Exceptional performance of Fe@carbon-rich nanoparticles prepared via hydrothermal carbonization of oil mill wastes for H2S removal

Carbon-encapsulated iron oxide nanoparticles (CE-nFe) have been obtained from an industrial waste (oil mill wastewater-OMW, as a carbonaceous source), and using iron sulfate as metallic precursor. In an initial step, the hydrochar obtained has been thermally activated under an inert atmosphere at three different temperatures (600°C, 800°C and 1000°C). The thermal treatment promotes the development of core-shell nanoparticles, with an inner core of α-Fe/Fe3O4 surrounded by a well-defined graphite shell. Temperatures above 800°C are needed to promote the graphitization of the carbonaceous species, a process promoted by iron nanoparticles through the dissolution, diffusion and growth of the carbon nanostructures on the outer shell. Breakthrough column tests show that CE-nFe exhibit an exceptional performance for H2S removal with a breakthrough capacity larger than 0.5-0.6 g H2S/gcatalyst after 3 days experiment. Experimental results anticipate the crucial role of humidity and oxygen in the adsorption/catalytic performance. Compared to some commercial samples, these results constitute a three-fold increase in the catalytic performance under similar experimental conditions.

Adaptation of sea turtles to climate warming: Will phenological responses be sufficient to counteract changes in reproductive output?

Sea turtles are vulnerable to climate change since their reproductive output is influenced by incubating temperatures, with warmer temperatures causing lower hatching success and increased feminization of embryos. Their ability to cope with projected increases in ambient temperatures will depend on their capacity to adapt to shifts in climatic regimes. Here, we assessed the extent to which phenological shifts could mitigate impacts from increases in ambient temperatures (from 1.5 to 3°C in air temperatures and from 1.4 to 2.3°C in sea surface temperatures by 2100 at our sites) on four species of sea turtles, under a "middle of the road" scenario (SSP2-4.5). Sand temperatures at sea turtle nesting sites are projected to increase from 0.58 to 4.17°C by 2100 and expected shifts in nesting of 26-43 days earlier will not be sufficient to maintain current incubation temperatures at 7 (29%) of our sites, hatching success rates at 10 (42%) of our sites, with current trends in hatchling sex ratio being able to be maintained at half of the sites. We also calculated the phenological shifts that would be required (both backward for an earlier shift in nesting and forward for a later shift) to keep up with present-day incubation temperatures, hatching success rates, and sex ratios. The required shifts backward in nesting for incubation temperatures ranged from -20 to -191 days, whereas the required shifts forward ranged from +54 to +180 days. However, for half of the sites, no matter the shift the median incubation temperature will always be warmer than the 75th percentile of current ranges. Given that phenological shifts will not be able to ameliorate predicted changes in temperature, hatching success and sex ratio at most sites, turtles may need to use other adaptive responses and/or there is the need to enhance sea turtle resilience to climate warming.

Closure of refractory gastrocutaneous fistula with endoscopically guided percutaneous suturing with the use of miniature biopsy forceps

Video 1Closure of a refractory gastrocutaneous fistula with endoscopically guided percutaneous suturing with the use of miniature biopsy forceps.

NGSEP 4: Efficient and accurate identification of orthogroups and whole-genome alignment

Whole-genome alignment allows researchers to understand the genomic structure and variation among genomes. Approaches based on direct pairwise comparisons of DNA sequences require large computational capacities. As a consequence, pipelines combining tools for orthologous gene identification and synteny have been developed. In this manuscript, we present the latest functionalities implemented in NGSEP 4, to identify orthogroups and perform whole genome alignments. NGSEP implements functionalities for identification of clusters of homologus genes, synteny analysis and whole genome alignment. Our results showed that the NGSEP algorithm for orthogroups identification has competitive accuracy and efficiency in comparison to commonly used tools. The implementation also includes a visualization of the whole genome alignment based on synteny of the orthogroups that were identified, and a reconstruction of the pangenome based on frequencies of the orthogroups among the genomes. NGSEP 4 also includes a new graphical user interface based on the JavaFX technology. We expect that these new developments will be very useful for several studies in evolutionary biology and population genomics.

Characteristics and Outcomes of Cancer Patients With Venous Thromboembolic Events After Treatment With Immune Checkpoint Inhibitors

OBJECTIVE

This study aimed to describe the clinical characteristics and outcomes of patients with venous thromboembolism (VTE) after Immune checkpoint inhibitors (ICI), focusing on patients with gastrointestinal (GI) immune-related adverse events (irAE).

METHODS

In this retrospective, single-center study, we report the clinical outcomes of adult cancer patients who developed a VTE within 2 years of ICI initiation. Patients were excluded if alternate causes of VTE were present apart from malignancy and cancer therapy. The cohort was classified into those with GI-irAE, non-GI-irAE, and no irAE. A control group with ICI exposure without irAE and VTE was selected for comparative analysis.

RESULTS

Of all ICI-treated patients, 1891 (17.2%) were diagnosed with VTE. In all, 501 (4.6%) had no etiology for VTE aside from malignancy and cancer therapy. Of these, 137 patients were included and classified as: 44 GI-irAE, 42 non-GI-irAE, and 51 no irAE. Chemotherapy within 6 months of ICI therapy was associated with increased VTE risk. There was no difference in the clinical course between those exposed to chemotherapy versus ICI therapy alone, time from ICI initiation to VTE, and VTE type, recurrence, or related hospitalization. While there was no difference in VTE-related mortality, the GI-irAE group was associated with lower all-cause mortality and superior overall survival.

CONCLUSION

Combined ICI and chemotherapy use increased VTE risk. There is a similar disease course of VTE after ICI exposure, regardless of other irAEs. Co-existing GI-irAE with VTE is associated with superior overall survival. Prospective studies are needed to evaluate the relationship between ICI therapy and VTE and irAE impact on VTE outcomes.

