Anxiety in MINOCA patients according to latest definitions

Background

Anxiety is a global public health problem affecting the lives of large numbers of patients (pts) and their families. Some studies suggest that pts with MINOCA (myocardial infarction with non-obstructive coronary arteries) have more anxiety levels than the rest of pts with myocardial infarction (MI). The aim of this study is to compare anxiety levels between pts with MINOCA and the rest of MI pts using a validated scale: The State Trait Anxiety Inventory (STAI).

Methods

An analytical and observational study was developed in a University Hospital. We analysed the clinical data of all consecutive MI pts admitted to our centre from July 2017 to December 2020. Inclusion criteria were determined by the 4th Universal Definition of Myocardial Infarction and the latest definitions of MINOCA according to the 2020 ESC Guidelines. A group of experts reviewed all MINOCA cases in order to exclude those who did not fulfil the selection standards and takotsubo syndrome and myocarditis pts were excluded.

STAI questionnaire was completed by each patient during admission. Data collected included “trait anxiety”, that refers to relatively stable individual differences in anxiety-proneness, whereas “state anxiety” is a temporary emotion due to a particular situation (hospitalization in this case). Total score in each subgroup ranges from 0 to 60 points, where a higher score correlates with major anxiety levels.

Follow up analysis included major adverse cardiovascular events (MACE: cardiovascular readmission, myocardial reinfarction, stroke and death from any cause). Survival analysis is based on Cox regression. Median follow-up was 25±23 months.

Results

From a total of 413 consecutive MI pts, 243 (58.8%) completed the questionnaire. Of them, 32 (13%) were MINOCA pts. There were no significant differences in trait anxiety between both groups (MINOCA mean value 21±14 points vs rest of MI 19±10 points, p=0.9), nor in state anxiety (20±14 vs 19±10 points, p=0.8). There were also no significant differences when data were analysed by percentiles: 37.5% of MINOCA pts were below P25 and 28% of the rest of MI were also in this percentile. At the other end of the scale, 31.3% of MINOCA pts were above P75, as well as 22.7% of the rest of MI pts (table 1). During follow up, punctuation in trait anxiety in MINOCA pts showed no differences in MACE (HR 1.01, CI 95% (0.9–1.07)), nor did punctuation in state anxiety (HR 1.01, CI 95% (0.9–1.06)). This was also observed in the rest of MI pts: trait anxiety HR 1.01, CI 95% (0.9–1.04) and state anxiety HR 0.9, CI 95% (0.9–1.01).

Conclusion

In this study, there were no significant differences in anxiety levels between MINOCA pts and the rest of MI pts. The lack of takotsubo pts in this study reflect real data from MINOCA according to the latest definitions. Subjective emotions could lead to mistaken findings, making it necessary to determine emotional disorders with validated and objective tools.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): European Society of Cardiology Table 1. Percentile values of STAI.

Insomnia incidence in myocardial infarction with and without obstructive coronary arteries

Background

Insomnia can either be a primary problem or it may be associated with other psychological conditions, ranging from anxiety to depression. Some studies have reported that pts with MINOCA (myocardial infarction with non-obstructive coronary arteries) have more emotional disorders than the rest of pts with myocardial infarction (MI). However, a relationship with insomnia has not been yet described.

The aim of this study is to compare insomnia levels between patients with MINOCA and the rest of MI patients using a validated scale: Insomnia Severity Index (ISI) (Figure 1).

Methods

We performed an analytical and observational study in which all consecutive MI pts from July 2017 to December 2020 were recruited. We used the latest definitions of MINOCA according to the 2020 ESC Guidelines. A group of experts reviewed all MINOCA cases in order to exclude those who did not fulfil criteria. Therefore, takotsubo syndrome and pts with myocarditis were excluded.

ISI questionnaire was completed by each patient during admission. Total score ranges from 0 to 28 points. Depending on the final score, pts could have no clinically significant insomnia (0–7 points), subthreshold insomnia (8–14 points), clinical insomnia of moderate severity (15–21 points) and severe clinical insomnia (22–28 points).

Follow up analysis included major adverse cardiovascular events (MACE: cardiovascular readmission, myocardial reinfarction, stroke and death from any cause). Survival analysis is based on Cox regression. Median follow-up was 25±23 months.

