were defined: patients with low activity alerts (group 1) and patients without low activity alerts (group 2). Primary outcome was defined as death by all causes and secondary outcome as HF hospitalizations and sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) episodes.

Results

From 121 patients with RPM, physical activity data was obtained in 104 (85,9%). Mean age was 63,98±12,44 years, 70,2% were males and follow-up was 59,19±38,491 months. Fifty-four (51,9%) had implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D), 46 (44,2%) transvenous implantable cardioverter defibrillator (ICD), and 4 (3,8%) CRT pacemaker (CRT-P). The aetiology was idiopathic in 42,5% and ischemic in 40,2%. Mean left ventricular ejection fraction was 34,08±11,40% and mean physical activity duration was 2,25±1,84 hours/day. Forty-eight (53,7%) had low activity alerts (group 1) and 56 (46,3%) had no low activity alerts (group 2). In group 1 mean period of low activity was 52,978±15,75 days/year. Patients from group 1 were older (p=0,001), had more oncological disease (p=0,041) and peripheral artery disease (p=0,028). Three deaths occurred in total, all in group 1 (p=0,039) and HF hospitalizations were more frequent in group 1 (1,68±2,59 vs 0,69±1,32, p=0,005). Low activity burden was also associated with atrial fibrillation burden (r=0,473, p<0,05) and number of episodes of VT or VF (r=0,267, p=0,007). A decrease of 50% or more in mean duration of physical activity, but above 1 hour/day, was associated with increase HF hospitalizations (1,83±2,13 vs 1,05±1,95, p=0,006).

Conclusion

Low physical activity data obtained from CIEDs was associated with HF hospitalizations, arrhythmic events and death by all causes, independently of multifactorial algorithms. A decrease in basal activity even above alert threshold, was associated with HF hospitalizations and may be an even earlier sign of HF decompensations.

Funding Acknowledgement

Type of funding sources: None.

Lower rate limit in cardiac resynchronization therapy defibrillators

Background

There is few data about programmed lower rate limit (LRL) in real world heart failure (HF) patients with cardiac resynchronization therapy–defibrillators (CRT-Ds) and its influence in clinical outcomes. Heart rate score (HRS) is the percentage of all atrial-paced and sensed events in the single tallest 10 beats/min device histogram bin and may indicate impaired heart rate variability.

Purpose

We hypothesized that higher LRL programming is associated with worse clinical outcomes as arrhythmic events and HF decompensations in chronic HF patients with CRT-Ds.

Methods

LRL was evaluated and HRS was calculated from remote monitoring in 126 HF patients with CRT-D. Primary outcome was defined as HF hospitalizations and related admissions to the emergency department and secondary outcome as number of device therapies, sustained ventricular tachycardia (VT) and ventricular fibrillation (VF).

Results

Mean age was 69,03±10,39 years, 81 (64,3%) were males and mean follow-up was 53,72±46,13 months. Mean left ventricular ejection fraction was 30,31±8,33% and 29 (23,0%) were in NYHA III–IV. HF aetiology was idiopathic in 39 (43,3%), ischemic in 32 (25,4%) and alcoholic cardiomyopathy in 8 (6,3%). Thirty-seven (29,4%) patients had atrial fibrillation and 33 (26,2%) coronary disease. LRL ranged from to 40 to 80 bpm and mean LRL was 52,64±9,64 and mean HRS 49,60±23,17%. Programmed LRL was higher in women (p=0,014), patients with atrial fibrillation (AF) (p=0,012) and coronary disease (p=0,015). Higher LRL correlated with HF hospitalizations and related admissions to the emergency department (ED) (r=0,541, p=0,001), VT or VF episodes (r=0,337, p=0,005) and CRT-D number of therapies (r=0,342, p=0,004) and higher HRS (r=0,547, p<0,05).

Conclusion

Higher LRL programming was associated with higher HRS, HF decompensations with hospitalization or admission to the emergency department, VT or VF episodes and CRT-D therapies in a real world population. More studies are required but lower LRL may be preferred in HF patients.

Funding Acknowledgement

Type of funding sources: None.

Impact of coronavirus disease 2019 on adult patients with congenital heart disease

Background

COVID-19 is responsible for a worldwide pandemic, causing more than 18,000 deaths to date in Portugal. Data already exists regarding the increased risk of adverse events in patients with cardiovascular diseases, however the impact of SARS-CoV-2 infection in patients (P) with congenital heart disease (CHD) is still under investigation.

Purpose

To study the impact of COVID-19 in a adult patients with CHD

Methods

Adult patients seen at the CHD outpatient's clinic at a tertiary centre, who became infected with SARS-CoV-2 infection up to December 2021 were included. Assessment of patients' symptoms, need for hospitalization and admission in an intensive care unit was assessed based on medical records.

Results

We identified seventy-nine patients (pts) with COVID-19 infection. Symptoms were present in 67 (84%). The median age was 44 (15) years, 52% were females. Eight P (10%) had complex cyanotic disease; seven Tetralogy of Fallot; five (6%) transposition of great arteries; eight (10%) right ventricle obstacle; two (3%) atrioventricular canal defect; sixteen (20%) atrial septal defect; nine (11%) ventricular septal defect; eight (10%) aortic coarctation; two (3%) had Eisenmenger syndrome. 49% of P had previous surgery or percutaneous procedure. 63% of P were at New York Heart Association (NYHA) class of I and 30% at NYHA II. Mild symptoms were reported by 56 P (71%). Ten adults (7,9%) experienced moderate symptoms (dyspnea and hypoxia) that led to hospitalization for oxygen therapy, none required mechanical ventilation. One death was reported in an 83-year-old patient with non-corrected interventricular communication and compromised biventricular function. There was a significant association between the gravity of CHD and hospitalizations (p=0.02).

Conclusion

Our pts had mainly mild to moderate symptoms and did not appear to have a disproportionately negative outcome; the need for hospitalization was more frequent in patients with higher CHD gravity. These findings are in line with the emerging data regarding COVID-19 in CHD P, and may be in part explained by the patient's young age and functional status.

Funding Acknowledgement

Type of funding sources: None.

Biventricular or left univentricular pacing in heart failure patients: is there a better strategy

Background

Cardiac resynchronization therapy (CRT) is a cornerstone in treatment of heart failure (HF) with reduced left ventricular ejection fraction (LVEF) and ventricular dyssynchrony. Biventricular (BiV) pacing is often the preferred method and corrects electrical and mechanical dyssynchrony but Left ventricular (LV) preferential pacing is may preserve conduction via the right bundle branch, preventing deleterious effects from right ventricular. The evidence is sparse and there is doubts whether which programming strategy is better.

Purpose

We hypothesized that BiV is non-inferior to preferential LV pacing in HF patients with reduced LVEF and CRT devices in cardiovascular death and HF hospitalizations.

Methods

We retrospectively evaluated 147 patients with HF patients with reduced LVEF and CRT devices. Two groups were defined: LV pacing (group 1) and BiV pacing (group 2). Primary outcome was defined as cardiovascular death and secondary outcome as HF hospitalizations and NYHA class after CRT.

Results

Mean age was 70,26±10,6 years, 68,1% were males and follow-up was 52,22±44,51 months. One hundred and twenty six (85,7%) patients had implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D) and 21 (14,3%) CRT pacemaker (CRT-P). Mean LVEF was 31,1±8,5% and mean QRS duration before CRT implantation was 149,5±48,6 ms. Thirty-nine (36,4%) patients were in NYHA III–IV. HF aetiology was idiopathic in 51 (47,2%), ischemic in 36 (33,3%) and alcoholic cardiomyopathy in 9 (8,3%). Forty-five (40,5%) patients had atrial fibrillation and 37 (35,6%) coronary disease. Patients in group 2 were more frequently males than group 1 patients (46 (78,0%) vs 32 (56,1%) respectively, p=0,012). There were no differences in regard to age, LVEF, HF aetiology or other comorbidities between groups. In 57 (49,1%) CRT was programming in preferential LV pacing and 50 (50,9%) in BiV pacing. There were 2 deaths in group 1 and 3 in group 2 (OR 0.80, 95% CI 0.27–2.40). There were 0,98±3,17 hospitalizations per patient and there were no differences in HF hospitalizations between groups (OR 1.01, 95% CI 0.92–1.18) or NYHA after 6 months of CRT (p=0,364).

