Late outcomes of ST-elevation myocardial infarction treated by pharmaco-invasive or primary percutaneous coronary intervention

AIMS

Pharmaco-invasive percutaneous coronary intervention (PI-PCI) is recommended for patients with ST-elevation myocardial infarction (STEMI)who are unable to undergo timely primary PCI (pPCI). The present study examined late outcomes after PI-PCI (successful reperfusion followed by scheduled PCI or failed reperfusion and rescue PCI)compared with timely and late pPCI (>120 min from first medical contact).

METHODS AND RESULTS

All patients with STEMI presenting within 12 h of symptom onset, who underwent PCI during their initial hospitalization at Liverpool Hospital (Sydney), from October 2003 to March 2014, were included. Amongst 2091 STEMI patients (80% male), 1077 (52%)underwent pPCI (68% timely, 32% late), and 1014 (48%)received PI-PCI (33% rescue, 67% scheduled). Mortality at 3 years was 11.1% after pPCI (6.7% timely, 20.2% late) and 6.2% after PI-PCI (9.4% rescue, 4.8% scheduled); P < 0.01. After propensity matching, the adjusted mortality hazard ratio (HR) for timely pPCI compared with scheduled PCI was 0.9 (95% CIs 0.4-2.0) and compared with rescue PCI was 0.5 (95% CIs 0.2-0.9). The adjusted mortality HR for late pPCI, compared with scheduled PCI was 2.2 (95% CIs 1.2-3.1)and compared with rescue PCI, it was 1.5 (95% CIs 0.7-2.0).

CONCLUSION

Patients who underwent late pPCI had higher mortality rates than those undergoing a pharmaco-invasive strategy. Despite rescue PCI being required in a third of patients, a pharmaco-invasive approach should be considered when delays to PCI are anticipated, as it achieves better outcomes than late pPCI.

Reperfusion strategy and late clinical outcomes of patients with ST-elevation myocardial infarction (STEMI) in the absence of standard modifiable risk factors (SMuRFs)

Introduction

There is growing evidence that patients presenting with STEMI in the absence of standard modifiable cardiovascular risk factors (SMuRFs; smoking, hypertension, hypercholesterolemia, diabetes) have poorer outcomes compared to those with atleast one SMuRF. It has been hypothesised that this may be in part due to decreased administration of pharmacotherapies in the post-infarct period due to perceived low risk. Long term outcomes of patients without SMuRFs based on reperfusion strategy received during the index admission have not been investigated.

Purpose

We sought to analyse late clinical outcomes of STEMI patients with and without SMuRFs based on reperfusion strategy received during the index admission.

Methods

All patients who underwent PCI between 2003 and 2014 were identified from a PCI centre STEMI database. Late clinical outcomes of patients with and without SMuRFs were analysed overall and based on reperfusion strategy [primary PCI (pPCI) vs pharmaco-invasive PCI (PI-PCI)]. Propensity matching was used to account for differences in baseline characteristics between the groups.

Results

Amongst 2,091 STEMI patients, 531 (25%) had no SMuRFs (51% pPCI, 49% PI-PCI) and 1560 (75%) had ≥1 SMuRF (52% pPCI, 48% PI-PCI). Unadjusted late mortality in SMuRF-less patients was 13.4% (18.8% pPCI, 7.7% PI-PCI) and for those with ≥1 SMuRF was 9.7% (11.0% pPCI, 8.4% PI-PCI). After propensity-matching clinical and angiographic characteristics, 5 year mortality rates were significantly higher for patients without SMuRFs compared to those with SMuRFs [HR 1.36, CI: 1.03–1.81, p=0.031]. This difference was attenuated for patients who underwent pPCI [HR 1.72, CI: 1.22–2.43, p=0.002]. Interestingly, this discrepancy was not observed amongst individuals who underwent pharmaco-invasive PCI [HR 1.13, CI: 0.53–1.48, p=0.638], as SMuRF-less patients had similar mortality rates to their counterparts. Long term rates of reinfarction, stent thrombosis and target vessel revascularisation were similar between the groups. Additionally, there was no significant difference in rates of stroke and major bleeding amongst all 4 subgroups.

Conclusion

Patients presenting with STEMI in the absence of SMuRFs have increased overall late mortality compared to those with at least one SMuRF. However, this difference was not observed in patients who underwent a pharmaco-invasive strategy, whereby patients without SMuRFs had similar outcomes to those with SMuRFs after adjusting for confounders. Our findings suggest the use of a pharmaco-invasive strategy in appropriate SMuRF-less patients presenting with STEMI.

