C3 Glomerulonephritis Presenting With Nephritic and Nephrotic Syndromes: Spontaneous Remission After Six Months on Dialysis

C3 glomerulopathy is a rare and complex renal disease driven by complement dysregulation, with variable presentation and pathophysiology. We report the case of a middle-aged male patient presenting with nephritic and nephrotic syndromes and low serum C3, whose biopsy established the diagnosis of C3 glomerulonephritis. He was found to be homozygous for the complement factor H-related protein (CFHR)3-CFHR1 deletion, which has been associated with the development of anti-factor H autoantibodies. However, the lack of consistent and accessible nephritic factor assays prevented full clarification of the mechanisms involved in the disease. Interestingly, despite not receiving treatment due to suspicion of malignancy and perceived poor renal prognosis, there was spontaneous recovery after six months on hemodialysis. This case reflects the enduring challenges in establishing the diagnosis and prognosis of C3 glomerulonephritis.

Lessons from Four Decades of Systemic Amyloidosis with Renal Involvement

BACKGROUND

Apart from ATTR amyloidosis, the epidemiology and outcomes of the most common subtypes of systemic amyloidosis in Portugal remain primarily unknown.

METHODS

This retrospective cohort study evaluated patients with renal biopsy-proven amyloidosis, diagnosed from January 1978 to December 2019. Follow-up started at kidney disease presentation and ended at death or August 2020. Clinical presentation, survival, and prognostic factors were analysed.

RESULTS

Of 123 patients with amyloid nephropathy, 111 had definite amyloid typing and were analysed. AA amyloidosis was the most frequent type (56.1%) and was related mainly to chronic infection (47.8%) and chronic inflammatory arthritis (29.0%). AL amyloidosis was present in 25.2% of patients and hereditary forms in 6.5% (4.1% AFibE526V, 2.4% ATTRV30M). During follow-up, 73.9% of AA and 54.8% of AL patients progressed to end-stage renal disease, and 79.7% of AA and 77.4% of AL died; median overall survival was 66.0 (95% CI, 33.0-99.0) and 18.0 (95% CI, 9.3-26.7) months (p = 0.025), respectively. There were no significant differences in renal outcome and survival on dialysis between these two types. In multivariate analysis, cardiac involvement at presentation (HR 6.26 [95% CI, 2.89-13.56]) and estimated glomerular filtration rate <30 mL/min/1.73 m2 (HR 2.05 [95% CI, 1.06-3.99]) independently influenced AA and AL amyloidosis survival. Cardiac involvement at presentation was an independent predictor of death (HR 9.65 [95% CI, 2.91-31.95]) and early mortality in AL amyloidosis.

CONCLUSIONS

In Portugal, AA amyloidosis and related chronic infections are still relevant. Regarding AL amyloidosis, the low incidence and advanced disease at presentation result from missed and erroneous diagnoses, leading to delayed referrals and poor outcomes in these patients.

MO520: Prevalence of Anemia in Patients With Stage 3 or 4 Chronic Kidney Disease in Portugal–The Nefropor Study

BACKGROUND AND AIMS

Anemia is a highly prevalent and modifiable comorbidity in patients with chronic kidney disease (CKD), which tends to aggravate as the disease progresses. The economic burden of anemia in CKD is high, and quality of life issues (e.g. fatigue, reduced productivity) is common in these patients.

Data on the prevalence and treatment of anemia in CKD stages 3 and 4 (based on the estimated glomerular filtration rate according to KDIGO classification) in Portugal are lacking.

The NEFROPOR study aimed to estimate the prevalence of anemia in patients with CKD stage 3 or 4 admitted to a Nephrology consultation between 1 January and 31 March 2017 and characterize anemia treatment in this patient population.

METHODS

NEFROPOR was a retrospective, multicentric study carried out in 10 Portuguese centers. All patients aged ≥18 years with stage 3 or 4 CKD admitted to a Nephrology consultation in one of those centers between 1 January and 31 March 2017 were invited to participate, and data for up to 24 months after admission were collected from patients’ clinical files. Retrieved data included age, body mass index (BMI), anemia status according to the World Health Organization (WHO) diagnostic criteria, and anemia treatment type and duration. Three assessments of the prevalence anemia were performed: at the time of the first Nephrology visit (presentation), at the first analytical results and the overall prevalence in the study cohort. Statistical analysis was performed in SPSS Statistics (v26) and a 0.05 significance level was adopted.

RESULTS

A total of 176 patients were included in this study, mostly (61.9%) male, with a median age of 76 years (range, 26–97) and a mean BMI indicative of pre-obesity (28.2; standard deviation, 4.2). CKD stage 3b was predominant (43.2%), followed by stage 4 (32.4%) and stage 3a (24.4%). The most frequent CKD etiologies in this cohort were diabetes (39.8%), followed by arterial hypertension (27.8%) and unknown cause (25.6%). Arterial hypertension was largely the most frequent comorbidity, present in 90.3% of patients, followed by diabetes (54.0%). Although less prevalent, coronary artery disease (18.2%) and congestive heart failure (14.8%) were also identified in this patient population.

A total of 44.9% of patients [95% confidence interval (CI), 37.7%–52.3%] had anemia at presentation, which was significantly associated with CKD stage, diabetes, peripheral vascular disease and myocardial infarction comorbidities, and diabetes and unknown CKD etiology.

The overall prevalence of anemia in the study cohort was 61.9% (95% CI 54.6%–68.9%), and it was significantly associated with diabetes and peripheral vascular disease comorbidities and with diabetes and primary glomerulonephritis as CKD etiologies.

The prevalence of anemia at the first analytical results was 49.4% (95% CI 42.1%–56.8%), and it was significantly associated with CKD stage, diabetes, non-skin cancer, peripheral vascular disease and myocardial infarction comorbidities, and diabetes as CKD etiology.

Figure 1 shows the evolution of anemia treatment in this cohort over 24 + months.

CONCLUSION

The three estimates of the prevalence of anemia in this study were consistent with each other, particularly those for the first visit and first analytical results. The latter were also consistent with evidence in the literature reporting a prevalence of anemia in the population of patients with CKD stages 3 and 4 between 40% and 60%. The overall prevalence of anemia in this study was 12%–15% higher than first visit and first analytical results estimates, in agreement with the fact that this refers to a cumulative prevalence.

These data support the need for optimized and individualized treatment strategies for patients with CKD stages 3 and 4, maximizing the efficiency of health-care resource use.