Results

From a total of 413 consecutive MI pts, 244 (59%) completed the questionnaire. Of them, 32 (13%) were MINOCA pts. There were no statistically significant differences in insomnia levels between both groups (Table 1). Even in absolute terms, both groups presented same mean levels: MINOCA mean value 7.6±6 points vs rest of MI 7.7±6 points, p=0.8. When separated by sex, women in the MI group had higher punctuation levels than men (24% of moderate clinical insomnia in women vs 8.9% of men, p=0.03). Punctuation in ISI questionnaire showed no significant differences in MACE in MINOCA pts (HR 0.9, CI 95% (0.7–1.2)), nor in the rest of MI pts (HR 0.9, CI 95% (0.9–1.03)).

Conclusions

Levels of insomnia were similar in MINOCA pts than in the rest of MI pts. Follow up showed no differences in MACE between both groups regarding insomnia according to ISI. Women had higher punctuation levels than men, with more clinical insomnia in a moderate grade. Subjective emotions could lead to mistaken findings, making it necessary to use ISI questionnaire or other objective validated scales to correctly study some disorders and their distribution in different populations.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Society of Cardiology Table 1. Insomnia severity indexFigure 1. ISI Questionnaire

[From a pathogen's genome to an effective vaccine: the four-component meningococcal serogroup B vaccine]

Invasive meningococcal disease (IMD), caused by the bacterium Neisseria meningitidis, entails significant mortality and morbidity. Disease incidence is highest in infants <1 year and young children globally. In Europe, N. meningitidis serogroup B is responsible for over 50% of overall IMD cases, whereas the majority of IMD cases in Latin America is caused either by serogroup B or C. The development of an effective vaccine against serogroup B has challenged the researchers for over half a century. Serogroup B capsular polysaccharide was an inappropriate vaccine antigen, and the success of outer membrane vesicle (OMV) vaccines was restricted to homologous bacterial strains. Reverse vaccinology led to the development of a 4-component meningococcal vaccine including three novel antigens, and OMVs (4CMenB). Each vaccine component has a different target. 4CMenB has been authorised based on its immunogenicity and safety data because the low disease incidence precluded formal clinical efficacy studies. Human serum bactericidal antibody (hSBA) assay tests functional antibodies in the serum of vaccinated individuals (i.e. the vaccine immunogenicity), and is the accepted correlate of protection. Vaccine strain coverage has been assessed both through hSBA assays and a more conservative method named Meningococcal Antigen Typing System (MATS). Effectiveness data of 4CMenB have been collected in the field since 2013. The vaccine proved effective in outbreak control in North America, and recent data from the introduction of the vaccine in the United Kingdom infant national immunisation programme reveal a vaccine effectiveness of 82.9% for the first two doses, with an acceptable safety profile.

Usefulness of endoscopic ultrasonography (EUS) for selecting carcinoid tumors as candidates to endoscopic resection

INTRODUCTION

Carcinoid tumors (CTs) represent the most common type of neuroendocrine tumors (NETs). Digestive CTs in the gastroduodenal and colorectal tracts may be assessed using endoscopy and echoendoscopy or endoscopic ultrasonography (EUS) with the goal of attempting local resection with curative intent without having recourse to surgery.

OBJECTIVE

Endpoints in this study included:--Assessing the usefulness of EUS for selecting CTs as candidates to endoscopic excision. --Assessing the effectiveness of local resection (complete carcinoid resection) and the safety (complications) of the technique involved.

PATIENTS AND METHODS

OUr series included 18 patients (12 males and 6 females) with 23 tumors. Sixteen patients (10 males and 6 females) were selected, with age ranging from 40 to 81 years (mean: 57 years), biopsied, endoscopically treated digestive carcinoid tumors, and a previous negative extension study. Twenty-one 2-to-20-mm (mean size 8 mm) tumors were resected in 23 procedures. After endoscopy plus biopsy and echoendoscopy (EUS), excision was carried out with conventional polypectomy snare mucosectomy and submucosal injection with saline and/or adrenaline in most cases (15), and mucosectomy technique following lesion ligation with elastic bands for six cases. Two cases underwent transanal endoscopic surgery (TEM), one of them following non-curative polypectomy. A total of 23 local procedures were performed with the key goal of assessing efficacy (complete resection: CR) and safety (complications).

RESULTS

There were no severe complications except for the last gastric mucosectomy for a 6-mm carcinoid, where a miniperforation occurred that was solved by using 3 clips (1/23: 4.3%).EUS sensitivity was 94%. Complete resection was 90.5% (19/21).

CONCLUSIONS

The endoscopic mucosal resection of selected carcinoid tumors is a safe, effective technique. EUS is the technique of choice to select patients eligible for endoscopic resection (carcinoids smaller than 20 mm in superficial layers, with an unscathed muscularis propria and negative extension study).