Conclusion

BiV pacing was not inferior to LV-only pacing in regard to cardiovascular death, HF hospitalizations and NYHA class improvement. There was no clear advantage for one pacing strategy over the other but more studies are still required.

Funding Acknowledgement

Type of funding sources: None.

Suboptimal coronary flow after PCI in STEMI patients: clinical implications and predictors

Background

Even in experienced angioplasty centers, percutaneous coronary intervention (PCI) in the acute setting of ST-elevation myocardial infarctions (STEMI) is associated with a low, but still significant rate of suboptimal coronary flow. Identification of its clinical impact and potential modifiable risk factors is important.

Purpose

To evaluate the clinical impact of suboptimal coronary flow after PCI in STEMI patients and to access potential predictors of suboptimal coronary flow.

Methods

We retrospectively evaluated 103 hospitalized patients with acute STEMI who were admitted to our center between 2018 and 2019 and underwent PCI. Coronary flow was accessed using the Thrombolysis in myocardial infarction (TIMI) Flow Grading System. Patients were divided into suboptimal patency of the culprit-vessel, defined as TIMI flow ≤2 (group 1, n=8 (7,8%)) and optimal patency of the culprit-vessel defined as TIMI flow 3 (group 2, n=95 (92,2%)). Glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) formula.

Results

Mean age 58,15±12,6 years and 85,4% were males. Seventy-eight patients (75,7%) had history of smoking, 45 (43,7%) dyslipidemia, 20 (19,4%) previous acute coronary syndrome, 18 (17,5%) diabetes, 17 (15,5%) were obese and 4 (3,9%) had chronic kidney disease. The revascularization strategy was primary PCI in 55 (54,4%) patients and fibrinolytic therapy with facilitated PCI in 48 (46,6%) patients. Infarct-related artery was the left anterior descending artery in 45 (45,5%) and multivessel disease was present in 38 (38,0%). Angiographic no-reflow after PCI was 3,0%. Intrahospital cardiovascular death occurred in 4 (3,9%) patients and was significantly associated with suboptimal flow (p=0,036) and there was no association with stent thrombosis. Predictors of suboptimal flow were higher blood urea nitrogen, creatinine and GFR at hospital admission (p=0,017 and p=0,012), peak creatinine (p=0,012) and stent length (p=0,038). Suboptimal flow was associated with higher Zwolle score (p=0,010) and ischemic Paris score (p=0,036).

Conclusion

Failure to achieve optimal culprit-vessel patency after PCI in STEMI patients, although infrequent, is associated with increased hospital cardiovascular death. Longer stents could be and important modified risk factor. Renal dysfunction is an important comorbidity that should be promptly identified and could be partially improved with medical treatment.

Funding Acknowledgement

Type of funding sources: None.

Acute ST-elevation myocardial infarction: are men and women particular cases of STEMI ?

Funding Acknowledgements

Type of funding sources: None.

Background

ST-segment elevation myocardial infarction (STEMI) has high levels of morbidity and mortality. Multiple risk factors may contribute to clinical outcomes and some studies demonstrate gender-related differences in baseline characteristics and in-hospital management.

Purpose

To access the difference in clinical characteristics and prognostic outcomes between men and women who were admitted in our Cardiac Intensive Care Unit with STEMI diagnosis.

Methods

We retrospectively analyzed 121 non-consecutive patients with STEMI during a mean follow-up period 135 ± 31 weeks.

We accessed baseline characteristics and time course of events (symptom onset-to-door admission; time to first EKG; time to fibrinolytic therapy; door-to-cath lab time and time from fibrinolytic therapy to PCI (for patients transferred from another centers).

Primary endpoint (PE) was a composite of in-hospital cardiovascular death, arrhythmic events or STEMI evolution in Killip-Kimbal III or IV.

Secondary endpoint (SE) was in-hospital major bleeding events, considered intracerebral hemorrhage, cases of hemodynamic compromise or requiring a blood transfusion.

Tertiary endpoint (TE) included admissions to the emergency department or hospitalization by heart failure decompensation, acute or chronic coronary syndromes and all-cause mortality.

Results

Of the 121 patients, 102 were male (84.3%) and 19 (15.7%) female. The mean age was 58.3 ± 12.7 years and women had a superior mean age (69.8 ± 12.2 years) vs. Men mean age 56 ± 11.6 years.

Hypertension was more prevalent in women (84.2% vs. 47.1%, respectively; p 0.003) and also diabetes – 36.8% of women had type 2 diabetes (vs 10.8% of men) and 5.3% of these female patients requires insulin therapy (vs 2% of men; p 0.021).

According to Charlson Comorbidity Index (CCI), women had a higher disease burden with 73.7% of them included into the moderate or severe group of mortality risk, compared to 42.2% of men (p 0.014).

Conversely, less women smoke (31.6% vs. 82.2%; p <0.001) and less frequently chest pain was the onset symptom (78.9% vs. 95.1%; p 0.04).

Time since symptom onset to door admission was estimated on 510 ± 1149 minutes and the mean women delay was superior (557 ± 858 minutes).

Regarding to in-hospital hemorrhagic events (secondary endpoint), female patients had a statistically significant higher risk (22.2% vs. 7.1%, p 0.045), independently of hypertension, diabetes or anticoagulant therapy (r=0.249; ANOVA p-value < 0.005), but it was associated with higher CCI (p 0.033). No other gender differences in outcomes or survival function were observed.

Conclusion

Our study demonstrates gender-related differences among patients with STEMI. Indeed, women were older, had more clinical cardiovascular risk factors and tend to delay hospital admission after symptoms onset. Secondary endpoint was statistically more frequent in women, but no other differences in outcomes were observed.

Risk scores in predicting adverse events after an acute coronary syndrome

Funding Acknowledgements

Type of funding sources: None.

Introduction

ST-segment elevation myocardial infarction (STEMI) is a serious event that usually occur in patients with cardiovascular risk factors and is associated with great morbidity and mortality.

PARIS ischemic risk score and TIMI score were validated to evaluate ischemic risk in STEMI patients who underwent percutaneous coronary intervention (PCI) and to estimate mortality, respectively.

Despite these specific purposes, the usefulness of these scores in predicting adverse cardiovascular events (ACE) is unknown.

Objectives

To assess the prognostic value of PARIS and TIMI scores for cardiovascular events, coronary ischemic events and mortality in patients after STEMI.

Methods

Retrospective single center cohort study enrolled 103 patients with STEMI diagnosis between 2018 and 2019, during a mean follow-up period 30.30 ± 6.46 months and patients were included regardless of the reperfusion strategy.

Primary endpoint (PE) was a composite of acute coronary events (ACE), admissions to the emergency department by heart failure (HF) decompensation or chronic coronary syndrome and HF hospitalization. Secondary endpoint (SE) was ACE. Cardiovascular and non-cardiovascular death was determined.

PARIS ischemic risk score was calculated and patients were stratified into low (0-2), intermediate (3-4) or high (≥ 5) ischemic risk categories. TIMI score was also assessed.

Results

Out of 103 patients with STEMI diagnosis, the median age was 58.15 ± 12.6 years and 85,4% were male. Fifty-seven patients (55.3%) had hypertension, 45 (43.7%) dyslipidemia, 18 (17.5%) diabetes, 17 (15.5%) were obese and seventy-eight patients (75.7%) had history of smoking. Twenty (19.4%) patients had a previous acute coronary syndrome and 15 underwent PCI.

Twenty-five (24.3%) patients were included in low PARIS ischemic risk category, 53 (51.5%) in intermediate risk and 20 (19.4%) in high risk category.

PE occurred in 16 patient (15.5%) and SE in 7 patients (6.8%).

Eight patients died during the follow-up period (7.8%), 4 of cardiovascular causes (50%), 3 of non-cardiovascular causes (37.5%) and 1 of unknown cause.

PARIS ischemic risk score showed prognostic value for PE, with an area under the curve (AUC) of 0.65, 95% confidence interval (CI) 0.506-0.806 and p-value 0.039.