Funding Acknowledgement

Type of funding sources: None.

Obstructive sleep apnoea and 12-month weight loss in adults with class 3 obesity attending a multidisciplinary weight management program

BACKGROUND

Although there is a strong association between obesity and obstructive sleep apnoea (OSA), the effects of OSA and CPAP therapy on weight loss are less well known. The aim of this study in adults with class 3 obesity attending a multidisciplinary weight management program was to assess the relationship between OSA and CPAP usage, and 12-month weight change.

METHODS

A retrospective cohort study of all patients commencing an intensive multidisciplinary publicly funded weight management program in Sydney, Australia, between March 2018 and March 2019. OSA was diagnosed using laboratory overnight sleep studies. Demographic and clinical data, and use of CPAP therapy was collected at baseline and 12 months. CPAP use was confirmed if used ≥4 h on average per night on download.

RESULTS

Of the 178 patients who joined the program, 111 (62.4 %) completed 12 months in the program. At baseline, 63.1 % (n=70) of patients had OSA, of whom 54.3 % (n=38) were using CPAP. The non-OSA group had more females compared to the OSA with CPAP group and OSA without CPAP group (90.2 % vs. 57.9 % and 62.5 %, respectively; p=0.003), but there were no significant baseline differences in BMI (50.4±9.3 vs. 52.1±8.7 and 50.3±9.5 kg/m², respectively; p=0.636). There was significant weight loss across all three groups at 12 months. However, there were no statistically significant differences across groups in the percentage of body weight loss (OSA with CPAP: 6.3±5.6 %, OSA without CPAP: 6.8±6.9 %, non-OSA: 7.2±6.5 %; p=0.844), or the proportion of patients who achieved ≥5 % body weight loss (OSA with CPAP: 57.9 %, OSA without CPAP: 59.4 %, non-OSA: 65.9 %; p=0.743). In patients with T2DM, there was a significant reduction in HbA1c from baseline to 12 months (7.8±1.7 % to 7.3±1.4 %, p=0.03), with no difference between groups (p=0.997).

CONCLUSIONS

This multidisciplinary weight management program resulted in significant weight loss at 12 months, regardless of OSA diagnosis or CPAP use in adults with class 3 obesity. Larger studies are needed to further investigate the effects of severity of OSA status and CPAP use in weight management programs. Until completed, this study suggests that the focus should remain on implementing lifestyle changes and weight management regardless of OSA status.

COVID-19 pandemic and admission rates for and management of acute coronary syndromes in Israel

Background

Since the COVID-19 pandemic outbreak several countries have reported a decrease in the number of patients admitted with non-ST elevation myocardial infarction (NSTEMI).

Purpose

We aimed to evaluate admission trend and outcomes of patients with NSTEMI in the COVID-19 era in a nationwide survey.

Methods

A prospective, multicenter, observational, nationwide study involving 13 medical centers across Israel. All NSTEMI patients admitted to intensive cardiac care units (ICCUs) over an 8-week period during the COVID-19 outbreak were compare them with NSTEMI patients admitted 2 years earlier (control period) during the Acute Coronary Syndrome Israeli Survey (ACSIS) 2018.

Results

There were 624 (43%) NSTEMI patients, of them 349 (56%) hospitalized during the COVID-19 era and 275 (44%) during the control period, representing a 27% increase in NSTEMI admission rate during the COVID-19 era. Approximately 76% were male, median age was 67 years (IQR 58–76). There were no differences in baseline characteristics between the two study periods. During the COVID-19 era, more patients arrived at the hospital via an emergency medical system (EMS) compared with the control period (p for trend = 0.005)

Time from symptom onset to hospital admission was longer in the COVID-19 era [687.00 (IQR147–2805) vs. 178.00 (IQR 102- 407), respectively, p-value &lt;0.001]. Nevertheless, time from hospital admission to reperfusion was similar in both groups. Rate of percutaneous coronary intervention was higher in the COVID-19 era group (91.3% vs. 59.7%, respectively, p&lt;0.001). In-hospital mortality rate was similar in both groups (2.3% vs. 4.7%, respectively, p=0.149) as was the 30-day mortality rate (3.7% vs. 5.1%, respectively, p=0.238).

Conclusions

In contrast to previous reports, in Israel, admission rate of NSTEMI was increased during the COVID-19 era. With longer time from symptoms to admission, but with the same time from hospital admission to reperfusion therapy and with similar in-hospital and 30-day mortality rates.

Funding Acknowledgement

Type of funding sources: None.