[Improving the specification quality of inclusion criteria of patients in chemotherapy clinical trials]

OBJECTIVES

To assess the quality improvement of chemotherapy prescriptions for patients included in clinical trials (CT) analyzing whether the prescription is specified for patient participation, after having identified the major risks factors and the appropriate corrective measures are applied.

METHODS

Retrospective study of omissions collected during 2006 and 2007. After collecting all the information, we analyzed the risks factors and introduced improvement measures (information to prescribers and the beginning of electronic prescription). The 2007 data were then evaluated. Variables analyzed: CT, number of prescriptions, principal investigator, prescriber, department, anti-neoplastic involved and pathology.

RESULTS

Oncology and Haematology make up 57.1% of hospital trials. In 2006, 1625 chemotherapy prescriptions were received and there were 151 incorrect prescriptions (9.3%), and in 2007, 1858 prescriptions with 65 (3.5%) incorrect. In 2006, there was a higher frequency of incorrect prescriptions in Haematology (34.1%) and (Oncology (8.6%)). In 2007 Hematology had just 1.8% of omissions and in Oncology it decreased to 3.6%. As regards the pathology, the error rate has virtually disappeared in multiple myeloma prescriptions (34.1 to 2.2%) and decreased in breast cancer (10.8 to 4.4%). The non-fulfillment rate is higher when the prescriber is not the principal investigator.

CONCLUSIONS

The overall frequency of prescriptions with errors decreased significantly from 9.3% to 3.5%, with an extraordinary reduction in Haematology (34.1% to 1.8%) related to the multiple myeloma trials. The corrective measures implemented have proved to be useful in CT.

[Interventionist endoscopic ultrasonography. A retrospective analysis of 60 procedures]

INTRODUCTION AND OBJECTIVE

interventionist endoscopic ultrasonography is increasingly used because of its growing indications. We present here our retrospective and initial experience (60 procedures) with endoscopic ultrasonography (EUS) both for diagnosis (EUS-FNA) and therapy (EUS-guided tumorectomy and mucosectomy).

PATIENTS AND METHOD

in a group with 27 cases including 10 submucosal tumors (SMTs), 2 adenopathies, and 15 potential pancreatic tumors (8 pancreatic cancers), a sectorial EUS-FNA at 7.5 MHz was performed for diagnosis prior to therapy (mainly surgical). A pancreatic pseudocyst was drained. In 21 cases with 27 SMTs (10 patients with 13 carcinoids) a tumorectomy was carried out using the standard loop or assisted polypectomy technique with submucosal injection, and in a few cases (two) using elastic band ligation following a radial EUS at 7.5, 12, or 20 MHz. In 6 cases of superficial gastroesophageal cancer or gastric dysplasia an endoscopic mucosal resection (classic EMR) was performed after EUS or MPs at 7.5 and 20 MHz. Fifty-five patients with 60 lesions, 29 femaes and 26 males with a mean age of 60 years (30-88 years) were retrospectively analyzed.

RESULTS

diagnostic precision (P), sensitivity (S), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) for EUS-FNA was 85, 83, 100, 100, and 43%, respectively, when comparing results with specimen histology. P was higher for adenopathies (100%) and pancreatic tumors (87%) than for SMTs (80%). No complications arose, except for one episode of upper gastrointestinal bleeding (UGIB) (3.7%) that was endoscopically and satisfactorily treated in a gastric SMT. In the group with 21 patients (10 carcinoids with 13 tumors) 27 SMTs were endoscopically treated by tumorectomy with no perforation and only 2 UGIBs (7.4%), one of them self-limited, recorded. Endoscopic resection was complete in 92% of cases. No complications occurred with classic EMR, and all patients are still alive with no evidence of relapse, either local or metastatic. In this group the rate of complete resections was 100%.

CONCLUSIONS

EUS-FNA is a safe technique with high diagnostic accuracy. EUS-guided tumorectomy and mucosectomy are also safe and effective techniques in the endoscopic management of these tumors.

EUS-guided mucosectomy for gastrointestinal cancer

INTRODUCTION

the only way of improving prognosis and survival in gastrointestinal cancer is early diagnosis, with intramucosal localization as confirmed by endoscopic ultrasonography (EUS) or 20-MHz miniprobes (MPs) (T1) being most appropriate. Endoscopic mucosal resection (EMR) has proven effective in the treatment of this sort of lesions.

PATIENTS AND METHOD

in a group (18 cases) with 15 cases of superficial gastrointestinal cancer and 3 cases of severe gastric dysplasia, 9 cases (3 esophageal, 4 gastric, 2 rectal) underwent a classic EMR following EUS or a 7.5- and 20-MHz miniprobe exploration.