PARIS score also had predictive value for SE (AUC 0.816, 95% CI 0.604-1.000; p 0.004) as well as TIMI score (AUC 0.738, 95% CI 0.560 – 0.917; p 0.032).

Both scores showed a good prognostic value in evaluating all-cause mortality, with a slightly better predictive value for TIMI score (AUC 0.91, 95% CI 0.802 – 1.00) when compared to PARIS score (AUC 0.84, 95% CI 0.685 – 0.987).

Conclusion

This study revealed that PARIS and TIMI scores have a good discriminatory power to predict prognosis in STEMI patients. According to our study results, these scores could be an interesting tool to determine the likelihood of fatal and non-fatal outcomes, including ACS.

Hemorrhagic risk scores in hospitalized patients with acute coronary syndrome: can they (only) predict bleeding events?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Acute coronary syndrome (ACS) is a life-threatening condition and its therapeutic approach increases the risk of important bleeding events which are associated with a worse prognosis. Along with hemorrhagic events, a drop on hemoglobin level not related to bleeding or the development of anemia could have a negative impact on prognosis.

Both CRUSADE and PARIS bleeding risk scores are used to evaluate and to stratify the risk of major bleeding in ACS. However their actual predictive value has been questioned and validity of these scores in predicting in-hospital mortality (IHM) is not established.

Objectives

To evaluate the actual prognostic value of CRUSADE and PARIS bleeding scores in ACS patients during their hospitalization stay.

Methods

Retrospective single center cohort study including 103 hospitalized patients after an acute ST-segment elevation myocardial infarction (STEMI) regardless of its reperfusion strategy.

In-hospital major hemorrhagic events (IHMHE), considered intracerebral hemorrhage, those resulting in hemodynamic compromise or requiring a blood transfusion, were assessed. Data on hemoglobin levels (HL) at hospital admission and at the time of hospital discharge were also collected and a composite endpoint (CE) of IHMHE and a drop in HL  ≥ 3g/dL were elaborated.

Both scores were calculated for each patient, its predictive value and their impact on IHM were determined.

Results

Out of 103 patients enrolled, the median age was 58.15 ± 12.6 years and 85.4% were male.

Two IHMHE occurred, twenty patients (19.4%) had anemia at the time of hospital discharge and 16 of these patients (15.5%) were not anemic at the time of hospital admission. Nine (8.7%) patients had a drop in their HL of at least 3g/dL.

The five bleeding risk categories defined by CRUSADE investigators were used, with 48 (46.6%) patients in the very low risk category, 9 (8.7%) and 6 (5.8%) in the high and very high risk category, respectively.

Hospitalization length stay was 5.6 ± 4.1 days with an overall in-hospital mortality (IHM) of 5.8%.

Receiver operating characteristic curve (ROC) analysis showed that CRUSADE score had an excellent discriminatory power for the CE (AUC 0.927, 95% CI 0.854-1.000) and the PARIS score had an acceptable discriminatory value (AUC 0.775, 95% CI 0.616-0.935).

Both CRUSADE and PARIS bleeding scores also had prognostic value in evaluating IHM (AUC 0.929, 95% CI 0.856-1.000 and AUC 0.788, 95% CI 0.634-0.942, respectively).

No specific and independent predictors of IHMHE were found, neither related to individual characteristics nor to therapeutic approach.  

Conclusion

The presenting study showed that CRUSADE and PARIS scores still have discriminatory power to assess CE and to assess IHM in ACS patients. Their addition to stratification tools could be of interest.

STEMI treatment in remote areas – challenges of the only interventional angioplasty center located in an archipelago

Background

In remote islands lack of specialized medical facilities, long distance transfer and emergency medical system organization remains a challenge and fibrinolysis is necessary to achieve revascularization in optimal timing in ST-elevation myocardial infarction (STEMI) patients. Our angioplasty center is the only one located in an archipelago composed of nine islands, six of which do not have hospital facilities and only have small family health care units.

Purpose

To evaluate the reality and outcomes of our interventional angioplasty center and compare cardiovascular outcomes between STEMI patients from the main island and remote islands.

Methods

We retrospectively evaluated 103 patients with STEMI admitted to our center between 2018 and 2019. Patients from the main island where the center is located underwent primary percutaneous coronary intervention (PCI) (group 1, n=55) and patients from remote islands underwent fibrinolytic therapy followed by transference to our center with facilitated or rescue PCI (group 2, n=48). A subanalysis of the far remote islands without hospital facilities was also performed. Primary outcome was defined as cardiovascular death or re-infarction at two years and secondary outcome as intrahospital haemorrhagic complications.

Results

Mean age was 58,15±12,6 years, 85,4% were males and follow up period was 30,30±6,46 months. Seventy-eight patients (75,7%) had history of smoking, 45 (43,7%) dyslipidemia, 20 (19,4%) previous acute coronary syndrome, 18 (17,5%) diabetes and 17 (15,5%) were obese. Troponin I peak was 117,42±129,06 ug/L and 14 (13,6%) were in Killip Class III/IV. Infarct-related artery was the left anterior descending artery in 45 (45,5%) and multivessel disease was present in 38 (38,0%). In group 1 reperfusion after PCI was obtained in 91,5%. In group 2, 73,5% met criteria for reperfusion after fibrinolysis and 23,6% after rescue PCI. Mean time from fibrinolysis to PCI was 558±349 minutes. Rates of successful revascularization did not differ between groups, as well as complete patency of the culprit-vessel defined as thrombolysis in myocardial infarction (TIMI) flow 3 (91,5% vs. 97,2% and 90,0% vs. 93,0% respectively for group 1 and 2). Cardiovascular death at two years occurred in 4 (3,9%) patients and re-infarction in 11 (10,7%) and were similar between groups (3 (5,5%) vs. 1 (2,1%) and 8 (14,5%) vs. 3 (6,3%) respectively) as well as haemorrhagic complications (1 (1,8%) vs. 5 (10,4%) respectively). Nineteen (18,4%) patients were from far remote islands without hospital facilities and when comparing these patients with the others there was also no difference in primary outcome.

Conclusion

Even in remote islands, an organized STEMI network with attempted fibrinolytic treatment and coordinated transference of patients for facilitated or rescue PCI can provide successful revascularization with cardiovascular outcomes similar to those submitted to primary PCI.

Funding Acknowledgement

Type of funding sources: None.

Non-ST elevation myocardial infarction in patients with previous CABG: what is the best treatment option?

Background

Current European Society of Cardiology guidelines recommend an invasive strategy (IS) for the treatment of non-ST elevation myocardial infarction (NSTEMI) patients, but the clinical trials that support this recommendations included only a few patients with previous coronary artery bypass graft (CABG).

Purpose

To characterize NSTEMI patients with previous CABG who underwent medical and invasive management and to evaluate the prognostic impact of the type of strategy used.

Methods

Retrospective analysis of a cohort of patients from a multicenter national registry diagnosed with NSTEMI with a previous history of CABG between 2010 and 2021. Patient's baseline demographics, medical history and in-hospital management data was collected. Outcomes of in-hospital and six months follow-up all-cause mortality were accessed.

Results

A total of 890 patients were included in the analysis. Of these, 470 were medically managed (MM) – this group included 249 patients (53.1%) who underwent coronary angiography but did not perform any further revascularization. The remaining 420 underwent an invasive strategy (IS) and performed additional revascularization, mainly percutaneous (only 1 patient submitted to reCABG). Mean age was similar (MM 72±10 vs IS 71±10 years, p=0.147) and most patients were male (MM 81.5% vs IS 83.8%, p=0.362). MM patients had more chronic kidney disease (16.7% vs 9.9%, p=0.003), peripheral artery disease (20.5% vs 15.0%, p=0.003) and heart failure (20.5% vs 11.9%, p<0.001). Main presenting symptom was chest pain in both groups, however it was more frequent in the IS group (89.4% vs 94.5%, p=0.006) and dyspnea in the MM patients (6.3% vs 3.1%). Mean left ventricle ejection fraction was similar between groups (MM 49±12% vs IS 50±11%, p=0.290). Although the GRACE risk score was available for only 124 patients, high risk patients (GRACE score >140) were equally distributed among the two groups (55.9% vs 48.2%, p=0.395). An IS was associated with significant lower in-hospital mortality (4.5% vs 1.7%, OR 0.37, 95% CI 0.15–0.87, p=0.018). At six months follow-up an IS was also associated with lower mortality (6.6% vs 2.4%, HR 0.18, 95% CI 0.06–0.52, p=0.002), even after adjusting for the baseline differences (HR 0.41, 95% CI 0.20–0.85, p=0.016).