Acute myocardial infarction in the Covid-19 era: incidence, clinical characteristics and in-hospital outcomes – a multicenter registry

Background

A reduction in acute myocardial infarction (AMI) hospitalizations during the coronavirus pandemic has been previously documented. We aimed to describe the characteristics and in-hospital outcomes of AMI patients during the Covid-19 era compared to a recent previous registry.

Methods

We conducted a prospective, multicenter, observational study involving 13 intensive cardiac care units (ICCUs) to evaluate consecutive AMI patients admitted throughout an 8-week period during the Covid-19 outbreak. Data were compared to the corresponding period in 2018 using an acute coronary syndrome survey conducted in all ICCUs in Israel. The primary end-point was defined as a composite of sustained ventricular arrhythmia, pulmonary congestion, and/or in-hospital mortality.

Results

The study cohort comprised 1466 patients, of whom 774 (53%) were hospitalized during the Covid-19 outbreak. Overall, 841 patients were diagnosed with ST-elevation MI (STEMI): 424 (50.4%) during the Covid-19 era and 417 (49.6%) during the parallel period in 2018. No differences were detected in the admission rate of patients between the two study periods. STEMI patients admitted during the Covid-19 period tended to have fewer co-morbidities, but a higher Killip class (p value = 0.03). The median time from symptom onset to reperfusion was extended from 180 minutes (IQR 122–292) in 2018 to 290 minutes (IQR 161–1080, p&lt;0.001) in 2020. Hospitalization during the Covid-19 era was independently associated with an increased risk of the combined endpoint of heart failure, malignant arrhythmia, or death in the multivariable logistic regression model (OR 1.63, 95% CI 1.02–2.65, p value = 0.05).

Conclusion

While the admission rate of AMI and STEMI in Israel remained similar during both the Covid-19 era and the corresponding period in 2018, total ischemic time extended significantly during the Covid-19 period, which translated into a more severe disease status upon hospital admission, and a higher rate of in-hospital adverse events.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by a grant from a Fefer foundation for medical research

Barriers and Facilitators of Breast Cancer Screening amongst Culturally and Linguistically Diverse Women in South Western Sydney: A Qualitative Explorative Study

Breast cancer is the most common cause of cancer amongst Australian women and the second most common cause of cancer mortality. Despite the proven effectiveness of early intervention, screening rates remain subpar across many regions in New South Wales (NSW). Screening rates are particularly low within the culturally and linguistically diverse (CALD) area of South Western Sydney (SWS). The objective of this study was to qualitatively explore barriers and facilitators to breast screening from the perspectives of CALD women from SWS. CALD women aged ≥40 who resided in SWS were invited to participate in a semi-structured interview to explore barriers and facilitators to breast cancer screening. Interviews were recorded, transcribed verbatim and analysed thematically to identify recurring patterns in the data. Sixteen women from CALD backgrounds participated. Women in this study reported absence of symptoms, fatalistic beliefs and embarrassment during the procedure to be the primary reasons for reluctance to screen. Lack of general practitioner (GP) endorsement, transport issues and pain associated with the procedure were also reported as additional barriers to screening. Common facilitators to screening included encouragement from family and friends, family history of cancer and media adverts. CALD women have distinctive barriers to mammography, which lead to poor breast screening participation rates. Opportunistic health promotion in this area is warranted and may lead to better health outcomes amongst this population.

Field evaluation of deltamethrin/S-bioallethrin/piperonyl butoxide and cyfluthrin against dengue vectors in Malaysia

Deltacide (S-bioallethrin 0.71% w/v, deltamethrin 0.5% w/v, piperonyl butoxide 8.9% w/v excipients to 100% w/v) and Solfac UL 015 (cyfluthrin 1.5% w/v) were evaluated against the sentinel sugar-fed adults and 4th-instar larvae of Aedes aegypti at 17 storey high-rise apartments in Malaysia using ULV applications. The impact of both insecticides on field populations of Ae. aegypti and Ae. albopictus larvae was monitored weekly using bottle containers. Both Deltacide and Solfac UL 015 showed adulticidal and larvicidal effects. This was the first field trial using Deltacide against dengue vectors in Malaysia and showed its potential for use in dengue vector control programs.

The self-compressing tibial intramedullary nail

Laboratory evaluation of a self-compressing tibial nail demonstrated that significant, initial compression of a simulated fracture or nonunion can be obtained and controlled. However, when this nail was tested in cyclic loading, loss of its initial static compression occurred.