RESULTS

ultrasonographic studies showed a T1 in all but one esophageal case (Tis), and in both gastric dysplasias, with no changed layer structure being demonstrated in the latter (T0). No complications arose with classic EMR, and all 9 patients are alive and free from local or metastatic recurrence, except for one esophageal case, which recurred distally to the esophageal lesion (metachronous).

CONCLUSIONS

echoendoscopically-assisted EMR is a safe, effective technique in the endoscopic management of superficial gastrointestinal (esophageal, gastric, colorectal) cancer. Recurrence most likely depends upon cancer multiplicity.

Sequencing of the porB gene: a step toward a true characterization of Neisseria meningitidis

Variations in class 2/3 (PorB) proteins form the basis for meningococcal serotyping. Antibodies against these proteins are bactericidal, making serotyping results useful not only for epidemiological surveillance of meningococcal disease but also for identifying potential vaccine components. A total of 20 to 60% of meningococcal B and C isolates from any given population are nontypeable (NT) using a panel of monoclonal antibodies. To analyze the mechanisms responsible for the nonserotypeability characteristic in Neisseria meningitidis, we (i) established the nucleotide sequences of porB gene in 146 meningococcal strains (95 not recognized by the serotyping panel), (ii) identified 18 new allelic variants of the porB gene, (iii) correlated allelic variants with serotypes, (iv) suggest the nontypeability characteristic in those 95 NT strains, and (v) reject the possibility of variation in the levels of PorB expression.

Endoscopic staging of low-grade gastric malt lymphoma

INTRODUCTION

Endoscopic ultrasonography (EUS) has already proven useful in the assessment of submucosal lesions, and the staging of gastrointestinal cancer, particularly gastric MALT-type lymphoma. The goal of this paper was EUS staging.

PATIENTS AND METHOD

24 patients (10 females, 14 males) with a median age of 56 years and possibly gastric MALT lymphoma (25 cases) were studied using videoendoscopy, biopsies, and echoendoscopy with 7.5- and 20-MHz radial EUS, and also with 12- and 20-MHz miniprobes (MPs). Nineteen patients were definitely evaluated (7 females, 12 males) as having 20 MALT-type lymphomas, as five patients were post-hoc disregarded when an invasive, high-grade gastric lymphoma (3c) or plasmocytoma (2c) was subsequently demonstrated. Of these 19 patients, all had T1 lesions except for two with T2 lesions; one patient had a gastroduodenal T1 lymphoma. Echographic findings with MPs were compared to EUS (gold standard) and histology both before and after eradication. Then, patients were followed up every 1-3-6 months using videoendoscopy and MPs.

RESULTS

Echoendoscopy correctly identified T stages in 90% of cases. MPs identified T stages in 88% of cases, and N stages in 33% of cases, with results being slightly inferior to those obtained with conventional EUS (91 vs. 45%); they were consequently used for follow-up. After eradication, all but two patients are in complete remission and have been followed every 1-3-6 months using MPs without echographic abnormalities, except for a patient who relapsed.

Our cumulative experience with transendoscopic miniprobes

INTRODUCTION

Transendoscopic miniprobes (TEMPs) have nowadays precise indications, but may become a diagnostic alternative to both radial and sectorial endoscopic ultrasonography (EUS) in the near future.

PATIENTS AND METHODS

From November 1996 to July 2004 we carried out 620 examinations using TEMPs (124 during the last 12 months in 2003, with currently a mean of 11 examinations/month). Twenty explorations were performed with radial, 12.5 MHz (20 mm penetration), 6.2 F (2 mm diameter), 950 mm or 2000 mm Microvasive Endosound probes. Twenty explorations were performed using a 12 MHz (29 mm mean penetration) or 20 MHz (18 mm penetration) Olympus UM-2R/3R, or with a 12 MHz UM-DP12-25R or 20 MHz UM-DP20-25 R DPR-fitted Olympus probe, 2.5 mm in diameter and 2050 mm in length. A 20 MHz, 2.2 mm, wire-guided G20-29R was used for intraductal studies. In all, 580 examinations were carried out with both radial and linear, 12 MHz (240 E) or 20 MHz (60 E) Fuji probes, 2.6 mm in diameter and 1900 mm in length; and with a 7.5 MHz, 2.6 mm radial balloon microprobe with the well-known "preload" system that we have been using during the 1999-2004 period (280 E). Here we used a 3.2 mm working channel, whereas a 2.8 mm working channel was used with the remaining TEMPs.