Conclusions

In this cohort of patients with NSTEMI and previous CABG, an IS was linked to better outcomes during hospitalization and during six months follow-up. Randomized clinical trials are needed to address this issue.

Funding Acknowledgement

Type of funding sources: None.

Impact of COVID-19 pandemic on ST-elevation myocardial infarction: data from two Portuguese centers

Introduction

Recently during the COVID-19 pandemic there was a general belief in a reduction of hospital admissions due to non-infectious causes, namely cardiovascular diseases.

Objectives

To evaluate the impact of the pandemic in the admissions by ST elevation acute myocardial infarction (STEMI), during the first pandemic wave.

Methods

Multicentric and retrospective analysis of consecutive patients presenting in two Portuguese hospital centers with STEMI in two sequential periods – P1 (1st March to 30th April) and P2 (1st May to 30th June). A comparison of patient's clinical and hospital outcomes data was performed between the year 2020 and 2017 to 2019 for both periods.

Results

A total of 347 consecutive STEMI patients were included in this study. The patient's baseline characteristics and cardiovascular risk factors were similar across the considered periods. During P1 of 2020, in comparison with previous years, a reduction in the number of STEMI patients was observed (26.0±4.2 vs 16.5±4.9 cases per month; p=0.033), contrary to what was observed during P2 (19.5±0.7 vs 20.5±0.7 cases per month; p=0.500). Percutaneous coronary interventions in the setting of failed thrombolysis were more frequent (1.9% vs 9.1%; p=0.033). A global trend in longer delays in time-key bundles of STEMI care was noted, namely pain to first medical contact, door to needle, door to wire crossing and symptoms to wire crossing times, however without statistical significance. Mortality rate was six-fold higher during P1 comparing to previous years (1.9% vs 12.1%; p=0.005), and also an increase in the number of mechanical complications (0.0% vs 3.0%; p=0.029) was observed.

Conclusions

During the first COVID-19 pandemic wave there were fewer patients presenting with STEMI at catheterization laboratory for coronary angioplasty. These patients presented more mechanical complications and higher mortality rates.

Funding Acknowledgement

Type of funding sources: None.

Early and long term prognostic accuracy of 4 acute pulmonary embolism mortality risk scores

Background

Acute pulmonary embolism (PE) is a frequent condition associated with significant morbidity and mortality. Multiple scores have been developed and validated to predict 30-day mortality risk, however accurate prognostic assessment remains a challenge in clinical practice.

Purpose

To compare the performance of PESI, simplified PESI, Hestia and Bova scores in predicting in-hospital, 30-day and 1-year mortality risk for acute PE.

Methods

We retrospectively assessed consecutive patients from a single center registry who were hospitalized with acute PE between January 2017 and October 2020. Discriminative power of each score was assessed by receiver operating characteristic curve analysis. Charlson comorbidity index (CCI) was also assessed for comparison.

Results

A total of 131 patients with a mean age of 67.6±15.3 years were included with a mean follow-up of 46.3±17.7 months. Thirty-six patients (27.5%) had a recent hospitalization or major surgery and 26 (19.8%) a medical history of cancer. Besides anticoagulation, 7 patients (5.3%) underwent fibrinolysis. Overall in-hospital mortality was 8.4%, 30-day mortality 12.2% and 1-year mortality 19.8%. All acute PE scores, except Bova score, were significantly higher in those patients who died during hospitalization and on 30-day and 1-year follow-up. CCI was also higher in those patients. Discriminative power for in-hospital mortality was higher for PESI (c-statistic 0.84, 95% CI 0.74–0.93, p=0.002), followed by sPESI (c-statistic 0.77, 95% CI 0.65–0.90, p=0.010) and Hestia (c-statistic 0.77, 95% CI 0.61–0.92, p=0.011). The Bova score showed a poor discriminative power for prediction of in-hospital mortality (c-statistic 0.61, 95% CI 0.43–0.78, p=0.325). For 30-day and 1-year mortality PESI score still maintained the best performance with acceptable discriminative power (c-statistic 0.73, 95% CI 0.61–0.85, p=0.007 for 30-day mortality; c-statistic 0.80, 95% CI 0.71–0.89, p<0.0001 for 1-year mortality). However at longer follow-up CCI had a better performance to predict worse outcomes (c-statistic 0.79, 95% CI 0.65–0.92, p=0.001 for 30-day mortality; c-statistic 0.83, 95% CI 0.74–0.92, p<0.0001 for 1-year mortality).

Conclusions

All scores, except Bova score, showed overall good performance in stratifying mortality for acute PE, however PESI score performed better in this population particularly at shorter follow-up. At longer follow-up, although PESI score maintained an acceptable performance, comorbidities seem to play a bigger role. The different performance of multiple scores highlights the complexity of this condition.

Funding Acknowledgement

Type of funding sources: None. ROC curves for mortality risk scores

New York Heart Association class change on heart failure patients with implantable devices: does it matters?

Background

Chronic heart failure (CHF) is a pathology with high prevalence and an important cause of morbidity and mortality. Benefits of implantable devices have been demonstrated in selected groups of patients with benefits on symptoms and heart failure hospitalization.

Purpose

To determine the clinical impact of New York Heart Association class change (NYHA) in patients with CHF and Cardiac Implantable Electric Devices (CIEDs).

Methods

We retrospectively enrolled 178 consecutive patients with CHF and CIEDs between November 2003 and January 2021, during a follow-up period of 51±43,9 months. Patients demographic characteristic and NYHA class change impact on occurrence of arrhythmic events, heart failure hospitalization (HFH) or long-term admission in an emergency department were assessed. Patients with NYHA class change were considered responders to therapy.

Results

Out of 178 patients enrolled in this study, sixty-seven (37,6%) had a reduction ≥1 in NYHA functional class and in this group, 61 patients (91,0%) had a cardiac resynchronization therapy (CRT) and 9% had an implantable cardioverter defibrillator. Mean age 68±11,3 years, 44 (65,7%) patients were male, 33 (49,2%) were in NYHA class II, 30 (44,8%) NYHA class III and 4 (6%) NYHA class IV. Mean QRS width 129,9±63,1 ms before CIEDs. Fifty-eight patients (86,6%) had an improvement in one NYHA functional class and 9 patients (13,4%) in two NYHA functional class.

Fourty NYHA responders patients (59,7%) had paroxistic or permanent atrial fibrillation and 31,9% had an epicardial coronary artery disease, that was a negative predictor of NYHA response (p=0,012).

A total of 35 (19,7%) enrolled patients experience non-sustained ventricular tachycardia (NSVT) and 74,3% were non-responders (p=0,019).

There was fifteen and twenty HFH at 2 and 5 years of follow-up, respectively, and we observed that an improvement in NYHA class was associated with a reduction in HFH at 2 years of follow-up (p=0,043; OR 0,029, 95% CI 0,050–1,06) and 5 years of follow-up (p 0,027, OR 0,252; 95% CI 0,069 – 0,915). Emergency department (ED) admission related to HF decompensations was significantly reduced at 2 years of follow-up (p=0,035, OR 0,22, 95% CI 0,048 – 1,0) and at 5 years of follow-up (p=0,001, OR 0,15, 95% CI 0,044 – 0,55).

There was no difference on cardiovascular or all-cause mortality.

Conclusion

CHF patients with CIEDs and improving on NYHA class have less NSVT episodes, HFH and HF decompensations with ED admission, both at 2 and 5 years of follow-up.

Funding Acknowledgement

Type of funding sources: None.

Non-sustained ventricular tachycardia on remote patient monitoring in heart failure patients

Background

Non-sustained ventricular tachycardia (NSVT) is commonly found in patients with structural heart disease and was historically obtained from registers of external ambulatory monitoring. The advent of remote patient monitoring (RPM) in Cardiac implantable electronic devices (CIEDs) has made it possible to detect asymptomatic NSVT in Heart Failure (HF) patients more frequently, but its impact in real world is uncertain.