A methodology for using Lambda phages as a proxy for pathogen transmission in hospitals

BACKGROUND

One major concern in hospitalized patients is acquiring infections from pathogens borne on surfaces, patients, and healthcare workers (HCWs). Fundamental to controlling healthcare-associated infections is identifying the sources of pathogens, monitoring the processes responsible for their transmission, and evaluating the efficacy of the procedures employed for restricting their transmission.

AIM

To present a method using the bacteriophage Lambda (λ) to achieve these ends.

METHODS

Defined densities of multiple genetically marked λ phages were inoculated at known hotspots for contamination on high-fidelity mannequins. HCWs then entered a pre-sanitized simulated hospital room and performed a series of patient care tasks on the mannequins. Sampling occurred on the scrubs and hands of the HCWs, as well as previously defined high-touch surfaces in hospital rooms. Following sampling, the rooms were decontaminated using procedures demonstrated to be effective. Following the conclusion of the simulation, the samples were tested for the presence, identity, and densities of these λ phages.

FINDINGS

The data generated enabled the determination of the sources and magnitude of contamination caused by the breakdown of established infection prevention practices by HCWs. This technique enabled the standardized tracking of multiple contaminants during a single episode of patient care. Unlike other biological surrogates, λ phages are susceptible to common hospital disinfectants, and allow for a more accurate evaluation of pathogen transmission.

CONCLUSION

Whereas our application of these methods focused on healthcare-associated infections and the role of HCW behaviours in their spread, these methods could be employed for identifying the sources and sites of microbial contamination in other settings.

203 TRANSITIONS TO LONG-TERM CARE: EXPERIENCE OF A COHORT OF COMMUNITY-DWELLING OLDER ADULTS RECEIVING INTEGRATED CARE

Background

Data from the Nursing Home support scheme 2018 (NHSS) shows the majority of applications to the NHSS come from acute hospitals (44%) followed by referrals from the community (38%). We examined this transition in a cohort of community dwelling older adults to assess how many transition from home to nursing home and, when admission to nursing home from hospital occurred, the indications for same.

Methods

Retrospective examination of Integrated Care Team (ICT) and Acute Hospital data from 2019 in respect of a cohort of older adults. Transitions in care to nursing home including residence at time of admission, last acute hospital presentation prior to nursing home admission and commencement of NHSS application recorded.

Results

319 patients referred to the integrated care service in 2019, average age 81 and 58% female, predominantly from outpatient clinics in the Medicine for the Older Person’s service. 47 patients had moved to nursing home; within this cohort 14 (29.7%) transitioned from home, 28 (59.6%) transitioning after acute hospital admission. Main reasons for presentation to hospital were: Intercurrent acute illness (n=11); Falls (n=6); progression of dementia (n=4). Fair Deal application commenced in community by ICT in 20 of the 47 (42.5%) patients including 8 of 28 patients (28.5%) admitted to hospital prior to moving to nursing home.

Conclusion

This preliminary evaluation highlights the importance of advance care planning in this population when acute hospital admissions can be difficult to predict. Involvement of the ICT can help this transition and lead to shorter hospital stays.

Evaluation of a multisensory algorithm to prevent acute decompensation of heart failure in patients implanted with a cardioverter defibrillator: rationale and design

Background

Heart failure (HF) is a chronic disease affecting 64 million people worldwide and places a severe burden on society because of its mortality, numerous re-hospitalizations and associated costs [1–4]. HeartLogic is an algorithm incorporating several biometric parameters which aims to predict HF episodes. It provides an index which can be monitored remotely, allowing preemptive treatment of congestion to prevent acute decompensation [5–7].

Objectives

We aim to provide real-world data on the impact of pre-emptive HF management, guided by the HeartLogic index on unscheduled HF hospitalizations in a substantial cohort of patients.

Methods

The HeartLogic French Study is an investigator-initiated, prospective, multi-centre, non-randomized study. All in all, 310 patients with a history of HF (left ventricular ejection fraction ≤40%; or at least one episode of clinical HF with elevated NT-proBNP ≥450 ng/L) and implanted with a cardioverter defibrillator enabling HeartLogic index calculation will be included across 10 French centers. The HeartLogic index will be monitored remotely on a weekly basis for 12 months and in case of HeartLogic index ≥16, the local investigator will contact the patient for assessment and adjust HF treatment as necessary. The primary endpoint is unscheduled hospitalization for HF. Secondary endpoints are all-cause mortality, cardiovascular death, HF-related death, and unscheduled hospitalizations for ventricular or atrial arrhythmia. Blood samples will be collected for biobanking, and quality of life will be assessed. A blind and independent committee will adjudicate the events.

Conclusions

The HeartLogic French Cohort Study will provide robust real-world data on HF hospitalization in a cohort of patients managed with the HeartLogic algorithm allowing preemptive treatment of congestion.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific

Ventricular fibrillation complicating acute myocardial infarction in women

Background

Very little data is available in women presenting with ventricular fibrillation in the setting of acute myocardial infarction.

Purpose

To investigate sex-discrepancies in the incidence, characteristics and outcomes of acute myocardial infarction complicated by ventricular fibrillation.

Methods

Data were analyzed from the FAST-MI registry, which prospectively included 14,406 patients with acute myocardial infarction (mean age 66±14 years, 72% male, mean left ventricular ejection fraction 52±12%, 59% with ST elevation myocardial infarction). All consecutive patients admitted to French cardiac intensive care units ≤48 hours from acute myocardial infarction onset during a 1-month period every five years during 1995 and 2015 were included. This analysis focused on ventricular fibrillation occurring during the initial in-hospital stay for acute myocardial infarction in women compared to men.

Results

A total of 359 patients developed ventricular fibrillation during acute myocardial infarction, including 81 women (2.0% of 4,091 women overall) and 278 men (2.7% of 10,315) (p=0.02). ST-elevation myocardial infarction (OR 2.29, 95% CI 1.75–2.99, p<0.001) was independently associated with occurrence of ventricular fibrillation, while female gender (OR 0.73, 95% CI 0.56–0.95, p=0.02), hypertension (OR 0.75, 95% CI 0.60–0.94, p=0.01) and prior MI (OR 0.69, 95% CI 0.50–0.96, p=0.03) were protective factors. Women were less likely to have percutaneous coronary intervention during hospitalization than men (48.1% vs. 69.1%, OR 0.48, 95% CI 0.29–0.80, p<0.001). One-year mortality was higher in women compared to men (23.1% vs. 7.0%, HR 5.5, 95% CI 1.7–17.2, p=0.001). However, after adjustment for age, type of myocardial infarction and percutaneous coronary intervention, female gender was no longer associated with a worse one-year mortality (adjusted HR 1.04, 95% CI 0.71–1.51, p=0.85).