RESULTS

Twenty GI-tract examinations were performed with one Microvasive probe, which broke down when attempting its passage through the papilla. Currently we use a 20 MHz, 2.2 mm Olympus G20-29R guided microprobe for intraductal studies. We performed 100 gut examinations using one single Fuji TEMP (12 or 7.5 MHz). Organs explored included: esophagus and stomach, 60%; rectum and colon, 30%; other (duodenum, papilla, bile ducts), 10%.

INDICATIONS

cancer staging, 35%; submucosal lesions, 30%; other, 35% (including 20% of esophageal non-tumoral conditions).

COMPLICATIONS

aspiration, perforation, and mortality, 0%. Morbidity, 10%, at the expense of abdominal pain as induced by endoscopy itself. All strictures were successfully passed, except for one malignant stenosis in the rectum.

CONCLUSIONS

During a 93-month period (1996-2004) we performed 620 explorations with TEMPs, with a current average of 11 examinations/month. TEMP durability is around 100 gut explorations. The esophagus and stomach were examined in 60% of cases. Primary indications included gut cancer staging and submucosal lesions (65%). Perforation and mortality rates amounted to 0%.

Evaluation of an immunocapture-agglutination test (Brucellacapt) for serodiagnosis of human brucellosis

We evaluated the validity and the usefulness of a new test for the diagnosis of human brucellosis based on an immunocapture-agglutination technique. A total of 315 sera from 82 patients with a diagnosis of brucellosis, 157 sera from patients in whom brucellosis was suspected but not confirmed, and 412 sera from people living in rural areas with endemic brucellosis were studied. The seroagglutination test (SAT), Coombs anti-Brucella test, and Brucellacapt test were evaluated. All the initial sera from the 82 patients proved to be positive in Brucellacapt and Coombs tests, while only 75 (91.4%) were positive in the SAT. If a >/=1/160 diagnostic threshold titer was defined for the Brucellacapt test, Coombs test, and SAT, the sensitivities were 95.1, 91.5, and 65.8%, respectively. Taking the same diagnostic threshold titer for the 157 sera from the unconfirmed but suspected patients, the specificities of the Brucellacapt, Coombs, and SAT were 81.5, 96.2, and 100%, respectively; for the 412 control sera, the specificities were 99.0, 99.8, and 100%. The diagnostic efficiency (area below the receiver operating characteristic curve) of Brucellacapt was 0.987852 (95% confidence interval [CI], 0.95109 to 0.99286), very similar to the diagnostic efficiency of the Coombs test (0.97611; 95% CI, 0.94781 to 0.99146) and higher than that of SAT (0.91013; 95% CI, 0.86649 to 0.94317). The results of the Brucellacapt test were compared with those of the Coombs test (correlation coefficient, 0.956; P = 0.000) and SAT (correlation coefficient, 0.866; P = 0.000). The study shows very good correlation between the Brucellacapt and Coombs tests, with a high concordance between titers obtained in the two tests. Nevertheless, lower correlation and concordance were found between the Brucellacapt and Coombs tests when the results for titers of >/=1/160 were compared (0.692; P = 0.000). In acute brucellosis, the Brucellacapt and Coombs tests render positive titers of >/=1/160. When the titers are lower, they increase significantly in the following 30 days, despite the evolution of SAT titers. In contrast, Brucellacapt and Coombs titers are always high (>/=1/640) in brucellosis with long evolution, whether SAT titers are higher or lower than 1/160.

[Echo-endoscopy: the clinical implications after a period of more than 16 years of its existence]

Endosonography is an imaging diagnostic technique recently introduced in our country. It allows us to perform an ultrasound from within the digestive tube. Because of the transducer proximity to the gut wall and the high frequency of emission we are able to visualize with great resolution small lesions as well as differentiate the five layers of the gastric wall and examine structures close to the digestive lumen with a 7 to 8 cm penetration. This is a brief introduction to the basic pillars of endosonography and its main indications, well defined after sixteen years of clinical practice.

[The value of endoscopic ultrasonography in the study of submucosal tumors of the digestive tract]

Twenty-one consecutive patients with 24 possible submucosal lesions of the digestive tract were studied. Endoscopic ultrasonography (EUS) differentiated between 17 true positive submucosal tumors and 3 true negative extrinsic compressions. False positives were interpreted in 3 cases and in one patient no lesion was echoendoscopically observed (false negative). The sensitivity was 94%, the specificity 50% and the positive and negative predictive values were 82% and 75%, respectively. In conclusion, EUS may be the method of choice for the study of submucosal tumors since it allows visualization of the five layers of the wall of the digestive tract in which a tumor may originate, determination of its sonographic features, depth and exact size, in addition to the invasion of neighboring organs. Moreover, EUS may aid in collecting material for cytology and microscopy by fine needle aspiration puncture (FNAP) by EUS.