The complexity of neuropsychiatric manifestations of COVID-19 in South Africa

SARS-CoV-2 was first identified in Wuhan City, China, in 2019. Initially it was associated with the development of pulmonary disease, but research over the past 2 years has identified effects on multiple systems. Neuropsychiatric manifestations of COVID-19 have been reported in countries around the world, including new-onset psychosis in patients with no personal or family psychiatric history. We present the first case series describing neuropsychiatric manifestations of patients in Johannesburg, South Africa (SA). All four patients presented with their index-episode psychosis, and evidence of COVID-19 infection. The patients had varied psychiatric presentations, from delirium and psychosis to mania, and all responded well to low doses of antipsychotics. One patient had newly diagnosed HIV in addition to COVID-19. Further research is needed to determine the prevalence of neuropsychiatric manifestations in acute SARS-CoV-2 infections in SA.

Endothelial Dysfunction Is Associated with Cerebrovascular Events in Pre-Dialysis CKD Patients: A Prospective Study

Background: Patients with chronic kidney disease (CKD) have markedly increased rates of end stage renal disease, major adverse cardiovascular/cerebrovascular events (MACCEs), and mortality. Endothelial dysfunction (ED) is an early marker of atherosclerosis that is emerging as an increasingly important non-traditional cardiovascular risk factor in CKD. There is a lack of clinical studies examining the association between ED and both cardiovascular and renal endpoints in patients with CKD. Aims: We examined the association between reactive hyperemia index (RHI), a validated measure of endothelial function measured by peripheral arterial tonometry (PAT), with traditional cardiovascular risk factors in pre-dialysis CKD patients and prospectively evaluated the role of RHI as predictor of renal and cardiovascular outcomes in this population. Methods: One hundred and twenty pre-dialysis patients with CKD stages 1 to 5 (CKD group) and 18 healthy kidney donor candidates (control group) were recruited and had a successful RHI measurement by PAT. General demographic and clinical information including traditional cardiovascular risk factors were registered from all participants. Thereafter, patients were prospectively followed-up for a median time of 47 (IQR 19–66) months to determine associations of RHI with renal outcomes, MACCEs, hospitalizations or mortality. Results: In the CKD patient population, the mean age was 57.7 ± 15.5 years, the mean eGFR was 54.9 ± 36.7 mL/min/1.73 m² (CKD-EPI) and 57 were males (47.5%). At baseline, in univariate analysis, RHI in the CKD group correlated positively with eGFR (r = 0.332, p < 0.0001) and correlated negatively with age (r = −0.469, p < 0.0001), Charlson index (r = −0.399, p < 0.0001), systolic blood pressure (r = −0.256, p = 0.005), and proteinuria (r = 0.211, p = 0.027). Reactive hyperemia index in the control group did not significantly differ from RHI observed in patients with CKD stages 1 to 5 (2.09 ± 0.40 vs. 2.01 ± 0.06, p = 0.493). In adjusted analysis, only age (β = −0.014, p = 0.003) remained independently associated with RHI at baseline. During follow-up, 8 patients suffered a MACCEs, 33 patients experienced renal function deterioration, 17 patients were hospitalized for medical reasons and 6 patients died. RHI at baseline was not significantly associated with CKD progression (1.94 vs. 2.02, p = 0.584), hospitalizations (1.90 vs. 2.04, p = 0.334), and all-cause mortality (1.65 vs. 2.01, p = 0.208) or MACCEs (1.77 vs. 2.01, p = 0.356), but was significantly associated with cerebrovascular events (1.27 vs. 2.02, p = 0.004) and with a composite cardiovascular outcome (MACCEs, hospital admissions and death; 1.73 vs. 2.07, p = 0.035). Conclusion: Our results suggest that RHI may be a predictor for the development of cerebrovascular events in pre-dialysis CKD patients who may benefit from more aggressive preventive measures.

Clearing the clouds: Case-report and review of the literature

In peritoneal dialysis (PD), a cloudy dialysate is an alarming finding. Bacterial peritonitis is the most common cause, however, atypical infections and non-infectious causes must be considered. A 46-year-old man presented with asthenia, paraesthesia, foamy urine and hypertension. Laboratory testing revealed severe azotaemia, anaemia, hyperkalaemia and nephrotic-range proteinuria. Haemodialysis was started through a central venous catheter. Later, due to patient preference, a Tenckhoff catheter was inserted. Conversion to PD occurred 3 weeks later, during hospitalization for a presumed central line infection. A month later, the patient was hospitalized for neutropenic fever. He was diagnosed an acute parvovirus infection and was discharged under isoniazid for latent tuberculosis. Four months later, the patient presented with fever and a cloudy effluent. Peritoneal fluid (PF) cytology was suggestive of infectious peritonitis, but the symptoms persisted despite antibiotic therapy. Bacterial and mycological cultures were negative. No neoplastic cells were detected. Mycobacterium tuberculosis eventually grew in PF cultures, despite previous negative molecular tests. Directed therapy was then initiated with excellent response. Thus, facing a cloudy effluent, one must consider multiple aetiologies. Diagnosis of peritoneal tuberculosis is hampered by the lack of highly sensitive and specific exams. Here, diagnosis was only possible due to positive mycobacterial cultures.

Evolution of in-hospital management in ST Segment Elevation Myocardial Infarction in Portuguese hospitals over the years

Objectives

To assess the evolution of in-hospital management of ST Segment Elevation Myocardial Infarction (STEMI) over the years in Portuguese hospitals and its impact on in-hospital complications and mortality

Methods

A nationwide electronic prospective registry that included all patients admitted to Portuguese hospitals with a diagnosis of acute coronary syndrome since 2002 until 2019 was used to collect all data relative to patients admitted with a STEMI diagnosis during that time frame. Data on demographic data, clinical data, revascularization strategy, medication during hospitalization. We compared the data and its evolution over the years to assess for trends. For statistical analysis, Qui-square tests were used to assess tendencies in categorical variables, and Kruskal-Wallis tests were used to assess tendencies in numerical variables. A p-value &lt;0.05 was considered statistically significant.

Results

During the study, a total of 24425 patients were admitted for STEMI in Portuguese hospitals, 74.3% were male and average age of 63.9±13.6 years.

We report a progressive increase in patients treated with aspirin, P2Y12 inhibitors (from 22.2% to 97.6% – p&lt;0.001), beta blockers 62.% to 72.4% – p&lt;0.001), ACE inhibitors (68.9% to 78.2% – p&lt;0.001) and statins (72.1% to 88.4% – p&lt;0.001), a progressive decrease in GP 2a3b inhibitors (20.9 to 14.6% – p&lt;0.001), enoxaparin (55.2% to 29.9% – p&lt;0.001), nitrates (82.7% to 16.1% – p&lt;0.001), calcium channel blockers (5.0% to 3.1% – p&lt;0.001) and inotropes (12.0% to 5.6% – p&lt;0.001).

There was an increase of the use primary coronary angioplasty (36.4% to 73.2% – p&lt;0.001), and of drug eluting stents (0% to 70.1% – p&lt;0.001) a decrease in the use of fibrinolysis (75.7% to 1.6% – p&lt;0.001), bare metal stents (88.1% to 0.3% – p&lt;0.001) and intra-aortic balloon pump (1.8% to 0% – p=0.009), but not in invasive mechanical ventilation (2.5% to 1.9% – p=0.142).