Conclusion and relevance

Women have lower risk of developing ventricular fibrillation during acute myocardial infarction compared to men. However, they are less likely to receive early coronary interventions than men, possibly contributing to worse outcomes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): French Society of Cardiology

Temporal sequence of atrial fibrillation and chronic obstructive pulmonary disease diagnosis is associated with mortality risk

Background

Chronic obstructive pulmonary disease (COPD) is concomitantly present in 13% of atrial fibrillation (AF) patients and negatively impacts prognosis in AF patients (1). Nevertheless, the temporal sequence and time between diagnosis of each disease may vary between individuals (2).

Purpose

To describe whether the temporal sequence of diagnosis of AF and COPD is associated with mortality in patients with both AF and COPD diagnosed.

Methods

This nationwide study assessed all patients between 18 to 85 years diagnosed with both COPD and AF between 1999 and 2018 in Denmark. Follow up started at the time of the second diagnosis. Three groups were defined according to the temporal sequence of diagnosis: COPD diagnosed at least 1 year before AF (COPD-First), AF diagnosed at least 1 year before COPD (AF-First) and COPD and AF diagnosed within a one-year time frame (AF∼COPD).

Results

Among 62,806 patients analyzed (75.0 [69.0–79.7] years; 56.5% males; mean follow-up 2.2 years) 27,809 (44.3%) were in the COPD-First group, 19,556 (31.1%) in the AF-First group and 15,441 (24.5%) in the AF∼COPD group. While age was similar across groups, the sex distribution differed, with the lowest proportion of males (53.1%) in the COPD-First group and the highest (61.2%) proportion of males in the AF-First group. Moreover, cardiovascular risk factors and diseases were more frequent in the AF-First group and the lowest in the COPD-First group.

After 5 years of follow up, 31,494 (58.6%) died. Males died more frequently than females (59.4% vs. 57.4%). Mortality was higher in the COPD-First group (61.8% for COPD-First, 55.1% for AF-First and 57.2% for AF∼COPD, Figure 1) and the causes of death were different among the 3 groups (38.8%, 24.1%, 27.0% for pulmonary cause and 26.1%, 32.8% and 36.6% for cardiac cause in the COPD-First, AF first and AF∼COPD respectively).

In a multivariable Cox-regression model adjusted for age, sex, type 2 diabetes, history of acute myocardial infarction, cancer, chronic kidney disease, stroke, AF∼COPD group (HR 1.14, 95% CI 1.11–1.17; P<0.0001) and COPD-First group (HR 1.26, 95% CI 1.23–1.29; P<0.0001) had a higher risk of death as compared to the AF-First group. Using time between diagnoses in a restricted cubic spline and adjusting for potential cofounders a COPD diagnosis preceding an AF diagnosis was associated with a higher risk of death than an AF diagnosis preceding a COPD diagnosis (Figure 2).

Conclusion

In patients with AF and COPD, the temporal sequence of diagnosis impacts prognosis, independently of other comorbidities. A concomitant diagnosis of AF in patients with already previously diagnosed COPD is associated with the worst prognosis.

Funding Acknowledgement

Type of funding sources: None.

Balance shift of activin/inhibin cytokines as part of the atrial structural remodelling of patients with aortic stenosis in atrial fibrillation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto Salud Carlos III

Fondos Feder

INNVAL 18/20

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, particularly in aortic stenosis (AS) patients. AF increases the risk of embolic stroke, heart failure, and mortality. The pathophysiological substrate for persistent AF is atrial fibrosis. Key players of fibrosis homeostasis are cytokines of the transforming growth factor-β (TFG-β) superfamily. In particular, dysregulation towards upregulating profibrotic TGF-β signalling versus antifibrotic bone morphogenetic protein 7 (BMP7) may result in pathological atrial remodelling and AF development in AS patients. However, the role of activins/inhibins in the clinical pathogenesis and vulnerability to AF remains unknown. In contrast to activins, inhibins do not signal directly but function by antagonizing activin signalling.

Purpose

To assess the contribution of activin A [homodimer of inhibin βA (INHβA)] and inhibin A [heterodimer of INHβA and inhibin α (INHα)] to the arrhythmogenic atrial remodelling and AF in AS patients.

Methods

The study was performed with intraoperative biopsies of the right atrium (RA) obtained from AS patients with AF (n=23) or sinus rhythm (SR) (n=23), matched for sex, age and systolic function. The specificity of the findings was validated in AF patients (n=10) without AS. mRNA (qPCR) and protein (co-immunoprecipitation and western blot) were quantified in  RA. Stepwise multiple logistic regression analysis was used to identify predictors of AF, including as independent variables the transcript levels of TGF-β family members and remodelling-related elements.

Results

INHβA and INHα transcripts were downregulated in the RA of AF compared to SR patients (INHβA: 0.52±0.1 vs 0.99±0.1**; INHα: 0.16±0.03 vs 0.59±0.1***). The fraction of INHβA protein co-immunoprecipitated with an antibody to INHα showed lower levels in AF than in SR patients (0.83±0.03 vs 1.21±0.09*). On the other hand, in the fraction of unbound proteins, INHβA did not differ between SR and AF patients. These results suggest that the INHβA subunits coupled into the antagonistic dimer inhibin A were downregulated in the RA from AS patients with AF.