Field efficacy of fipronil 3G, lambda-cyhalothrin 10%CS, and sumithion 50EC against the dengue vector Aedes albopictus in discarded tires

The efficacy of three insecticides, fipronil 3G, lambda-cyhalothrin 10%CS, and sumithion 50EC were evaluated against the dengue vector Aedes albopictus in discarded tires in Kuala Lumpur, Malaysia. The dosage given for each insecticide was 0.01 g of active ingredient/m2. Fipronil 3G was the most effective larvicide with a residual activity of up to two weeks, causing 88% mortality in Aedes albopictus. Lambda-cyhalothrin 10%CS was effective for one week causing 92% larval mortality and two weeks with 63% larval mortality. Sumithion 50EC had a residual efficacy of one week with 79% larval mortality.

Identification of two electron-transfer sites in ascorbate peroxidase using chemical modification, enzyme kinetics, and crystallography

Chemical and mutagenic modification combined with X-ray crystallography has been used to probe the ascorbate binding site in ascorbate peroxidase (APX). Chemical modification of the single Cys residue in APX with Ellman's reagent (DTNB) blocks the ability of APX to oxidize ascorbate but not other small aromatic phenolic substrates. DTNB-modified APX (APX-TNB) exhibits only 1.3% wild-type activity when ascorbate is used as the substrate but full activity when aromatic substrates, guaiacol or pyrogallol, are used. Stopped-flow studies show that APX-TNB reacts normally with peroxide to give compound I but that the rates of reduction of both compounds I and II by ascorbate are dramatically slowed. Conversion of Cys32 to Ser leads to approximately 70% drop in ascorbate peroxidase activity with no effect on guaiacol peroxidase activity. These results indicate that uncharged aromatic substrates and the anionic ascorbate molecule interact with different sites on APX. The 2.0 A X-ray crystal structure of APX-TNB shows clear electron density for the TNB group covalently attached to Cys32 in all four molecules of the asymmetric unit, indicating complete and specific modification. It appears that the ascorbate site is blocked by DTNB modification which is well removed from the exposed delta-heme edge where aromatic substrates are thought to bind. This is the first experimental evidence indicating that ascorbate oxidation does not occur at the exposed heme edge but at an alternate binding site in the vicinity of Cys32 near Arg172 and the heme propionates.

Field evaluation of cyfluthrin and malathion 96 TG ULV spraying at high-rise flats on dengue vectors in Malaysia

Cyfluthrin (Solfac ULO15) and malathion 96 TG were evaluated against sentinel sugar-fed adults and 4th-instar larvae of Aedes aegypti at high-rise flats in Malaysia by ULV spraying. The impact of both insecticides on field populations of Aedes spp. (Ae. aegypti and Ae. albopictus) larvae were monitored weekly using containers. Both cyfluthrin and malathion 96 TG showed adulticidal effects but cyfluthrin showed more significant larvicidal effect than malathion 96 TG (P < 0.05).

Field evaluation of Vectobac G, Vectobac 12AS and Bactimos WP against the dengue vector Aedes albopictus in tires

The efficacy of three formulations of Bacillus thuringiensis var. israelensis was studied against Aedes albopictus in discarded tires. The formulations were: Vectobac G (corn cob formulation), Vectobac 12AS (aqueous suspension), and Bactimos WP (wettable powder formulation). Both Vectobac G and Vectobac 12AS were effective for 24 hr with more than 80% mortality. Both Vectobac formulations were significantly more effective than Bactimos WP for 24 hr after treatment (P < 0.0005). A week after treatment, Vectobac 12AS was significantly different than Bactimos WP (P < 0.05). However, Vectobac G did not differ significantly from Bactimos WP (P > 0.05); two weeks after spraying there was no significant difference among the various formulations (P > 0.05).

The Drosophila schnurri gene acts in the Dpp/TGF beta signaling pathway and encodes a transcription factor homologous to the human MBP family

Decapentaplegic (dpp), a TGF beta-related ligand, plays a key role in Drosophila development. Although dpp receptors have been isolated, the downstream components of the signaling pathway remain to be identified. We have cloned the schnurri (shn) gene and show that it encodes a putative zinc finger transcription factor homologous to the human major histocompatibility complex-binding proteins 1 and 2. Mutations in shn affect multiple events that require dpp signaling as well as the transcription of dpp-responsive genes. Genetic interactions and the strikingly similar phenotypes of mutations in shn and the dpp receptors encoded by thick veins and punt suggest that shn plays a downstream role in dpp signaling.