Purpose

To determine the clinical impact of NSVT detection in RPM in ischemic and non-ischemic chronic heart failure patients with reduced ejection fraction (HFrEF) and CIEDs.

Methods

We retrospectively enrolled 121 consecutive patients with HFrEF, CIEDs and RPM. Patients were evaluated through routine episodic CIEDs interrogation, routine clinical evaluations and continuous monitoring data obtained from CIEDs and transmitted remotely to the care team and divided into NSVT positive (Group 1) and negative groups (Group 2). Primary endpoint was admissions to the emergency department by HF decompensation and secondary endpoint was the occurrence of arrhythmic events. A sub-analysis of non-ischemic HF was also performed.

Results

NSVT was detected in 78 (72,2%) patients. The mean number of episodes of NSVT was 611,68±3271,25 during the follow-up period or 2,445±16,688 in 24 hours. Mean age was 62,40±13,218 years, 71,9% were males and mean follow-up period was 56,30±39,37 months. Fifty-eight patients (47,9%) had transvenous implantable cardioverter defibrillator (ICD), 48 (39,7%) implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D), 14 (11,6%) subcutaneous ICD (S-ICD) and 1 (0,8%) CRT pacemaker (CRT-P). Medium left ventricular ejection fraction (LVEF) was 34,70±12,53%, 25 (23,14%) were in NYHA III-IV and 46 (39,0%) were ischemic (29 (37,7%) in Group 1 and 11 (37,9%) in Group 2). NSVT was associated with the occurrence of sustained ventricular tachycardia (VT) (1,88±0,186episodes of VT in group 1 and 0,03±0,186 in group 2, p=0,012), ventricular fibrillation (VF) (1,44±5,325 episodes of VT in group 1 and 0,03±0,186 in group 2, p=0,011) and admissions to the emergency department by HF decompensation at 5 years (r=0,310, p=0,011). A sub-analysis in non-ischemic HF patients also showed correlation between NSVT and VT (r=0,602, p<0,05) and admissions to the emergency department by HF decompensation at 5 years (r=0,382, p=0,014).

Conclusions

On remote patient monitoring with CIEDs, NSVT in HF patients was associated with arrhythmic events and may serve as a predictor for HF decompensations.

Funding Acknowledgement

Type of funding sources: None.

Prognostic significance of non-sustained ventricular tachycardia on stored electrograms of heart failure patients with cardiovascular implantable electronic devices

Background

Non-sustained ventricular tachycardia (NSVT) is commonly found in patients with structural heart disease and was historically obtained from registers of external ambulatory monitoring. The advent of Cardiac implantable electronic devices (CIEDs) has made it possible to detect asymptomatic NSVT in Heart Failure (HF) patients more frequently, but its true impact in real world is uncertain, and often does not lead to a change in clinical intervention.

Purpose

To determine the prognostic significance of NSVT detection on stored electrograms of CIEDs in HF patients with systolic left ventricle dysfunction.

Methods

We retrospectively enrolled 132 consecutive HF patients (mean age 67,5±11,1 years, males 72,0%) with systolic left ventricle dysfunction and CIEDs (biventricular pacemakers with or without cardiac defibrillators). Patients were evaluated through CIEDs interrogation and clinical evaluations and divided into NSVT positive (Group 1) and negative groups (Group 2). Mean follow-up period was 62,8±7,1 months.

Results

NSVT was detected in 51 (38,6%) patients. 70 (53,0%) had implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D), 37 (28,0%) transvenous implantable cardioverter defibrillator (ICD), 13 (9,8%) CRT pacemaker (CRT-P) and 12 (9,1%) subcutaneous ICD (S-ICD). Medium left ventricular ejection fraction (LVEF) was 31,1±7,9%, 20,6% were in NYHA III-IV and 47,0% were ischemic (49% Group 1 and 45,7% Group 2, p=0,708). Dyslipidemia was more prevalent in Group 2 (p=0,042). In total 11 (8,3%) patients died, 2 (1,5%) from sudden cardiac death and 5 (3,8%) from cardiovascular death. NSVT was associated with CIEDs treatments (hazard ratio [HR]2,52; 95% confidence interval [CI]1,2–5,1; p=0,001), ventricular fibrillation (VF) (HR: 3,71, 95% CI: 1,19–11,58; p=0,018), sustained ventricular tachycardia (VT) (HR: 9,06, 95% CI: 2,82–29,12; p<0,05) and composite outcome of VT, VF, HF re-admissions and related admissions to emergency department (ED) and death by all causes (HR: 2,52; 95% CI: 1,20–5,10; p=0,011). NSVT at 1 year was associated with HF readmissions at 1 year (p=0,004).

Conclusions

On extended monitoring possible with CIEDs, NSVT in HF patients was associated with a worse prognosis and may serve as a predictor of significant arrhythmic events, HF hospitalizations and mortality. These findings enhances the importance of remote monitoring and optimization of therapeutic modalities in these patients along with a close supervision.

Funding Acknowledgement

Type of funding sources: None.

Gynaecological cytology in women under the age of 30—the impact of P16/KI67 dual-staining cytology

Background

The HPV detection test is not recommended as a primary screening of cervical lesions, before the age of 30, because the high rate of HPV infections with a high rate of spontaneous resolution in this age group. This study aims to evaluate the performance of p16/Ki67 dual staining in detecting high-grade squamous cervical lesions in these women.

Methods

Cervical-vaginal samples from 67 women HPV positives under the age of 30 and cervical biopsies of 41 of these women. Results of p16/Ki67 dual staining, cytology and histology were analysed. In 53 of the women, 159 results of p16/Ki67 dual staining, HPV test and cytology, obtained in 3 follow-up medical visit, were compared.

Results

The p16/ki67 dual staining was positive in 23.9% and negative in 76.1% of all 67 women. All women with high squamous intraepithelial lesion cytology, 39.1% with low squamous intraepithelial lesion cytology, 17.4% with negative for intraepithelial lesion cytology and 10% with atypical squamous cells cytology, were p16/Ki-67 dual staining positives. In the 41 women with histological diagnosis, p16/ki67 dual staining showed a sensitivity of 87.5% and a specificity of 96% to detect HSIL. When comparing, the tests differ significantly (P < 0.001), p16/ki67 dual staining was positive in 24% of positive cytology and in 19.5% of positive HPV tests.

Conclusions

Our results demonstrate that p16/Ki67 dual stain has good sensitivity and specificity to detect HSIL and can be useful on women under the age of 30, avoiding excessive diagnosis and reducing colposcopy referrals. Further studies are required in a large number of women.

Cognitive-behavioural therapy role in the prevention of psychosis

Introduction

About 30% of individuals in ultra-high risk (UHR) of psychosis develop overt psychosis within 3 years, and about 40% of those who don’t will keep experiencing ongoing attenuated psychotic symptoms and persistent functional disability. During this prodromal period, it’s possible to prevent the transition to a first-episode psychosis.

Objectives

To conduct a short review of literature on the role of cognitive-behavioural therapy (CBT) in preventing psychosis in ultra-high risk patients.

Methods

We performed a literature search on PUBMED, using the query: “Cognitive Behavioral Therapy” [Mesh] AND “psychosis” AND “prevention”. We focused on data from systematic reviews, clinical trials and meta-analysis published on last 5 years, either in English or Portuguese.

Results

Some authors claim cognitive-behavioural therapy (CBT) as first-choice treatment in clients with ultra-high risk (UHR) for psychosis. CBT aims to normalize extraordinary experiences with education and to prevent delusional explanations. On a Japanese study, the total score of Positive and Negative Syndrome Scale (PANSS) significantly improved on post-intervention and follow-up assessments, with large effect sizes observed. Teaching families to apply CBT with their offspring may bolster therapeutic gains made in time-limited treatment. CBT showed an 83% probability of being more effective and less costly than routine care.

Conclusions

Patients with UHR for psychosis can be treated successfully with CBT to postpone and prevent the transition to a first-episode psychosis. CBT for UHR has been included in the European guidelines and awaits dissemination and implementation in mental health services.