Less patients had moderate to severely impaired left ventricle ejection fraction (28.8% to 14.9% – p&lt;0.001), and there was a significant reduction in almost all in-hospital complications: re-infarction (2.0% to 1.0% – p&lt;0.001); heart failure (36.2% to 9.9% – p&lt;0.001); cardiogenic shock (10.8% to 3.9% – p&lt;0.001); AV block (5.8% to 2.5% – p&lt;0.001); mechanical complications (2.8% to 0.4% – p&lt;0.001); stroke (1.3% to 0.4% – p&lt;0.001); in-hospital mortality (9.9% to 3.8% – p&lt;0.001); as well as length of stay ([4–10] days to [3–6] days – p&lt;0.001). Exceptions were and increase in major bleeding (0.9% to 1.8% – p&lt;0.001) and resuscitated cardiac arrest (3.9% to 4.5%, p=0.001).

Conclusion

In 17 years, we report a progressive evolution of the in-hospital treatment of STEMI patients in Portuguese hospitals, with a higher prescription of guideline recommended medications, use of invasive reperfusion techniques and last generation stents, resulting in a lower rate of in-hospital complications and mortality.

In-hospital outcomes over the years

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Registo Nacional de Síndromes Coronárias Agudas - Sociedade Portuguesa de Cardiologia

Clinical characteristics and natural history of PRKAG2 syndrome

Purpose

Mutations in the PRKAG2 gene cause a syndrome characterized by hypertrophic cardiomyopathy, conduction disease and ventricular preexcitation. Only a small number of cases have been reported, and the natural history of the disease is poorly understood. The aim of this study is to describe phenotype and natural history of PRKAG2 mutation in a large multicenter international cohort.

Methods

We retrospectively studied clinical, electrocardiographic and echocardiographic data from 90 individuals with PRKAG2 mutations (53% males, 33±21 years) from 27 centers.

Results

At baseline evaluation, 93% of patients were in NYHA functional class I-II. Maximum left ventricular (LV) wall thickness was 18±8 mm and LV hypertrophy (LVH) was present in 60 (67%) subjects at baseline. LV ejection fraction was 61±12%. Seventeen pactients (19%) had a pacemaker (mean age at implantation 37±15and 16 (18%) had atrial fibrillation (AF) (mean age 41±23 years) and 33% had ventricular preexcitation or had undergone an accessory pathway ablation. After a median follow-up of 6 years (IQR:2.3–13.9), 71% of individuals had LVH, 29% had AF, 21% a de novo pacemaker (mean age at implantation 38±18 years), 14% required admission for heart failure (HF), 8% experienced sudden cardiac death or equivalent, 4% required a heart transplant and 13% died.

Conclusions

PRKAG2 syndrome is a severe, progressive cardiomyopathy characterized by high rates of AF, conduction disease, advanced HF and life-threatening arrhythmias. Outcome is not clearly related to the classical features of preexcitation and severe LVH, which are not always present.

Natural history of PRKAG2 syndrome

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Instituto de Salud Carlos III (ISCIII)

Premature acute coronary syndrome

Introduction

The prevalence of acute coronary syndrome (ACS) at an early age is rising, resulting in higher morbidity and mortality rates.

Purpose

To characterize patients admitted with premature ACS, comparing with those with non-premature ACS.

Methods

A retrospective study encompassing patients of a National Registry of ACS was performed. We compared two groups: one composed of men &lt;55 and women &lt;65 years-old; and other with men ≥55 and women ≥65 years-old at the ACS admission. Clinical characteristics, in-hospital evolution and 1-year clinical outcomes were analysed. Primary endpoint was the composite of in-hospital mortality, stroke and re-myocardial infarction (MI). Secondary endpoints were re-MI, stroke, in-hospital and 1-year mortality, 1-year cardiovascular (CV) and non-CV readmissions.

Results

A total of 26523 patients were enrolled and 6637 (25%) had premature ACS, with a mean age of 49±7 years-old. It was found a larger prevalence of smoking habits, obesity and dyslipidemia, but not diabetes. ST-segment elevation MI (STEMI) was the main admission diagnosis (51,2% vs 40,3%), with more frequent activations of the STEMI network (17,1% vs 12,8%) and a consequently shorter time from symptom onset to admission (483 vs 584 min). Coronary angiogram was largely performed in younger patients (91,4% vs 82,1%), mainly revealing one-vessel disease (49,3% vs 34,3%). They had lower Killip-Kimbal (KK) class (6% vs 18,1% with KK class &gt;1) and mostly preserved left ventricular ejection fraction (LVEF) (67,3% vs 58,6%). Major bleeding (0,9% vs 1,7%), sustained ventricular tachycardia (1,1% vs 1,5%) and mechanical complications (0,2% vs 0,7%) were uncommon. Composite endpoint was more frequent in non-premature ACS patients (6,2% vs 1,9%). Non-premature age, KK class &gt;1, multivessel disease and depressed LVEF were independent predictors of primary endpoint (each with p&lt;0,001). Younger patients had inferior rates of in-hospital mortality (1% vs 4,7%), re-MI (0,5% vs 1%) and stroke (0,4% vs 0,7%). One-year mortality (1,7% vs 9,1%), and 1-year CV (9,7% vs 15,5%) and non-CV readmissions (3,7% vs 8,2%) were also lower. All comparative data presented have a statistically significant p-value (p&lt;0,012).

Conclusions

Premature ACS affects 25% of the ACS population, mostly presenting with STEMI, but generally associated with better clinical evolution. Nevertheless, primary prevention is essential to correct modifiable CV risk factors and reduce coronary events in these patients.

Funding Acknowledgement

Type of funding source: None

Mechanical Dispersion as a powerful echocardiographic predictor of outcomes after Myocardial Infarction

Introduction

Several studies have addressed the importance of transthoracic echocardiography (TTE) in risk prediction of subsequent adverse events after ST elevation myocardial infarction (STEMI). While several traditional echo parameters have a well-established prognostic value, data derived from 2D-Speckle Tracking Echocardiography (2DSTE) needs further investigation.

Objectives

To determine if 2DSTE parameters provide additional information beyond conventional echocardiography to predict long-term adverse outcomes in patients admitted with STEMI

Methods

Retrospective, single-center study, that included all patients without previous cardiovascular events admitted with STEMI (who underwent primary coronary angioplasty) between 2015 and 2017. Patients with poor acoustic windows, severe valvular disease, irregular heart rhythm, and those who died during hospital stay were excluded. We reviewed all pre-discharge TTE to assess conventional parameters of LV systolic and diastolic function and data obtained by 2DSTE: global longitudinal strain (GLS) and peak strain dispersion (PSD), an index that is the standard deviation from time to peak strain of all segments over the entire cardiac cycle. Demographic and clinical data was obtained through electronic hospital records. Minimum follow-up was 2 years. The primary endpoint was a composite of all-cause mortality and cardiovascular re-admission at follow-up. Survival analysis was used to determine independent predictors of the primary endpoint.