Logistic regression analysis shows that RA transcript levels of TGF-ß1 (B=1.34) and COL1A1 (B=0.39) constituted significant positive predictors of AF, whereas INHβA (B=-6.8) and BMP-7 (B=-0.92) were significant negative predictors. A ROC analysis confirmed the accuracy of the model and yielded an area under the curve of 0.93 (CI 95% 0.86 to 1, ***). In addition, the variables determined as significant to predict presence of AF in patients with AS, did not constitute significant predictors of AF in patients with no LV pressure overload.

Conclusion

Our results provide new insights into a change in the balance between activin and inhibin cytokines in the atrial tissue that may have a pathogenetic role in the appearance of atrial fibrillation in valvular AS patients.

Activation of bone morphogenetic protein type 1A receptors (BMPR1A) by THR184 halts the progression of the left ventricular remodelling under pressure overload

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by grants from Spain´s Ministerio de Economía y Competitividad [(PI18/00543, CIBERCV (CB16/11/00264), co-funded by Fondo Europeo de Desarrollo Regional (FEDER)]; Instituto de Investigación Sanitaria Marqués de Valdecilla, IDIVAL (INNVAL18/20; PREVAL18/03); Grants4Targets from BAYER AG (ID 2017-03-2088).

Background

Aortic valve stenosis (AS) confronts the left ventricle (LV) with a progressive pressure overload that leads to myocardial remodelling (hypertrophy and fibrosis) and ultimately to heart failure. BMP7, through BMPR1A-mediated pSMAD1/5/(8)9 signalling, protects the LV against maladaptive remodelling. Small BMP-based molecules for therapeutic applications are gaining momentum in different clinical fields. A synthetic peptide agonist of BMPR1A, THR184, has been reported to prevent and reverse experimental renal fibrotic processes.

Purpose

To assess the potential of THR184 to halt or reverse the LV pathological remodelling induced by pressure overload in mice and evaluate the mechanisms involved in cultured cells.

Methods and Results

Mice subjected to a 4-week transverse aortic constriction (TAC) period received daily i.p injections of THR184 (n=9) (5µg/g) or saline (n=10) during the 3rd and 4th weeks after TAC, when LV remodelling was already ongoing. LV morphology and function were assessed by echocardiography. LV samples were analysed by qPCR and Western blot. THR184 halted the LV morpho-functional deterioration developed four weeks after TAC as compared to the saline group: [LV mass: THR184, 3.74±0.27 mg vs saline, 4.44±0.71 mg*; long-axis systolic function (MAPSE): THR184, 0.60±0.04 mm vs saline, 0.49±0.06 mm*; LV filling pressures (E/e’): THR184, 36.92±5.41 vs saline, 58.41±19.34**]. Moreover, THR184 partially reverted LV dysfunction, both systolic (MAPSE: 4 wk, 0.60±0.04 mm vs 2 wk, 0.49±0.03 mm***) and diastolic (E/e’: 4 wk, 36.92±5.41 vs 2 wk, 46.87±10.04*). The myocardial overexpression of the remodelling-related genes induced by TAC was attenuated by THR184 compared to saline: [Collagen I (Col I): THR184, 6.77±1.72 vs saline, 14.61±1.94 ***); β myosin heavy chain (β-MHC): THR184, 3.08±1.52 vs saline, 5.67±1.14*]. The expression of pSMAD1/5/(8)9 was reduced in saline-treated TAC mice (TAC, 0.67±0.09 vs sham, 1.04±0.05*), while it was rescued in THR184-treated TAC mice (THR184, 1.11±0.14 vs saline, 0.67±0.09**). In cultured cells, THR184 reduced TGF-β1-mediated transcriptional activation of Col I in 3T3 fibroblasts (THR184, 2.40±0.45 vs TGF-β1, 4.34±0.55***) and β-MHC in H9C2 cardiomyocytes (THR184, 1.02±0.38 vs TGF-β1, 4.10±1.56*). The involvement of BMPR1A in the effects of THR184 was supported by the antagonism with LDN or DMH2.

Conclusion

THR184 activated BMPR1A signalling through pSMAD1/5/(8)9 to halt the maladaptive remodelling of the LV by counteracting TGF-β1-mediated pro-fibrotic and pro-hypertrophic actions. We provide a preclinical proof-of-concept on THR184, a BMP7-based BMPR1A agonist, to treat the deleterious consequences of LV pressure overload.

More than half of all sudden cardiac deaths occur in persons without a history of cardiovascular disease: A study of 54,028 deaths in Denmark

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Copenhagen University Hospital, Rigshospitalet

Background

Sudden cardiac death (SCD) is a major public health problem accounting for a large proportion of global mortality. Previous studies suggest that SCD often occurs in the general population in persons not previously diagnosed with cardiovascular disease. It is evidently challenging to identify high-risk persons in an overwhelmingly large population of mainly healthy individuals and studies are needed to further characterize these SCD cases.

Purpose

To estimate SCD burden in patients not previously diagnosed with cardiovascular disease and to characterize these SCD cases.

Methods

All deaths in Denmark (population of 5.5 million) in 2010 were manually reviewed case-by-case. Autopsy reports, death certificates, and information from nationwide health registries were systematically examined to identify all SCD in 2010. The Danish National Patient Register contains information on all in- and outpatient activities at Danish hospitals and emergency departments and was used to identify all SCD cases with a previous cardiovascular diagnosis.

Results

There were 54,028 deaths in Denmark in 2010, of which 6,867 (13%) were categorized as SCD. Overall incidence rate of SCD was 124 (95%-CI: 121-127) per 100,000 person-years. Of all SCD, 59% were not diagnosed with cardiovascular disease prior to death. SCD incidence in persons with and without a history of cardiovascular disease was 790 (95%-CI: 762-820) and 78 (95%-CI: 75-80) per 100,000 person-years, respectively. This corresponds to an incidence rate ratio of 10 (95%-CI: 10-11). SCD cases with no previously diagnosed cardiovascular diseases were younger (median age 75 vs. 80 years, p<0.001), more often female (45 vs. 42%, p=0.019), and on average had a lower household income (p=0.002) (Table 1). SCD cases not diagnosed with cardiovascular disease prior to death in general had fewer comorbidities, except for psychiatric diseases, which were more common in the undiagnosed group (Table 1).