Post-traumatic stress disorder after first-episode psychosis

Introduction

A psychotic episode may be sufficiently traumatic to induce symptoms of post-traumatic stress disorder (PTSD), which could impact outcomes in first-episode psychosis (FEP). Yet, post-traumatic stress disorder is often left untreated and undiagnosed in the presence of psychosis.

Objectives

To conduct a short review of literature on the prevalence and impact of PTSD after FEP.

Methods

We performed a literature search on PUBMED, using the query: “Stress Disorders, Post-Traumatic” [Mesh] AND “first episode” AND “psychosis”. We focused on data from systematic reviews, clinical trials and meta-analysis published on last 10 years, either in English or Portuguese.

Results

Approximately one in two people experience PTSD symptoms and one in three experience full PTSD, following a FEP. Prevalence may be higher in affective psychosis, inpatient samples and patients previously suffering from depression and anxiety. PTSD Symptom Scale – Self-Report (PSS-SR) can be a useful screening instrument, but there is no established evidence-based intervention for PTSD in people with FEP. Coercive intervention such as involuntary hospitalization, seclusion, restraint or being forced to take medication, as well as being around sick or anxious patients, can be upsetting and traumatizing.

Conclusions

Our data showed high rates of psychosis-related PTSD. To prevent PTSD, conditions of hospitalization should be optimized and the use of coercive treatments should be limited. Subjects with recent-onset psychosis should be screened for PTSD symptoms. Evidence-based interventions to treat PTSD symptoms in the context of FEP are needed to address this burden and improve outcomes.

Psychiatric manifestations of anti-NMDAR encephalitis

Introduction

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disorder characterized by neuropsychiatric symptoms before progressing to seizures, complex movement disorder, autonomic dysfunction and hypoventilation.

Objectives

Presenting a review of the psychiatric manifestations of anti-NMDAR encephalitis.

Methods

Search on Pubmed® and Medscape® databases with the following keywords: “psychiatric”, “anti-NMDA receptor encephalitis” and “anti-NMDAR encephalitis”. We focused on data from systematic reviews and meta-analyzes. The articles were selected by the authors according to their relevance.

Results

Studies show that 77% to 95% of patients with anti-NMDAR encephalitis initially present psychiatric manifestations. Age and sex distribution are young women, and the frequency of cases is lower after 40 years of age. The most common psychiatric symptoms are agitation (59%) and psychotic symptoms (54%). The psychotic symptoms more common are visual (64%), auditory (59%) hallucinations and persecutory delusions (73%). Catatonia is described in 42% of patients. Antipsychotic treatment induces an adverse drug reaction (33%), the neuroleptic malignant syndrome represents 22% of the cases. Delays in distinguishing this disease from a psychiatric disorder can have serious complications, with a mortality of up to 25% in patients receiving limited or delayed immunotherapy.

Conclusions

It’s important to consider anti-NMDAR encephalitis in the differential diagnosis of patients with an acute onset psychosis or unusual psychiatric symptoms. Antipsychotic treatment should be use with caution when suspected or confirmed anti-NMDAR encephalitis. Without appropriate treatment, patients may suffer a protracted course with significant long-term disability or death. A clinical index of suspicion is required to identify patients who would benefit from cerebrospinal fluid testing and immunotherapies.

Disclosure

No significant relationships.

Impulse control disorders and dopamine agonists

Introduction

Impulse control disorders (ICDs) are an adverse effect of dopamine agonists (DAAs) that affects the quality of life and can lead to legal, criminal and familiar problems.

Objectives

Presenting a review of the mechanisms, prevalence and factors associated with the development of an ICD due to DAA use.

Methods

Search on Pubmed database with combination of the following keywords were used: “Impulse control disorders”, “dopamine agonist” or “therapy”. We focused on data from studies published between 2015 and 2020. The articles were selected by the author according to their relevance.

Results

DAAs are mainly indicated in the treatment of Parkinson’s Disease (PD), and are also used on symptoms of restless legs syndrome (RLS) and prolactinoma or lactation inhibition. Dopamine replacement therapy act on dopamine receptors in the nigrostriatal and the reward pathways, which plays a role in addictive behavior. The prevalence of ICDs ranged from 2.6 to 34.8% in PD patients and a lower prevalence in RLS patients. Some of the ICDs reported were pathological gambling, hypersexuality, compulsive shopping, obsessive hobbying, punding, and compulsive medication use. The factors associated with the development include the type of DAAs, dosage, male gender, younger age, history of psychiatric symptoms, earlier onset of disease, longer disease duration, and motor complications in PD.

Conclusions

Further studies are needed to clarify the pathophysiology of the ICD in DAA therapy and determinate premorbid risk factors. The percentage of patients with ICDs is underrated, so it’s important to improve the patient’s evaluation, using validated and consensual assessment tools.

Phenocopy syndrome of frontotemporal dementia

Introduction

Frontotemporal dementia (FTD) is a group of neurodegenerative disorders characterized by behavioral or language changes with progressive executive dysfunction. It´s subdivided into two variants, the behavioral and language variants. The phenocopy syndrome of frontotemporal dementia (phFTD) mimics the behavioral variant, but doesn´t show frontotemporal atrophy in neuroimaging and doesn´t progress to frank dementia over the years.

Objectives

Presenting a review of phenocopy syndrome of frontotemporal dementia.

Methods

Search on Pubmed® and Medscape® databases with the following keywords: “frontotemporal dementia and phenocopy” or “FTD phenocopy”. We focused on data from systematic reviews and meta-analyzes published in the last five years. The articles were selected by the authors according to their relevance.

Results

Mutations in GRN and MAPT gens and genetic expansion of C9orf72 have been identified. The discovery of the C9orf72 expansion in psychiatric disorders (psychosis, bipolar disorder or depressive disorder), for some authors, represents that phFTD is a psychiatric pathology. In fact, there’s a higher frequency of psychiatric and psychological symptoms in phFTD compared to the variants of FTD. Usually are male patients who don´t have significant cognitive deficits, with preservation of executive functions and episodic memory. Until now, there are no definitive biomarkers of the disease. The prognosis is more benigne, unlike FTD, which has an average survival of 3 years since diagnosis.

Conclusions

phFTD is a clinical and scientific challenge. The neurobiological bases remain unknown, requiring further studies in this field. The identification of markers that can differentiate patients with typical FTD and phFTD can facilitate prognosis orientation and pharmacological an non-pharmacological treatment.

Mapping social reward and punishment processing in the human brain: A voxel-based meta-analysis of neuroimaging findings using the social incentive delay task

Social rewards or punishments motivate human learning and behaviour, and alterations in the brain circuits involved in the processing of these stimuli have been linked with several neuropsychiatric disorders. However, questions still remain about the exact neural substrates implicated in social reward and punishment processing. Here, we conducted four Anisotropic Effect Size Signed Differential Mapping voxel-based meta-analyses of fMRI studies investigating the neural correlates of the anticipation and receipt of social rewards and punishments using the Social Incentive Delay task. We found that the anticipation of both social rewards and social punishment avoidance recruits a wide network of areas including the basal ganglia, the midbrain, the dorsal anterior cingulate cortex, the supplementary motor area, the anterior insula, the occipital gyrus and other frontal, temporal, parietal and cerebellar regions not captured in previous coordinate-based meta-analysis. We identified decreases in the BOLD signal during the anticipation of both social reward and punishment avoidance in regions of the default-mode network that were missed in individual studies likely due to a lack of power. Receipt of social rewards engaged a robust network of brain regions including the ventromedial frontal and orbitofrontal cortices, the anterior cingulate cortex, the amygdala, the hippocampus, the occipital cortex and the brainstem, but not the basal ganglia. Receipt of social punishments increased the BOLD signal in the orbitofrontal cortex, superior and inferior frontal gyri, lateral occipital cortex and the insula. In contrast to the receipt of social rewards, we also observed a decrease in the BOLD signal in the basal ganglia in response to the receipt of social punishments. Our results provide a better understanding of the brain circuitry involved in the processing of social rewards and punishment. Furthermore, they can inform hypotheses regarding brain areas where disruption in activity may be associated with dysfunctional social incentive processing during disease.