Results

377 patients were included, mean age 62±13 years, 72% male. Mean LVEF was 50±10% with 19% of patients having LVEF &lt;40%. Mean indexed left atrium volume (LAVi) was 33±10 ml/m2, mean GLS was −14±4%, and PSD was 60±22 msec. Average follow-up was 36±11 months, with a combined endpoint of mortality and hospitalization of 27% (n=102)

Univariate analysis of echocardiographic variables revealed an association between heart rate, LVEF, indexed LV end-systolic volume, indexed stroke volume, LAVi, GLS and PSD with the endpoint. However, on multivariate analysis only LAVi [HR 1.030 (95% CI 1.009 - 1.051), p-value = 0.005] and PSD [HR 1.011 (95% CI 1.002 - 1.020), p-value = 0.012] remained independent predictors of the primary endpoint.

We determined that a PSD value higher than 52 msec has a sensitivity of 76% and a negative predictive value of 83% for mortality and hospitalization, and that this cut-off point discriminates patients at a higher risk of events in Kaplan-Meier Survival analysis with a Log-Rank p-value=0.001.

Conclusion

PSD derived by longitudinal strain analysis is a promising prognostic predictor after STEMI. PSD outperformed conventional echocardiographic parameters in the risk stratification of STEMI patients at discharge.

Kaplan-Meier Survival Curves

Funding Acknowledgement

Type of funding source: None

Evolution of hospital discharge medication and 6 months outcomes of ST-Segment Elevation Myocardial Infarction patients in Portugal over the years

Objectives

To assess the evolution of hospital discharge management, 6 months hospitalization and mortality over the years of all patients admitted with ST segment elevation myocardial infarction (STEMI) in Portugal.

Methods

A nationwide electronic prospective registry that included all patients admitted to Portuguese hospitals with a diagnosis of Acute Coronary Syndrome since 2002 until 2018 was used to collect all data relative to patients admitted with a STEMI diagnosis during that time frame. Data on demographic data, clinical status, revascularization strategy, discharge medication and 6 months hospitalization and mortality were obtained. We compared the data and its evolution over the years to assess for trends. For statistical analysis, Qui-square tests were used to assess trends in categorical variables, and Kruskal-Wallis tests were used to assess trends in numerical variables. A p-value &lt;0.05 was considered statistically significant.

Results

During the study, a total of 23807 patients were admitted for STEMI in Portuguese hospitals, 74.3% were male and average age of 63.9±13.6 years.

We report a progressive and significant increase the use of primary angioplasty versus fibrinolysis (24.3% to 98.4%, p&lt;0.001), in coronary angioplasties (36.4% to 73.2%, p&lt;0.001), in the use of drug-eluting stents (0% to 70.1%, p&lt;0.001), and a decrease in the patients that underwent surgery (6.8% to 1.3%, p&lt;0.001) and intra-aortic balloon pump (1.8% to 0%, p=0.009), resulting in a decrease in in-hospital mortality from 9.9% to 6.1% (p&lt;0.001).

At discharge, we report a progressive increase in the prescription of P2Y12 inhibitors (21.1% to 95.2%, p&lt;0.001), beta-blockers (68.8% to 83.8%, p&lt;0.001), RAAS inhibitors (69.5% to 86.7%, p&lt;0.001) and statins (79.6% to 94.9%, p&lt;0.001), while the prescription of aspirin (94.1% para 94.8%, p=0.428), calcium channel blockers (5.3% to 5.6%, p&lt;0.684) stayed stable, and there was a decrease in the prescription of nitrates (52.9% to 5.8%, p&lt;0.001). Hospital admissions at 6 months consistently and progressively reduced over time (18.6% to 8.5%, p&lt;0.001) as well as mortality (6.7% para 4.3%, p&lt;0.001).

Conclusion

Post discharge treatment of STEMI patients in Portuguese hospitals has evolved according to guidelines, with higher prescription of medication proven to reduce outcomes, resulting in lower hospitalization rates and mortality.

6 Month Outcomes over the years

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Sociedade Portuguesa de Cardiologia

Recurrent syncope, which patient should we follow more closely

Introduction

The importance of education is well recognized in patients presenting with syncope, in order to reduce the recurrence rate.

Purpose

To determine a predictive score of recurrent syncopal episodes after the first medical assessment.

Methods

We conducted a retrospective study enrolling patients followed in our Syncope Consultation from January 2015 to November 2019. Clinical and episodes characteristics, as well as diagnostic studies were analysed. Correlation between variables was performed by the Chi-square and T-Student tests, with a significance level of 95%. Independent predictors of recurrent syncope were identified through a binary logistic regression analysis, considering p=0.05. Then, a discriminatory function was applied using the Wilks lambda test to determine the discriminant score of the analysed groups. SPSS 24.0 was used for statistical analysis.

Results

A total of 694 patients were included, and 420 (60.5%) had recurrent syncope at the first evaluation. After educational approach, 97 (14%) maintained recurrent episodes. In this subgroup, the mean age was 63.7±22.8 years-old and 88.7% already had previous recurrent syncope (vs 56.1%; p&lt;0.001). The prodrome of malaise was common (40.2% vs 26.8%; p=0.008), but 32% of these patients had syncope without prodromes (vs 21.8%; p=0.032). They also had frequently first-degree atrioventricular (AV) block (22.5% vs 6.8%; p&lt;0.001) and 51.7% had a final diagnosis of reflex syncope. No previous medication with calcium channel blockers (CCB) (p&lt;0.001), malaise (p=0.011), not having Q-waves in the electrocardiogram (p=0.022) and the presence of first-degree AV block (p&lt;0.001) were independent predictors of recurrent syncope. A predictive score of recurrence was determined using the formula: 0.108 − 1.556 x (medication with CCB) + 0.989 x (malaise) − 1.031 x (Q-waves) + 2.406 x (first degree AV block). Variables should be replaced by 1 or 0, depending on whether the condition is present or not. A cut-off of 0.283 was obtained with a specificity of 96.1% and a discriminative power of 81.2%.

Conclusion

In our patients presenting with syncope, recurrence rate reduced from 60,5% to 14% just with educational measures. To help identify patients who maintain recurrence, we determined a predictive score using clinical data from the first visit, with a good discriminative power and excellent specificity. It could be used to strengthen education, to direct diagnostic studies and to shorten follow-up visits, but it still needs validation to be used in clinical practice.