Conclusion

In this large and nationwide study of all SCD in Denmark in 2010, more than half of all SCD occurred in persons without a history of cardiovascular disease. This suggests that SCD is often first manifestation of disease. We currently do not have accurate tools for SCD risk stratification in the general population and future research is needed to identify modifiable and easily measured risk factors of SCD in the general population.

Racial disparities in out-of-hospital cardiac arrest in Denmark

Introduction

American studies have pointed out racial disparities regarding sudden cardiac death occurrence and outcomes. Black individuals have higher sudden cardiac death rates and lower survival compared with white subjects (1). Although income and social status partly explain differences in outcomes (2), sudden cardiac death is 2-fold higher in black individuals after adjustment on these characteristics (3,4).

In Denmark, immigrants account for 9.1% of the population (5) but to date, no data exists regarding Out-of-Hospital Cardiac Arrest (OHCA) incidence.

Purpose

The main objective of this study was to compare the incidence of OHCA among native and immigrant individuals between 2001 and 2014 in Denmark.

Methods

This nationwide study included all patients identified from the Danish Cardiac Arrest Registry with OHCA of presumed cardiac cause between 18 and 80 years from 2001 to 2014 (6).

The primary outcome was OHCA occurrence defined as a clinical condition of cardiac arrest resulting in resuscitation efforts either by bystanders or by EMS personnel. The immigrant status was defined as native or immigrant according to the national database from Statistics Denmark. An immigrant was defined as a person born abroad whose both parents were either foreign citizens or born abroad.

The odds ratio of OHCA between immigrants and native Danes were adjusted according to age, sex, income, and education level.

Results

A total of 33,730 OHCA were recorded between 2001 and 2014. Among them, 1,684 occurred in immigrants and 32,046 in natives. Compared to natives, immigrant victims of OHCA were younger (62.0 [51.0, 71.0] vs. 66.0 [56.0, 74.0], p<0.001), and more often had a history of diabetes (20.5% vs. 14.0; p<0.001), myocardial infarction (11.9% vs. 8.7%; p<0.001) and chronic heart failure (17.0% vs. 14.7%; p<0.01). Female proportion was not statistically different between the two groups (30.2% vs. 31.3% of immigrants and natives respectively; p=0.32).

The incidence of OHCA was 61.0/100,000 person-years in natives and 35.0/100,000 person-years in immigrants (OR=0.57; 95% CI 0.54–0.60; p<0.001). Between 2001 and 2014, the OHCA incidence decreased from 71.4 [67.9–75.0] to 70.9 [68.2–73.6]/100 000 person-years in natives (p=0.99) and from 40.2 [30.8–51.5] to 36.5 [31.1–42.6] /100,000 person-years in immigrants (p=0.91) (Figure).

After logistic regression, compared to natives, the immigrant status was associated with 0.61-fold odds of OHCA when adjusting on age and sex (OR=0.61; 95% CI 0.59–0.65; p<0.001), and 0.65-fold odds of OHCA when adjusting on age, sex, income, and education level (OR=0.66; 95% CI 0.63–0.70; p<0.001).

Conclusion

This is the first study assessing the incidence of OHCA in immigrants versus natives in a European country. Despite higher cardiovascular burden, the incidence of OHCA was lower in immigrants even when adjusted on sex, age, income, and education reflecting a selection of individuals migrating to Denmark.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Fédération Française de Cardiologie

P14.81 Brain metastases of lung adenocarcinoma - Clinicopathological profile and outcomes of a single-centre

BACKGROUND

Brain metastases (BM) in patients with non-small cell lung cancer (NSCLC) are considered a major determinant of overall survival (OS). Historically, surgical resection (SR), stereotactic radiosurgery (SRS), or/and whole-brain radiation therapy (WBRT) followed by chemotherapy has been the treatment modalities for BM from lung adenocarcinoma. Recent insights into the biology of adenocarcinoma have led to a wealth of novel therapies, including tyrosine kinase inhibitors (TKIs). Here, we review the pattern of brain metastasis in lung adenocarcinoma patients and management strategies in our centre.

MATERIAL AND METHODS

We performed a single-centre retrospective analysis of patients with lung adenocarcinoma and BM between 2017–2020. Data were collected from electronic medical records, including clinical and histopathological features and outcomes. Survival curves were estimated with the Kaplan-Meier method and compared using the log-rank test.

RESULTS

We identified 29 patients, 65% male, median age 65 years (range 38–84); 55% ECOG PS 0–1; 59% smokers; 55% had extracranial metastases (ECM) and 66% were symptomatic, 24% were EGFR mutated, the frequency of ALK rearrangement was 14%, in 14% the molecular testing was not performed. We treated 59% with WBRT, 12% with SRS, 11% with SR+WBRT and 4% with SR+SRS; 14% were referred for palliative care. Clinical deterioration during local therapy was observed in 32% of the patients and, consequently, they haven’t undergone systemic treatment. After local treatment, 26% received chemotherapy (CT) and 28% received TKIs therapy. Median OS (mOS) was 11.3 months (95% CI 2.4–20.3) for the CT subgroup; mOS for the TKIs subgroup was not reached, but the 1-year survival rate was 67%.

CONCLUSION

BM confers a worse prognosis in lung adenocarcinoma patients. Currently, targeted systemic treatments in patients with driver mutations improve survival and have demonstrated efficacy in lung adenocarcinoma metastatic to the brain. Further research is needed to find better treatments for BM in NSCLC patients with no driver mutations.

The use of instant messaging in clinical data sharing: the EHRA SMS survey

Funding Acknowledgements

Type of funding sources: None.

Background

Nowadays, instant messaging (IM) provides fast and widespread communication. These platforms and apps enable the physicians to quickly share and send clinical data to their peers, to send information to their patients regarding their illnesses and to be reached for counselling and advise. Nevertheless, the use of IM has never been assessed in the cardiology community up until now.

Purpose

To assess the habits of cardiologists related to modern communication tools, their primary and secondary uses in clinical practice and the potential differences and preferences between different media in terms of ease of access, usefulness and trustworthiness.