Drosophila Dpp signaling is mediated by the punt gene product: a dual ligand-binding type II receptor of the TGF beta receptor family

Signaling by TGF beta-related factors requires ligand-induced association between type I and type II transmembrane serine/threonine kinases. In Drosophila, the saxophone (sax) and thick veins (tkv) genes encode type I receptors that mediate signaling by decapentaplegic (dpp), a member of the bone morphogenetic protein (BMP) subgroup of TGF beta-type factors. In this report, we demonstrate that the Drosophila punt gene encodes atr-II, a previously described type II receptor that on its own is able to bind activin but not BMP2, a vertebrate ortholog of dpp. Mutations in punt produce phenotypes similar to those exhibited by tkv, sax, and dpp mutants. Furthermore, punt will bind BMP2 in concert with tkv or sax, forming complexes with these receptors. We suggest that punt functions as a type II receptors for dpp and propose that BMP signaling in vertebrates may also involve sharing of type II receptors by diverse ligands.

Characterization of tolloid-related-1: a BMP-1-like product that is required during larval and pupal stages of Drosophila development

The Drosophila tolloid (tld) gene product belongs to a family of developmentally important proteins that includes bone morphogenetic protein-1 (BMP-1). In Drosophila, tld is required at the blastoderm stage to establish pattern within the dorsal half of the embryo. Genetic analysis suggests that the major function of tld is to augment the activity of the decapentaplegic gene product, a close relative of the TGF-beta superfamily members, BMP-2 and BMP-4. In this report, we describe a new gene called tolloid-related-1 (tlr-1) that maps immediately proximal to tld. Sequence analysis indicates that tlr-1 has a large N-terminal extension relative to tld, but otherwise shows the same general organization of sequence motifs found in tld and other BMP-1 family members. These include a region of similarity to astacin, a crayfish metalloprotease, five copies of a repeat first found in complement proteins C1r and C1s, and two copies of an epidermal growth factor-like sequence. In situ hybridization experiments show that tlr-1 expression partially overlaps tld expression in early embryos, but shows unique transcriptional patterns in late stage embryos that are not seen with tld. In larval stages, both genes are expressed in identical patterns in imaginal discs and in the optic lobes of the brain, but tlr-1 is more abundant than tld. Deletions that eliminate tlr-1 expression cause lethality during larval and pupal stages of development. A small proportion of homozygous mutant flies eclose and show wing veination defects. Transgenic animals in which a tlr-1 cDNA is driven by the tld promoter fail to rescue tld mutations, and extra copies of tld fail to rescue tlr-1 mutations, implying that these genes have evolved functionally distinct features. We propose that tld and tlr-1 arose by gene duplication and that each has evolved independently to acquire distinct tissue specific roles in Drosophila development.

Extrapulmonary tuberculosis: five case reports

Since the 1950s, tuberculosis (TB) morbidity has been decreasing steadily in Israel. However, recent waves of Ethiopian immigrants have brought new cases and have renewed our awareness of the disease. As in other immigrant populations, the incidence of extrapulmonary TB is relatively high, challenging the clinician to make the correct diagnosis at an early stage. Many of the new immigrants settled in the Ashkelon are and were diagnosed and treated in our hospital. We present five cases of TB with extrapulmonary manifestations. Proof of TB infection was found in sites remote from the major clinical manifestation in four of the patients, emphasizing the difficulty in diagnosing the disease. Four of the patients recovered after treatment, but the patient admitted with neurological involvement remained comatose until her death.

The role of Renshaw cells in locomotion: antagonism of their excitation from motor axon collaterals with intravenous mecamylamine

The contribution of Renshaw cell (RC) activity to the production of fictive locomotion in the mesencephalic preparation was examined using the nicotinic antagonist mecamylamine (MEC). After the i.v. administration of 3 doses of MEC (1.0 mg/kg) the following observations were made: 1) ventral root (VR) evoked discharge of RCs was decreased by up to 87.7%, 2) recurrent inhibitory postsynaptic potentials recorded in alpha motoneurons were greatly reduced or abolished, and 3) the rhythmic firing of RCs during the fictive step cycle was abolished in 83% of the cells examined. Locomotor drive potentials (LDPs) in motoneurons persisted during the fictive step cycle after MEC administration. Bursts of motoneuron firing during each fictive step cycle were characterized by increased frequency and number of spikes after MEC, although the burst duration was unaltered for similar step cycle lengths. A greater number and frequency of spikes per burst was also observed in Ia inhibitory interneurons (IaINs), which remained rhythmically active after MEC administration. It is concluded that Renshaw cells are not an integral part of the spinal central pattern generator for locomotion, nor do they control the timing of the motoneuron or IaIN bursts of firing during fictive locomotion. The data are consistent with a role for RCs in limiting the firing rates of motoneurons and IaINs during each burst.