Funding Acknowledgement

Type of funding source: None

P871 Giant left ventricular (pseudo?)aneurysm complicating anterior myocardial infarction

Introduction

Clinical approach of cardiac aneurysms and pseudoaneurysms is significantly distinct. Therefore, it is crucial to accurately differentiate these two entities, which could be a real challenge.

Case report

We describe a case of a 55-year-old woman, with hypertension and previous smoking habits. She was admitted in our Cardiology Department with the diagnosis of anterior acute myocardial infarction, and was submitted to emergent coronariography, unveiling an occlusion of the middle segment of the anterior descending artery. She underwent successful primary percutaneous coronary intervention (PCI) 1h45 after the chest pain onset. Transthoracic echocardiogram (TTE) revealed depressed left ventricle ejection fraction (LVEF 30%), with akinesia of anterior and septal walls and all apical segments. She evolved in Killip-Kimbal class 2 and was discharged clinically stable. One week later, the patient performed a control TTE that showed an apical thrombus, with a small pericardial effusion, and she initiated warfarin. Three weeks later, a reevaluation TTE demonstrated a severe increase of the left ventricle dimensions, with LVEF 32%, and a small pericardial effusion. In apical 4-chambers incidence, it was visualized a linear structure (42 mm x 5 mm) attached to the endocardial border of the anterolateral apical segment and to the apical segment of the interventricular septum, of undefined nature. The apical segments were dyskinetic and had a very thin wall, which could correspond to aneurysm versus pseudoaneurysm. To clarify these findings, the patient performed a cardiac magnetic resonance revealing a large anterior myocardial infarction complicated with extensive myocardial necrosis, severe depression of LV systolic function (LVEF 25%) and septum rupture distal to the right ventricle apex (without connecting with it), compatible with a large apical pseudoaneurysm. The clinical case was discussed in the Heart Team and it was decided to perform cardiac surgery. However, surgical findings showed integrity of septal and free walls, and she underwent an aneurysmectomy, without further complications. Histological examination confirmed the presence of a thin myocardial wall with marked fibrosis and, consequently, the diagnosis of ventricular aneurysm. She was discharged clinically stable and maintains follow-up in Cardiology consultation of our Hospital.

Conclusion

In this patient, initially admitted with an anterior myocardial infarction submitted to primary PCI, follow-up with advanced imaging modalities pointed to the diagnosis of pseudoaneurysm. Despite the preoperative diagnosis, surgical findings were compatible with a giant left ventricular aneurysm. Even with high spatial resolution exams, postoperative evaluation of tissue layers remains the gold standard for this differential diagnosis.

Abstract P871 Figure. Apical pseudoaneurysm vs aneurysm

P879Discharge medication and 1-year outcomes in patients with myocardial infarction and nonobstructive coronary artery disease: a nationwide registry-based study

Introduction

Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 5% to 10% of all patients with myocardial infarction. Although these patients are often treated as if they had obstructive coronary artery disease (OCAD), optimal medical therapy for secondary prevention in MINOCA patients have not been prospectively studied. We hypothesize that the same treatment strategy as for OCAD is unlikely to be beneficial in MINOCA patients due to their heterogeneous nature.

Purpose

Characterize and assess the impact of discharge medication on 1-year mortality or hospitalization in patients with MINOCA.

Methods

Retrospective cohort study of consecutive patients with acute myocardial infarction (AMI) recorded in the Portuguese Registry of Acute Coronary Syndromes (ProACS) between 2010 and 1017. All patients who underwent coronary angiography and had no obstructive lesions (defined as <50% diameter stenosis) were included for analysis (n=829, 4.8% of a total of 17213). Patient demographics, clinical characteristics and medication at discharge were analyzed. The association between treatment and outcome was estimated by comparing treated and untreated groups using Cox proportional hazard models. The exposures considered were treatment at discharge with statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs), beta-blockers (BB), aspirin (ASA) or dual antiplatelet therapy (DAPT). The outcomes evaluated were 1-year all-cause mortality and 1-year hospitalization due to cardiovascular disease (CVD)

Results

829 patients (54% male, mean age 65±13 years) were included. 67% had hypertension, 20% diabetes mellitus, 45% hyperlipidemia, 66% were overweight, 23% were current smokers, 5.5% had history of heart failure, 4.3% valvular heart disease, 8% cerebrovascular disease and 4.7% chronic kidney disease. The admission diagnosis was most frequently non-ST elevation MI (79.3%) and mean left ventricular ejection fraction (%) was 56±12. 4 patients died during hospitalization (0.5%). At discharge, aspirin was prescribed in 85.7% patients, clopidogrel in 54.8%, ticagrelor in 7.5%, DAPT in 57.7%, ACEi/ARB in 79.2%, beta-blocker in 69% and statins in 90.2%. 1-year mortality and 1-year CVD hospitalization was 3.8% and 9%, respectively. After adjusting for covariates in Cox regression analysis, we found no association between any medication at discharge and 1-year outcomes.

Conclusion

A high proportion of patients are prescribed antiplatelet therapy, including DAPT. We found no significant 1-year beneficial effect of treatment with statins, ACEi/ARBs, BB, aspirin or DAPT in MINOCA. This may be partially explained by the highly heterogenous population and relative short-term follow-up. In MINOCA patients, treatment should be individualized after an exhaustive diagnostic workup to identify the underlying cause (e.g. CAD with spontaneous autolysis of an intracoronary thrombus, myocarditis or takotsubo syndrome).

P1721Determination of a predictive score of cardiogenic shock in acute coronary syndrome

Introduction

Cardiogenic shock is one of the leading causes of death in patients with acute coronary syndrome (ACS), reaching in-hospital mortality rates of 50%.

Purpose

To identify a predictive score of cardiogenic shock in patients with ACS.

Methods

We performed a retrospective, descriptive and correlational study encompassing patients admitted with ACS in a Cardiology service from 1st October 2010 to 1st October 2018. Demographic factors, risk factors, antecedents and clinical characteristics were analyzed. The correlation between the categorical variables was performed by the Chi-square test, while the T-Student test was applied to the continuous variables, with a significance level of 95%. Independent predictors of cardiogenic shock were identified through a binary logistic regression analysis, considering p=0,05. Then, a discriminatory function was applied using the Wilks lambda test to determine the discriminant score of the analized groups. Statistical analysis was conducted with SPSS 24.0.

Results

During this period, 4458 patients were admitted with ACS and 74 (1,7%) developed cardiogenic shock. In this subgroup, 59,5% were over 65 years of age, 63,5% were male and 93,2% presented with acute myocardial infarction with ST segment elevation. Also, 83,8% were in sinus rhythm at admission, 22,7% had creatinine>1,5 mg/dL and 17,9% had left ventricular ejection fraction (LVEF) <30%. The in-hospital mortality rate was 51,4%. LVEF <30% (p=0,018), creatinine>1,5 mg/dL (p=0,044) and absence of sinus rhythm at admission (p=0,041) were independent predictors of cardiogenic shock. A predictive score of this complication in patients with ACS was determined using the formula: 1,723 + 1,505 x (creatinine>1,5) + 4,483 x (LVEF <30%) – 2,094 x (sinus rhythm at admission). A cutoff of 0,58 was obtained with 44,4% sensitivity, 85,2% specificity and 85% discriminative power.