Methods

An online survey was promoted by the EHRA e-Communication Committee and the EHRA Scientific Initiative Committee during the ESC Digital Health Week. All cardiologists were invited to participate via Twitter, LinkedIn, Facebook and other dedicated channels. The survey consisted of 22 questions and was made anonymous. The questions were made on an individual-basis and collected on SurveyMonkey.

Results

287 physicians from 33 countries responded to the survey. The mean age of the respondents was 43.4 ± 11.5 years, and 74.8% of them were male. 88.3% of all respondents routinely sends and 90.3% receives clinical data through IM. IM is used at least once a week (36.4%) or even once or more a day (40.4%) for sharing clinical data. WhatsApp is the most used IM app to share clinical data (79.4%). On a scale of 1 to 5, IM was second only to face-to-face contact (average 4.46) as the preferred method for sharing clinical data (average 3.69) and was considered better than phone calls (average 3.34) and e-mails (average 3.21). Twelve-lead ECGs (88.6%), medical history (61.4%) and echo loops (55.7%) are the data shared most often. Among potential pros of IM, the respondents listed being a fast way of communication (82.0%) and making it easy to contact colleagues (76.7%), while privacy issues regarding IM apps providers (62.7%) and other colleagues (45.6%) were commonly perceived as drawbacks. Only 57.4% of all respondents anonymize clinical data before sharing them through IM, and only 44.0% of the data received are reported to be anonymized. Of note, 29.3% of the respondents were not aware of the European General Data Protection Regulation (GDPR) on data protection at the time of the survey, and 29.8% do not know if their institution has a specific policy regarding the use of IM for professional use.

Conclusions

IM apps are used by cardiologists worldwide to share and discuss clinical data and are preferred to many other methods of data sharing, being second only to face-to-face contact. IM are often used and to share many different types of clinical data, being perceived as a fast and easy way of communication. Cardiologists should be sensitised to appropriate use of IM in accordance to GDPR and local policies in order to prevent legal and privacy issues.

Applications of a Novel Microangioscope for Neuroendovascular Intervention

BACKGROUND AND PURPOSE

Visualization in neuroendovascular intervention currently relies on biplanar fluoroscopy and contrast administration. With the advent of endoscopy, direct visualization of the intracranial intravascular space has become possible with microangioscopes. We analyzed the efficacy of our novel microangioscope to enable direct observation and inspection of the cerebrovasculature, complementary to a standard fluoroscopic technique.

MATERIALS AND METHODS

Iterations of microangioscopes were systematically evaluated for use in neurodiagnostics and neurointerventions in both live animal and human cadaveric models. Imaging quality, trackability, and navigability were assessed. Diagnostic procedures assessed included clot identification and differentiation, plaque identification, inspection for vessel wall injury, and assessment of stent apposition. Interventions performed included angioscope-assisted stent-retriever thrombectomy, clot aspiration, and coil embolization.

RESULTS

The microangioscope was found helpful in both diagnosis and interventions by independent evaluators. Mean ratings of the imaging quality on a 5-point scale ranged from 3.0 (clot identification) to 4.7 (Pipeline follow-up). Mean ratings for clinical utility ranged from 3.0 (aspiration thrombectomy) to 4.7 (aneurysm treatment by coil embolization and WEB device).

CONCLUSIONS

This fiber optic microangioscope can safely navigate and visualize the intravascular space in human cadaveric and in vivo animal models with satisfactory resolution. It has potential value in diagnostic and neurointerventional applications.

A Culturally Adapted SMS Text Messaging Intervention to Promote Antiretroviral Therapy Adherence Among African Americans: Protocol for a Single-Arm Trial

Background

African Americans are disproportionally affected by HIV and have poorer rates of antiretroviral therapy (ART) adherence compared to other racial or ethnic groups in the United States. Factors associated with poor HIV disease outcomes are commonly associated with sociostructural barriers that prevent engagement with and retention in HIV care. SMS text messaging interventions to promote ART adherence among predominantly non-Hispanic White persons with HIV (PWH) have been shown to be efficacious; however, limited research has been devoted to culturally tailoring interventions for underrepresented racial/ethnic groups. Considering African Americans show poorer engagement along the HIV care continuum, we developed an individualized and culturally tailored two-way SMS text messaging intervention to improve ART adherence and associated virologic suppression among African American PWH.

Objective

In this paper we describe the protocol of a culturally tailored individualized Texting for Adherence Building (iTAB) intervention in a 24- to 48-week, single-arm study.

Methods

We developed a culturally tailored iTAB intervention, which we are implementing in a 24- to 48-week, single-arm study. Participants were recruited from the Family Health Centers of San Diego (FHCSD), a federally qualified health center. Patient inclusion criteria were (1) receiving care at the FHCSD, (2) living with HIV, (3) self-identification as Black, African American, or of African ancestry, (4) English speaking, (5) age 18 or older, (6) currently on ART, and (7) able to provide informed consent. Study enrollment began in November 2017 and closed in July 2019. A total of 90 participants from the FHCSD enrolled in the iTAB intervention, and we anticipate completing data collection in July 2020. Participants were assisted in individualizing and customizing their SMS text message preferences at the baseline study visit. Self-assessment measures are collected at baseline, interim, and final study visits. Problems related to sending/receiving SMS text messages and barriers to ART adherence are assessed at each interim study visit. The FHCSD staff monitors and tracks participants’ daily SMS text message responses to ART adherence reminders using a clinical dashboard.

Results

We hypothesize that the proportion of individuals achieving HIV virologic suppression (viral load <40 copies/mL) will be greater at the end of the intervention period compared to the proportion prior to study implementation. Additionally, we anticipate that rates of virologic suppression at the end of the intervention among participants receiving iTAB will be comparable to those among the general FHCSD non-African American population who did not receive iTAB. Finally, we anticipate a high response rate to iTAB SMS text messages as well as positive participant feedback at the end of the intervention with regard to the acceptability of, satisfaction with, and perceived efficacy of iTAB.