Atrial matrix remodeling in atrial fibrillation patients with aortic stenosis

BACKGROUND

This study aimed to evaluate atrium extracellular matrix remodeling in atrial fibrillation (AF) patients with severe aortic stenosis, through histological fibrosis quantification and extracellular matrix gene expression analysis, as well as serum quantification of selected protein targets.

METHODS

A posthoc analysis of a prospective study was performed in a cohort of aortic stenosis patients. Between 2014 and 2019, 56 patients with severe aortic stenosis submitted to aortic valve replacement surgery in a tertiary hospital were selected.

RESULTS

Fibrosis was significantly increased in the AF group when compared to sinus rhythm (SR) patients (p = 0.024). Moreover, cardiomyocyte area was significantly higher in AF patients versus SR patients (p = 0.008). Conversely, collagen III gene expression was increased in AF patients (p = 0.038). TIMP1 was less expressed in the atria of AF patients. MMP16/TIMP4 ratio was significantly decreased in AF patients (p = 0.006). TIMP1 (p = 0.004) and TIMP2 (p = 0.012) were significantly increased in the serum of AF patients. Aortic valve maximum (p = 0.0159) and mean (p = 0.031) gradients demonstrated a negative association with serum TIMP1.

CONCLUSIONS

Atrial fibrillation patients with severe aortic stenosis present increased atrial fibrosis and collagen type III synthesis, with extracellular matrix remodelling demonstrated by a decrease in the MMP16/TIMP4 ratio, along with an increased serum TIMP1 and TIMP2 proteins.

Prostate cancer, new treatment advances - immunotherapy

Prostate cancer (PCa) is the fourth most common cancer in the world and treatment is currently based on surgical removal and/or radiotherapy and/or hormone therapy. In the last few years' immunotherapy has become an important cancer treatment option. While the principles of immunotherapy evolved, only sipuleucel-T was approved by the Food and Drug Administration (FDA) which lead to further studies with other agents, starting a new era in immuno-oncology. A number of vaccines are under clinical investigation as well as checkpoint inhibitors. Despite the current enthusiasm, it is unlikely that any of the approaches alone can dramatically change PCa outcomes, but strategies combination is more promising and provide a reason for optimism. The goal of immunotherapy in PCa does not have to be the complete eradication of advanced disease, but rather the return to an immunologic equilibrium with an indolent disease state. With such concerted efforts, the future of immunotherapy in PCa looks brighter than ever, with many clinical trial results being published soon.

Blueberries effects in experimental diet-induced prediabetes: a focus on renal impairment

Introduction Benefits arising from blueberry (BB) consumption are well-described in type 2 diabetes evolution and inherent complications. Lending further support to this thesis, previous work from our group unequivocally demonstrates BB supplementation efficacy to manage prediabetic hepatic liver steatosis. Whether a similar effect also holds truth in early renal impairment is an unsolved issue.

Objectives To address blueberry juice (BJ) ability to exert renoprotective effects in experimental prediabetes.

Methodology Diet-induced prediabetes [high-sucrose (35% Hsu) and high-fat (60% HF)] was developed in adult male Wistar rats through the ingestion of HSu for 9 weeks supplemented by HF for another 14 weeks (HSuHF, n = 16). On W9, half of the former animals orally received BJ (25g/kg BW, HSuHF+BJ). Control animals (n = 8) received standard diet during the entire protocol. Functional [serum and urinary creatinine, uric acid, glucose; glomerular filtration rate (GFR)], structural [H&E and Oil Red O staining] and molecular [triglycerides content and inflammation (RT-qPCR, WB)] markers of renal injury were assessed along with metabolic profile.

Results Even though diet-induced glucose intolerance, insulin insensitivity and plasmatic hypertriglyceridemia were significantly ameliorated upon BJ treatment, this nutraceutical intervention was unable to halt or slow down renal lipidosis and glomerular crescent-like lesions apart from a slight amelioration of both GFR and IL-6 levels in HSuHF-treated rats.

Conclusion Unlike previous results clearly demonstrating the ability of BJ nutraceutical intervention to afford protection against metabolic impairment and hepatic steatosis evolution in experimentally diet-induced prediabetes, only a modest renoprotective effect was observed in functional and morphological renal endpoints. Future studies are warranted to dissect the divergent effects of BJ on early liver and kidney impairment.

Forssman Prevalence in a Portuguese Donor Population

Introduction Discovered in 1911 by Frederick Forssman, the Forssman (Fs) antigen (Ag) expression varies among species, being rarely present on human red blood cells (RBC). In 1987 three unrelated English families were identified with a phenotype designed Apae which was later classified as the 31st blood group: FORS. Since antibodies (Ab) anti-Fs has natural occurrence and the expression of the Ag occurs on the surface of the RBC, body fluids and organs, raises a potential role for this antigen in transfusion and transplantation implications.

Objectives Our main goals were to evaluate the prevalence of anti-Fs Ab and clarify its impact in transfusional medicine by classifying the type of immunoglobulin (Ig) involved.

Methodology 3-5% sheep RBC suspension with positive expression for Fs Ag was used to evaluate the presence of Ab anti-Fs in plasma samples from a Portuguese population of blood donor and classify the immunoglobulin involved. Standard tube technique was used in all the experiments.

Results From a total of 11877 donors, 117 (0,99%) showed weak reactions (between 0 and 1 in a scale from 0 to 4). All these samples would be further studied to evaluate the presence of the Arg296Gln in the GBGT1 gene. Also, from the 192 samples studied to classify the Ab involved, 52% revealed to be only IgM, being the rest a mixture between IgG and IgM.

Conclusion The population studied revealed few samples with negative reaction against the sheep RBC confirm the low-prevalence of this blood group. The majority from the Ab to be IgM was also corroborated although the presence of an IgG portion can be clinically significant once it can cross the placental barrier.

TESty – Typing Easier: an innovate device to characterize blood samples

Introduction In Portugal there are over 130,000 regular donors (2 to 4 blood donations/year), data from 2017. These data lead us to approximately 500,000 donations per year just in Portugal. In addition, we have over 300,000 transfusions per year that may require more than one unit of blood. All of these units, prior to administration, and all patients before a blood transfusion or even a transplant, must be properly classified regarding their blood type. Currently, the standard (tube) technique requires that at least 8 tubes be used per individual and the card, a device widely used today, requires the use of 1,5 per individual. It also requires the purchase of expensive laboratory equipment specifically for this purpose. The complex protocol, requiring access to laboratories with specific equipment without any other use (eg card centrifuges) and need to be performed by professionals specialized healthcare providers are the main disadvantages.

Objectives Our main goal was to develop a new cost effective and efficient device- TESTy which could allow the evaluation of a higher number of samples discarding the need of any supplementary device or equipment.

Methodology A 96-well V-bottom microplate was used as support device. After, an agarose gel and the antibodies serums were soaked in each well according to the specifications of the blood determination test.

Results After a six month evaluation, TESty provide the same results as expected and previously tested with the other two techniques available at the market.

Conclusion TESty can be revolutionary in the science transfusion world once it allows the screening of 12 samples simultaneously and this fact can save time and resources daily in our laboratories and blood banks. Also, for being a cost-effective product, it can be extended to undeveloped countries and contribute to assure the transfusion safety required.

Level of UV Exposure, Skin Type, and Age Are More Important than Thiopurine Use for Keratinocyte Carcinoma Development in IBD Patients

BACKGROUND

Retrospective studies observe an increased risk of keratinocyte carcinomas (KCs) in patients with inflammatory bowel disease (IBD) on thiopurine (TP) medication. The role of traditional risk factors such as skin type and sun protection behavior has not been studied in this population. This study aimed to examine traditional KC risk factors and thiopurine use on skin cancer development in an IBD cohort.

METHODS

Consecutive IBD patients were recruited from four specialist centers in Australia and New Zealand, each with varying UV exposure indices. Data pertaining to race, skin color, freckling and sun protection behavior, dose of TP therapy, and skin cancer development were elicited through a self-reported questionnaire.