Conclusion

Cardiogenic shock occurred in 1,7% of patients admitted with ACS and was associated with a high mortality rate. We determined a predictive score of this complication with a good discriminative power, which included LVEF <30%, creatinine >1,5 mg/dL and the rhythm on admission's electrocardiogram. By taking into account clinical variables, this score can be used at a very early stage of admission, allowing risk stratification of developing cardiogenic shock in each patient. However, it needs validation to be applied in clinical practice.

P844NAS2H score, a novel predictive score of 1-year all cause mortality in Acute Coronary Syndromes

Introduction

In patients admitted for Acute Coronary Syndromes (ACS), mortality is influenced by several clinical and therapeutical factors, and management of these patients should be guided by an estimate of individual risk.

Objective

To develop a simple predictive model of 1-year mortality in patients admitted for ACS.

Methods

The authors present a retrospective, descriptive and correlational study including all patients admitted for ACS in a Cardiology department between the 1st of October 2010 and the 1st of October 2017. A 1-year (1y) follow-up was made through registry consultation and phone call by a Cardiologist. Patients with 1y mortality (1yM) events were studied regarding baseline demographic and clinical characteristics, risk factors and hospitalization data, and a correlational analysis with Chi-square test for categorical variables and t-Student test for continuous variables (confidence level of 95%) was performed. Independent predictors of 1yM were identified through binary logistic regression analysis, using a significance level of 0,05. A discriminatory function was applied, and the Wilks lambda test was used to determine the discriminant score for the studied groups. The authors used SPSS 24,0 for statistical analysis.

Results

A total of 3251 patients were included, 826 (25,4%) of which were female, with a mean age of 65,5±13,4 years. In the studied sample, 268 patients (8,2%) died in the year following hospital discharge; this group had a mean age of 65,6±13,2 years, and 80 (29,9%) were female patients. There was a significant association between 1yM and multiple clinical, therapeutical and laboratorial variables, but after multivariate analysis only age greater than 65 years old (yo) [p=0,001], previous stroke [p=0,005], haemoglobin (Hb) <10mg/dL [p<0,001], brain natriuretic peptide (BNP) >100pg/mL [p=0,001], and left ventricular ejection fraction (LVEF) <50% [p <0,001] proved to be independent predictors of the studied outcome. Using these variables, the authors developed a scoring model to predict 1yM in patients admitted for ACS with the following formula = 0,002 + (0,736 x Age >65yo) + (0,91 x previous stroke) + (2,562 x Hb <10) + (0,63 x BNP >100) - (1,207 x FEVE >50%). In this function, variables should be substituted by 1 or 0, depending on wheter they are present or not. The discrimination cutoff was 0,57, with a 70,6% sensibility and 75,9% specificity, and a discriminant power of 75,4%.

Conclusion

Defining the mortality risk of ACS patients after discharge represents a real challenge and demands a careful evaluation of multiple factors in an attempt to achieve an accurate estimation of risk. The authors developed a predicting model for 1yM in ACS patients, with a good discriminant power, based on simple variables. The present score will require validation in a larger cohort of ACS patients before it can be applied in a clinical context.

P1698Age shock index is a simple bedside clinical risk stratification tool in patients with non-ST-segment elevation myocardial infarction

Introduction

Shock index (SI), (heart rate (HR)/systolic blood pressure (SBP)), has been reported to predict worse outcomes in different acute settings. Two derivatives, named modified SI (MSI), defined as HR/mean BP; and Age SI, defined as SI multiplied by age, were later developed, but only the former was tested for short-term outcomes in patients with myocardial infarction (MI). We hypothesize that Age SI may demonstrate higher prognostic accuracy than SI and MSI due to the added prognostic value of age in this population.

Purpose

Compare the prognostic performance of admission age SI, MSI and SI for predicting in-hospital mortality in patients with NSTEMI.

Methods

Retrospective cohort study of consecutive patients admitted to the Cardiology department of a tertiary care hospital with the diagnosis of NSTEMI between October 2010 and September 2018. Very high-risk patients in need of emergent treatment were excluded. Of the initial cohort of 2476 patients, we excluded 5 who presented cardiac arrest before or at hospital admission, 4 with cardiogenic shock, 95 with acute pulmonary oedema, 10 with SBP <80 mmHg, 1 with HR <40bpm and 1 with HR >160bpm. The primary outcome was all-cause in-hospital mortality. The discriminatory capacity of Age SI, MSI, SI for the primary outcome was assed using the ROC-AUC and compared with the DeLong method, and the value with highest Youden-index was considered the optimal cut-off point. Calibration was assessed using the Hosmer-Lemeshow (HL) test and adjustment for confounding variables was performed using logistic regression analysis.

Results

2359 patients were included [mean age 66±13 years; 1732 (73.4%) men], of whom 40 (1.7%) died during hospitalization. Discrimination by ROC-AUC was highest for Age SI (0.78 [95% CI 0.71–0.86)], compared to MSI (0.69 [95% CI 0.61–0.78]) and SI (0.69 [95% CI 0.61–0.78)], p<0.01 for comparison. All indexes demonstrated adequate calibration (HL: Age SI 7.4; MSI 4.5; SI 6.4; p>0.5). The optimal cut-off for Age SI was 40, which was present in 684 patients (29%) and had 75% sensitivity, 72% specificity, 4.5% positive and 99.5% negative predictive value (NPV) for in-hospital mortality (4.4% vs 0.6%, p<0.001). After adjusting for covariates, an Age SI higher than 40 was associated with increased in-hospital mortality (adjusted OR 3.2, 95% IC 1.06–9.55), p=0.039).

Mortality and Age Shock Index

Conclusion

Age SI demonstrated better discriminatory capacity and equal calibration, compared to SI and MSI for in-hospital mortality. An age SI higher than 40 was associated with a 3-fold increased risk of in-hospital death. This cut-off demonstrated excellent negative predictive value (99.5%) and may allow very early risk assessment in patients with non-ST-segment elevation MI (NSTEMI), before laboratorial values are available for GRACE calculation. This may guide initial therapy and help select the most appropriate initial site of care.

P4579Prediction of CABG indication in patients admitted for NSTEMI with the new CABG DAPE2S score

Introduction

A significant number of patients admitted for Non-ST Elevation Myocardial Infarction (NSTEMI) have multivessel complex coronary artery disease (CAD) and benefit from Coronary Artery Bypass Graft surgery (CABG). These patients frequently present high-risk surgical profiles, constituting a challenging group when it comes to balancing ischemic and haemorrhagic risk.