Conclusions

The iTAB intervention is a novel individualized two-way SMS text messaging intervention that has been culturally tailored for use among African Americans with HIV. We anticipate that iTAB will demonstrate efficacy in future randomized control trials and will be supportive of medication adherence among other populations facing health disparities.

International Registered Report Identifier (IRRID)

DERR1-10.2196/21592

Randall-type monoclonal immunoglobulin deposition disease: description of cardiac involvement

Background

Randall-type monoclonal immunoglobulin disease (MIDD) is a rare complication of a monoclonal plasma cell clone. MIDD differs from AL amyloidosis by the presence of Congo red negative non-organized immunoglobulin (Ig) deposits, most commonly light chains (LCDD) along basement membranes and sometimes heavy chains (HCDD) or light and heavy chains (LHCDD). As AL amyloidosis MIDD is a multi-systemic disease, and affects the heart. To date no study has focused on the clinical characteristics of heart disease in MIDD.

Purpose

The aim of this study was to describe the cardiologic features of patients with biopsy-proven MIDD and suspected cardiac involvement.

Methods

This multi-center, nation-wide retrospective study extracted from the database of the French reference center for AL amyloidosis and other Ig deposition diseases between 2012 to 2019. Diagnosis of cardiac involvement was assessed according to the International Society of Amyloidosis criteria for amyloid heart disease, as follows: left ventricular hypertrophy with a diastolic septum thickness ≥12mm, NTproBNP serum level ≥332 ng / L, histological evidence on cardiac or extra cardiac biopsy of typical linear non-organized Ig deposits along basement membranes. Severity was defined according to the Mayo Clinic classification for AL amyloidosis.

Results

Among 20 patients included (mean age was 70±9 years), 11 (55%) were males; 13 (65%) were LCDD, 3 (15%) HCDD and 4 (20%) LHCDD. At diagnosis, 19 (95%) had a history of hypertension, 3 (16%) had atrial fibrillation, 3 (15%) had NYHA grade 3 or 4 dyspnea. Mayo Clinic score was stage 3a in 4 patients (20%) and stage 3b in 6 patients (30%). The most frequent ECG changes were microvoltage (40%) and pseudo Q wave (40%); 64% of patients had altered sinus variability on 24-hour Holter monitoring, one patient had a high-grade conduction disorder and another had ventricular tachycardia. On echocardiography, all showed diastolic dysfunction; mean diastolic septum thickness was 13.5mm; only one patient had LVEF impairment but 38% had global longitudinal strain impairment. 10 patients had cardiac MRI, none showed contrast enhancement after gadolinium injection.

After median follow-up of 28 months, 4 patients were hospitalized for heart failure, including 2 with cardiogenic shock. Seven (35%) patients died within a median of 10 months from diagnosis. Among patients with Mayo clinic stage 3 (a or b), 67% died within a median of 8 months from the diagnosis.

Conclusions

To our knowledge, we present the first case series dedicated to the description of cardiac parameters in MIDD patients with cardiac involvement. Except for MRI appearance of cardiac infiltration, these patients showed features close to that of AL amyloid heart disease. Overall prognosis appears seemingly poor in MIDD patients with Mayo Clinic stage 3 cardiac disease.

Funding Acknowledgement

Type of funding source: None

Severe sleep apnea is associated with atrial fibrillation burden in pacemaker recipients

Background

New generation pacemaker allow the assessment day by day of sleep disordered breathing (SDB) based on impedance measurement. A recent study demonstrated that incidence of AF is higher in case of severe SA monitored by pacemaker

Purpose

The aim was to compare the atrial fibrillation (AF) burden between patients with severe and non-severe sleep apnea (SA) detected with pacemakers monitoring (SDB).

Methods

This retrospective study was carried out at our University Hospital. We included all patients with Microport CRM pacemaker implanted from 2013 to 2016 at our university hospital. Exclusion criteria were inactivation of sleep apnea monitoring (SAM), history of sleep apnea, missing data or invalid data. AF burden was assessed according to Fallback mode switch (FMS) duration. Respiratory disturbance index (RDI) was calculated as the average number of events (ventilation pause and reductions) per number of hours of monitoring. Patients with RDI&lt;20/h were compared with patients with RDI≥20/h (considered as severe SA group).

Results

404 patients (mean age = 79.7±10 years; 52.0% men) were included. The most prevalent indication for cardiac pacing was atrioventricular block in 57%. Mean RDI was 18.9 events per hour. 234 (58%) of them had a mean RDI &lt;20 and 170 (42%) had a mean RDI ≥20. Compared to patients with mean RDI&lt;20, those with mean RDI ≥20 were youngers (78.6±10 years Vs 81.8±8 years; p=0.02), were more likely to be male (58.2% Vs 47.5%: p=0.035) and had more heart failure history (28.8% Vs 19.2%: p=0.03). BMI was not different between groups (26.3±5. vs 26.3±4; P=0.33). Mean follow-up was 27 months. Patients with RDI ≥20 had a mean Atrial fibrillation duration longer than patients with RDI &lt;20 (631 min Vs 291 min respectively; p=0.014). RDI was correlated with FMS (r=0.26; p=0.0004). The stroke rate tended to be higher in the RDI ≥20 group (2.1% vs 5.4%) (p=0.12).

Conclusion

Severe SA detected by pacemaker was associated with longer AF duration. We did not find higher occurrence of stroke in the severe SA group.

Funding Acknowledgement

Type of funding source: None

Efficacy of deep sedation for patients with intractable electrical storm refractory to anti-arrhythmic drugs

Background

Sympathetic overactivity is implicated in the initiation and maintenance of electrical storm (ES). Deep sedation has empirically been considered as an efficient therapeutic option to blunt sympathetic tone and control ES.

Purpose

The aim of this multicenter study was to determine the efficacy of deep sedation in patients presenting intractable ES refractory to anti-arrhythmic drugs.

Methods

Patients requiring deep sedation for refractory ES from January 1st 2007 to July 31st 2018 were retrospectively included in 13 centers. The primary endpoint was the rate of acute response to sedation, defined as ES termination within 15 minutes after deep sedation.