RESULTS

A total of 691 IBD patients were included with 62 reporting KC development. Thiopurine usage was similar among patients who developed skin cancer compared with those who did not (92% vs. 89%, p = 0.3). There was no statistically significant association between KC development and TP dose or 6-thioguanine nucleotide levels. In multivariate modeling, four factors were independently and significantly associated with KC: age over 61 years old versus less than 30 years old (OR 6.76; 95% CI 2.38-19.18), residing in Brisbane versus Christchurch (OR 3.3; 95% CI 1.6-6.8), never staying in the shade versus staying in the shade ≥ 50% of the time (OR 3.8; 95% CI 1.4-10.5), and having a skin type that never tanned versus other skin types (OR 6.9; 95% CI 2.9-16.0).

CONCLUSION

Skin type, age, and sun protection behavior are more important risk factors for KC development than thiopurine medication use in this IBD population.

1167 Atrial strain predicts exercise capacity in patients with the fontan circulation

Funding Acknowledgements

None

Introduction

Atrial function has recently emerged as a valuable parameter, particularly for evaluation of ventricular diastolic dysfunction and heart failure. There is a strong need for reliable echocardiographic predictors of exercise capacity in univentricular hearts, but their particular anatomy makes it challenging. In this work we aimed to characterize the relationship between atrial strain and exercise parameters in the Fontan population.

Methods

Fontan patients followed in our outpatient clinic were prospectively evaluated with cardiopulmonary exercise test and transthoracic echocardiogram. The dominant atrium, i.e. the atrium connected to the dominant atrioventricular valve, was assessed with speckle-tracking echocardiography for active (εact), conduit (εcon), and reservoir (εres) strain; and εact/εres ratio. A single cardiac loop from the 4 chamber view was selected for this analysis and the ‘zero’ strain reference for atrial deformation analysis was set at the onset of the electrocardiogram P wave. Exercise capacity defined as the percentage of peak oxygen uptake (VO2), comparing with predicted values, was chosen as the dependent variable. Independent variables were selected among clinical and echocardiographic data. Statistical analysis was performed using SPSS version 23. T-student test was used for binomial and continuous variable correlation; single and multivariable linear regression was used for continuous variable correlation. Statistical significance was defined as p-value < 0.05.

Results

Fifty-two Fontan patients were assessed. Nineteen (37%) were excluded due to inadequate deformation tracking of the atrial wall. Mean age was 18.0 years (SD 6.9, min. 10.0 - max. 36.0), mean age at Fontan surgery was 7.0 years (SD 2.9, min. 3.0 – max. 18.0). Peak VO2 as a percentage of the predicted value was 66.5% (SD 18.8, min. 36.4 – max. 118.6). εact was -11.1% (SD 3.7, min. -21.1 – max. -4.8), εcon was 10.6% (SD 6.5, min. -0.5 – max. 6.5), εres was 21.7% (SD 5.2, min. 13.2 – max. 34.4) and εact/εres ratio was 0.54 (SD 0.23, min. 0.22 – max. 1.04). On univariate analysis, all atrial strain variables correlated with peak VO2. After adjusting for collinearity, multivariable regression defined age (estimate -1.6, 95% CI: -2.5 to -0.9, p-value < 0.001) and εact strain (estimate 1.8, 95% CI: 0.5 to 3.2, p-value = 0.011) as the strongest predictors of peak VO2 (r2= 0.479).

Conclusion

Peak VO2 defines exercise capacity and is a strong marker of prognosis in Fontan patients. There are very few echocardiographic variables capable of predicting it, in part due to a variable cardiac anatomy. We showed that atrial strain rate is a novel echocardiographic parameter that predicts peak VO2. In the Fontan circulation, a higher reliance on active atrial contraction for ventricular filling predicts lower exercise capacity. Therefore, atrial strain rate, whenever measurable, may provide a new method of risk stratification in this population.

Abstract 1167 Figure. Example of atrial strain curve.

A dry and fully dispersible bacterial cellulose formulation as a stabilizer for oil-in-water emulsions

Bacterial cellulose (BC) is an emerging alternative to plant cellulose in different applications. Several works demonstrated the potential of never-dried BC; however, envisioning real industrial applications, a dry product retaining its functional properties upon rehydration is preferable. A dry and completely redispersible formulation of BC with carboxymethyl cellulose (CMC) was prepared by Spray-drying. The obtained material showed a Zeta Potential of (-67.0 ± 3.9) mV, a Dv(50) of (601 ± 19.7) μm and was able to decrease the oil/water interface energy. The dry BC:CMC formulation was employed as a stabilizer in oil-in-water emulsions, in parallel with commercial plant celluloses and Xanthan gum. The emulsions were monitored over time by optical microscopy and characterized by rheological measurements. BC:CMC effectively stabilized emulsions against coalescence and creaming, at a concentration of 0.50 % - contrarily to other commercial dry celluloses - due to the Pickering effect and to the structuring of the continuous phase, as seen with Cryo-SEM.

4D flow MRI versus conventional 2D for measuring pulmonary flow after Tetralogy of Fallot repair

BACKGROUND

After tetralogy of Fallot (TOF) repair, pulmonary regurgitation and right ventricular function must be monitored. Conventional (2D) cardiac magnetic resonance (CMR) is currently the clinical reference method for measuring pulmonary regurgitation. However, 4DFlow CMR has been reported to provide a more comprehensive flow analysis than 2D CMR. We aimed to compare 4DFlow CMR to 2D CMR for assessing pulmonary regurgitation and flow, as well as aortic flow, in children and adults after surgical repair of TOF.

METHODS

Retrospective analysis of patients with repaired TOF admitted for cardiac MRI with 4DFlow acquisition from 2016 to 2018. Linear regression was used to assess correlations and Bland-Altman analyses were performed.

RESULTS

The 60 included patients had a mean age of 18.2 ± 10.4 years (range, 2-54 years). Significant correlations between the two techniques were found for pulmonary regurgitant fraction (R [2] = 0.6642, p < 0.0001), net pulmonary flow (R [2] = 0.6782, p < 0.0001), forward pulmonary flow (R [2] = 0.6185, p < 0.0001), backward pulmonary flow (R [2] = 0.8192, p < 0.0001), and aortic valve flow (R [2] = 0.6494, p < 0.0001). The Bland-Altman analysis showed no significant bias, narrow limits of agreement, and few scattered points. The correlation between pulmonary and aortic flow was better with 4DFlow CMR than with 2D CMR (R [2] = 0.8564, p < 0.0001 versus R [2] = 0.4393, p < 0,0001, respectively). Interobserver reliability was good.

CONCLUSION

These results establish the feasibility and reliability of 4DFlow CMR for assessing pulmonary flow in a large paediatric and adult population with repaired TOF. 4DFlow CMR may be more reliable than 2D MRI for pulmonary flow assessment after TOF repair.

Evaluation of cost and length of stay, linked to complications associated with major surgical procedures

INTRODUCTION

A lot of studies have demonstrated the possibility of reducing the number of post-operative complications in the domain of major surgical procedures with the use of medical preventive techniques. However, complications following surgical procedures are unfortunately frequent and are a major problem, not only because of the impact for the patient, but also because of economic consequences that they provoke. The aim of the present study is to evaluate the extra length of stay and the extra cost, born by the hospital and the social security, linked to complications, incurring after major surgical procedures.

MATERIAL AND METHODS

Study based on the data from 13 Belgian hospitals for the year 2012. Complications were extracted through medical discharge summaries. The cost born by the social security was assessed on the basis of the billing data, hospital cost are taken from cost accounting studies.

RESULTS

The rate of complication for all the hospitals is 6.6%. About 30.3% of inpatient stays having a major or extreme severity of index had a complication during the stay, 1.8% of stays with a minor or moderate severity of index had a complication. The extra length of stay is 19.38 days when the stay has had a complication (p < 0.001). The additional mean cost borne from the hospital perspective is €21 353.07 and €8 026.65 for the social security. This additional mean cost varies greatly from one hospital to another.

DISCUSSION/CONCLUSION

The present study has shown that the actual financing do not cover real hospital costs in the field of major surgical procedures having caused complications. Results should encourage Belgian authorities to propose and finance preventive measures in order to reduce these complications, which represent major economic impacts, not only for authorities but also for hospitals.