Objective

To develop a simple predictive risk model of referral to CABG in patients admitted for NSTEMI.

Methods

The authors present a retrospective, descriptive and correlational study including all patients admitted for NSTEMI in a Cardiology department between the 1st of October 2010 and the 1st of October 2018. Demographic profile, clinical characteristics, risk factors and hospitalization data of NSTEMI patients referred to CABG were studied, and a correlational analysis was performed with Chi-square test for categorical variables and t-Student test for continuous variables (confidence level of 95%). Independent predictors of CABG in patients with NSTEMI were identified through Binary logistic regression analysis, using a significance level of 0,05. A discriminatory function was subsequently applied, and the Wilks lambda test was used to determine the discriminant score for the studied groups. The authors used SPSS 24,0 for statistical analysis.

Results

A total of 2476 patients were included, 668 (27%) of which were female, with a mean age of 68,5±13,4 years. In the studied sample, 273 patients (11%) were proposed to CABG. The authors found a significant association between CABG and multiple clinical, laboratorial and therapeutical variables, but after multivariate analysis only male sex, previous Diabetes Mellitus, previous angina, previous Percutaneous coronary intervention, absence of a normal EKG, ST segment depression at admission, sinus rythm and brain natriuretic peptide (BNP) >100pg/mL proved to be independent predictors of referral. Using these variables, the authors developed a risk model to predict CABG referral in NSTEMI patients: −0,614 − (0,756 x female sex) + (0,305 x diabetes) + (0,631 x angina) − (1,513 x previous PCI) + (1,216 x sinus rythm) + (0,672 x ST depression) − (0,806 x normal EKG) + (0,562 x BNP>100). In this function, variables should be substituted by 1 or 0, depending on wheter the condition they specify is present or absent. The optimal discrimination cutoff was 0,23, with a 64% sensibility and 59% specificity, and a discriminant power of 60%.

Conclusion

Being able to predict referral to surgical revascularization in NSTEMI may help physicians to optimize a specific approach in each patient, in particular with regard to anti-thrombotic strategies. The authors developed a risk predicting model for CABG in NSTEMI patients based on simple clinical and laboratory variables, which will require validation in a larger cohort, before it can be applied in a clinical context.

3036Identifying low-risk patients eligible for early discharge after ST-segment elevation myocardial infarction

Introduction

Early discharge after ST-segment elevation myocardial infarction (STEMI) should be considered in low-risk patients after successful percutaneous coronary intervention (PCI) to reduce healthcare costs and improve resource utilization. The Zwolle criteria is recommended by current guidelines for the identification of low-risk patients but a new score, the FASTEST score, has recently demonstrated to add prognostic value over Zwolle score in small and unicentric studies.

Purpose

Assess if FASTEST score could better identify low-risk patients compared to Zwolle in a contemporary nationwide cohort of patients with STEMI who underwent primary PCI and complete revascularization.

Methods

Multicentric observational study of consecutive patients with ACS recorded in the Portuguese Registry of Acute Coronary Syndromes (ProACS) between October 2010 and January 2019. Patients who underwent primary PCI and received complete revascularization were included, and those with missing data for score calculation were excluded. The FASTEST score awards 1 point for each: femoral access, age>65, LVEF<50, TIMI<3; creatinine >1.5 mg/dl; stenosis of the left main coronary artery; and Killip≥2. The Zwolle score was calculated for comparison. The rate of hospital mortality and a composite of serious adverse events (heart failure, cardiogenic shock, re-infarction, mechanical complication, ventricular arrhythmia and major hemorrhage) was compared between low-risk patients as classified by FASTEST (score=0) or Zwolle (score≤3). One-year mortality and cardiovascular rehospitalization was compared between the two groups.

Results

We included 3322 patients (77.4% male, mean age 62±13 years, 49.5% with anterior STEMI). The FASTEST score identified 855 (25.8%) and Zwolle 2353 (70.7%) low-risk patients. Discrimination by AUC for hospital mortality was 0.92 (95% CI 0.91–0.93) for FASTEST score, significantly higher than Zwolle (0.83 (95% CI 0.82–0.84), p<0.001 for comparison) (Fig.1). Overall hospital mortality was 2.8%. 1 patient died in low-risk FASTEST compared to 24 (1%) in low-risk Zwolle (p=0.01). Low-risk Zwolle patients were more likely to suffer serious hospital adverse events compared with FASTEST score low-risk (19.5% vs 8.5%, p<0.001).

At one-year, 1384 patients had follow-up data. Mortality was significantly lower in low-risk FASTEST than Zwolle (1.5% vs 4.6%, p<0.001) and a tendency for less cardiovascular rehospitalization was also noted (5.4% vs 7.5%, p=0.08).

Figure 1. ROC-AUC for hospital mortality

Conclusion

Approximately one in every four patients were classified as low-risk according to FASTEST score, in contrast with 70% for Zwolle score. Low-risk FASTEST score patients exhibited significantly less hospital mortality (1 patient), hospital serious adverse events and 1-year mortality compared with low-risk Zwolle patients. FASTEST score demonstrated better discriminatory capacity for hospital mortality than Zwolle score and its use for risk stratification should be preferred.

P4600Intraventricular conduction disturbance and ventricular paced rhythms in patients with acute coronary syndromes

Introduction

Left or right bundle branch block (LBBB or RBBB) and ventricular paced rhythms (PM) difficult the diagnosis and often delay adequate treatment in patients with acute coronary syndromes (ACS). In the past few years, guidelines have placed a greater emphasis on the need for considering urgent revascularization in these patients.

Purpose

Evaluate initial revascularization strategy and short-term prognostic impact of LBBB, RBBB and PM in patients with ACS.

Methods

Multicentric observational study of consecutive patients with ACS recorded in the Portuguese Registry of Acute Coronary Syndromes (ProACS) between October 2010 and January 2019. Patients were categorized according to the ECG at admission: LBBB, RBBB, PM and normal QRS morphology. Patients with missing data on the ECG or the primary outcome were excluded. Demographic, clinical data and in-hospital outcomes were analyzed. The association between LBBB, RBBB, PM and in-hospital adverse outcomes was assessed using a logistic regression model. The primary and secondary outcomes were in-hospital mortality and a composite of in-hospital adverse events (heart failure, re-infarction or cardiac arrest), respectively.

Results

Of the original cohort, 18314 (94.3%) patients were included (mean age 66±13 years, 73.2% male): 243 (1.3%) had PM, 846 (4.6%) had LBBB, 1195 (6.5%) had RBBB and 16030 (87.5%) had normal QRS. Patients with abnormal QRS were significantly older, had more comorbidities, were less frequently diagnosed as ST-elevation MI (LBBB 18%; RBBB 35.1%; PM 7.8%; Normal 44.2%, p<0.001) and considered for urgent reperfusion (LBBB 13%; RBBB 33.6%; PM 5.8%; Normal 41.6%, p<0.001). Among patients who underwent non-urgent coronary angiography, the finding of an occluded culprit coronary artery was not higher compared to patients with normal QRS (Normal 15.2% vs LBBB 14.3%; RBBB 17.4%; PM 11.4%, p>0.05 for difference).

Overall in-hospital mortality was 3.4% (LBBB 6.6%; RBBB 8.1%; PM 5.3%; Normal 3.4%; p<0.001) and the composite endpoint of in-hospital adverse events was 17.4% (LBBB 35.6%; RBBB 27.3%; PM 23.5%; Normal 15.6%, p<0.001). After adjusting for cofounding variables, and using normal QRS as reference, only RBBB was shown to be significantly associated with increased in-hospital mortality (OR 1.94; 95% CI 1.43–2.66), p<0.001); and both RBBB (OR 1.75; 95% CI 1.5–2, p<0.001) and LBBB (OR 1.8; 95% CI 1.4–2.3, p<0.001), but not PM, were significantly associated with the composite endpoint of heart failure, re-infarction or cardiac arrest.

Conclusion

Compared to patients with normal QRS, those with LBBB, RBBB or PM less often undergo urgent revascularization and have higher rates of in-hospital adverse outcomes. In multivariate analysis, RBBB patients are almost two times more likely to die compared to those with normal QRS. LBBB and RBBB were independently associated with increased rates of in-hospital adverse events. PM was not associated with worse in-hospital outcomes.

Zika virus infections imported from Brazil to Portugal, 2015

Zika virus is an emerging arbovirus transmitted by Aedes sp. mosquitoes like the Dengue and Chikungunya viruses. Zika virus was until recently considered a mild pathogenic mosquito-borne flavivirus with very few reported benign human infections. In 2007, an epidemic in Micronesia initiated the turnover in the epidemiological history of Zika virus and more recently, the potential association with congenital microcephaly cases in Brazil 2015, still under investigation, led the World Health Organization (WHO) to declare a Public Health Emergency of International Concern on February 1, 2016.

Here, we present the clinical and laboratory aspects related to the first four imported human cases of Zika virus in Portugal from Brazil, and alert, regarding the high level of traveling between Portugal and Brazil, and the ongoing expansion of this virus in the Americas, for the threat for Zika virus introduction in Europe and the possible introduction to Madeira Island where Aedes aegypti is present.

Pulp tissue response to Portland cement associated with different radio pacifying agents on pulpotomy of human primary molars

The objective of this research was to evaluate the response of Portland cement associated with different radio pacifying agents on pulp treatment of human primary teeth by clinical and radiographic exams and microscopic analysis. Thirty mandibular primary molars were randomly divided into the following groups: Group I - Portland cement; Group II - Portland cement with iodoform (Portland cement + CHI3 ); Group III - Portland cement with zirconium oxide (Portland cement + ZrO2 ); and treated by pulpotomy technique (removal of a portion of the pulp aiming to maintain the vitally of the remaining radicular pulp tissue using a therapeutic dressing). Clinical and radiographic evaluations were recorded at 6, 12 and 24 months follow-up. The teeth at the regular exfoliation period were extracted and processed for histological analysis. Data were tested using statistical analysis with a significance level of 5%. The microscopic findings were descriptively analysed. All treated teeth were clinically and radiographically successful at follow-up appointments. The microscopic analysis revealed positive response to pulp repair with hard tissue barrier formation and pulp calcification in the remaining roots of all available teeth. The findings of this study suggest that primary teeth pulp tissue exhibited satisfactory biological response to Portland cement associated with radio pacifying agents. However, further studies with long-term follow-up are needed to determine the safe clinical indication of this alternative material for pulp therapy of primary teeth.

Establishment of a coastal fish in the Azores: recent colonisation or sudden expansion of an ancient relict population?

The processes and timescales associated with ocean-wide changes in the distribution of marine species have intrigued biologists since Darwin's earliest insights into biogeography. The Azores, a mid-Atlantic volcanic archipelago located >1000 km off the European continental shelf, offers ideal opportunities to investigate phylogeographic colonisation scenarios. The benthopelagic sparid fish known as the common two-banded seabream (Diplodus vulgaris) is now relatively common along the coastline of the Azores archipelago, but was virtually absent before the 1990s. We employed a multiple genetic marker approach to test whether the successful establishment of the Azorean population derives from a recent colonisation from western continental/island populations or from the demographic explosion of an ancient relict population. Results from nuclear and mtDNA sequences show that all Atlantic and Mediterranean populations belong to the same phylogroup, though microsatellite data indicate significant genetic divergence between the Azorean sample and all other locations, as well as among Macaronesian, western Iberian and Mediterranean regions. The results from Approximate Bayesian Computation indicate that D. vulgaris has likely inhabited the Azores for ∼40 (95% confidence interval (CI): 5.5–83.6) to 52 (95% CI: 6.32–89.0) generations, corresponding to roughly 80–150 years, suggesting near-contemporary colonisation, followed by a more recent demographic expansion that could have been facilitated by changing climate conditions. Moreover, the lack of previous records of this species over the past century, together with the absence of lineage separation and the presence of relatively few private alleles, do not exclude the possibility of an even more recent colonisation event.

Dengue myocarditis in Singapore: two case reports

The authors report two cases of complicated dengue viral infection with acute myocarditis involving young male adults, of which one was fatal. The first case presented with typical signs of myocardial disease: chest pain and diaphoresis with myocardial depression in the electrocardiograph. The second case deteriorated rapidly and demised within the first day of admission. Histology of the heart muscles showed multiple small foci of myocyte necrosis surrounded by lymphocytes, in keeping with viral myocarditis. Both cases fulfilled the World Health Organization (WHO) diagnosis of probable dengue: the first case had positive dengue serology, both IgM and IgG at day six of illness, and the second case was polymerase chain reaction (PCR) positive for dengue and identified as serotype 2. Despite the severe outcome, both cases did not completely fulfil the criteria for dengue haemorrhagic fever (DHF). Although severe cardiac impairment is not commonly reported in dengue infection, it can be life threatening.

Compressed domain topographic classification for capsule endoscopy

In this paper we compare the classification accuracy of using compressed domain color (CDC) descriptors versus traditional full decoded images, for the purposes of topographic classification of wireless capsule endoscopy images. Results using a dataset of 26469 images, divided into stomach, small intestine and large intestine show a difference in classification accuracy below 1%. We also show that errors are mostly located near zone transitions (the pylorus and the ileocecal valve) and motivate the need for other visual descriptors (e.g. shape, motion) for addressing these specific areas. We conclude we can use the advantages of CDC in this type of classification with minor accuracy sacrifice.