Results

Among the 116 patients, 55 (47.4%) had ES termination within 15 minutes and were considered “acute responders” to deep sedation. Clinical signs of congestive heart failure before deep sedation (OR=3.31, 95% CI:1.001–10.97, p=0.049) was the only independent predictor of non-acute response. Twenty-one non-acute responders (34.4%) had an extracorporeal membrane oxygenation (ECMO) implanted. Non-acute responders had a significantly lower in-hospital survival (Log-rank, p=0.010). ECMO implantation did not influence survival in non-acute responders to sedation. Acute response to deep sedation was an independent protector of in-hospital mortality, decreasing by 73% the risk of death (OR 0.27; 95% CI:0.10–0.70, p=0.008).

Conclusion

To the best of our knowledge, this multicenter study is the first analysis of the efficacy of deep sedation in patients with intractable ES refractory to anti-arrhythmic drugs, and demonstrating the positive impact of “acute response” on in-hospital survival.

Funding Acknowledgement

Type of funding source: None

Pacemakers capable of monitoring sleep-disordered breathing: impact on sleep apnea detection in real life

Background

Pacemaker recipients are at high-risk of sleep apnea (SA). New generation of pacemakers allow day by day, sleep-disordered breathing (SDB) monitoring. These devices measure variations in thoracic impedance and can detect apnea and hypopnea.

Purpose

The aim was To compare the rate of SA detection in patients implanted with and without pacemaker capable of monitoring (SDB).

Methods

This retrospective study included all consecutive patients implanted with a pacemaker between 2013 and 2016 at Poitiers university hospital. Pacemaker recipients allowing SDB monitoring (SDB monitoring group) and pacemaker recipients not allowing SDB monitoring (control group) were compared in terms of SA diagnosis, continuous positive airway pressure (CPAP) therapy initiation, newly AF discovered and stroke occurrence.

Results

Among the 1442 patients included (mean age 79 years, 39% of women, BMI = 27 kg/m2). 653 were in the SDB monitoring group and 789 in the control group. The 2 groups were not different in terms of age, body mass index, cardiovascular risk factor, cardiac function, and medication. Indication for cardiac pacing was atrioventricular block and sinus dysfunction in 56% and 23% of patients respectively. Mean follow-up was 24.7 months. 40 patients (7.5%) have been diagnosed with SA in the SDB monitoring group and 18 (2.7%) in the control group (p&lt;0.001). CPAP therapy was initiated in 33 (5%) patients in SDB monitoring group and in 16 (2%) patients for the control group (p=0.01). The rate of newly diagnosed AF was 15% in SDB monitoring and 7% in control group (p&lt;0.001). The incidence of stroke was 16 (2.4%) in the SDB monitoring group and 18 (3.4%) in the control group (P=0.45).

Conclusion

In real life conditions, pacemakers capable of monitoring SDB improve the diagnosis of SA and CPAP therapy rate.

Monitoring of sleep apnea after at least

Funding Acknowledgement

Type of funding source: None

PET and MRI guided adaptive radiotherapy: Rational, feasibility and benefit

Adaptive radiotherapy (ART) corresponds to various replanning strategies aiming to correct for anatomical variations occurring during the course of radiotherapy. The goal of the article was to report the rational, feasibility and benefit of using PET and/or MRI to guide this ART strategy in various tumor localizations. The anatomical modifications defined by scanner taking into account tumour mobility and volume variation are not always sufficient to optimise treatment. The contribution of functional imaging by PET or the precision of soft tissue by MRI makes it possible to consider optimized ART. Today, the most important data for both PET and MRI are for lung, head and neck, cervical and prostate cancers. PET and MRI guided ART appears feasible and safe, however in a very limited clinical experience. Phase I/II studies should be therefore performed, before proposing cost-effectiveness comparisons in randomized trials and before using the approach in routine practice.

Quantitative phase-mode electrostatic force microscopy on silicon oxide nanostructures

Phase-mode electrostatic force microscopy (EFM-Phase) is a viable technique to image surface electrostatic potential of silicon oxide stripes fabricated by oxidation scanning probe lithography, exhibiting an inhomogeneous distribution of localized charges trapped within the stripes during the electrochemical reaction. We show here that these nanopatterns are useful benchmark samples for assessing the spatial/voltage resolution of EFM-phase. To quantitatively extract the relevant observables, we developed and applied an analytical model of the electrostatic interactions in which the tip and the surface are modelled in a prolate spheroidal coordinates system, fitting accurately experimental data. A lateral resolution of ∼60 nm, which is comparable to the lateral resolution of EFM experiments reported in the literature, and a charge resolution of ∼20 electrons are achieved. This electrostatic analysis evidences the presence of a bimodal population of trapped charges in the nanopatterned stripes.

Tailoring a mobile health text-messaging intervention to promote antiretroviral therapy adherence among African Americans: A qualitative study

African Americans are disproportionately affected by HIV and socio-structural barriers that impact antiretroviral (ART) adherence. Two-way text-messaging interventions have shown promise in supporting adherence in US studies of mostly White people living with HIV (PLWH). However, culturally-appropriate tailoring is necessary to maximize intervention effectiveness among other racial/ethnic groups. Thus, to refine an existing text-messaging intervention, we examined barriers and facilitators to ART adherence among African Americans and perspectives on features to integrate into the extant intervention. Three focus groups, two with African American PLWH (n = 5 and n = 7) and one with providers of care (n = 11) were conducted; transcripts of audio-recordings were thematically analyzed. Adherence supports operated at individual, interpersonal, and structural/environmental levels (e.g., using reminders and pill organizers, wanting to protect partners from HIV, and positive interactions with providers). Adherence barriers also operated at multiple ecological levels (e.g., poor mental health, fear of disclosure of HIV status, and unstable housing). Participant-suggested features for refinement included: i) matching content to participants’ comfort with receiving messages referencing HIV or medication-taking, ii) culturally-tailoring content for African Americans, iii) tracking adherence, and iv) encouraging adherence interactions between patients and providers. Feedback from both patients and providers is foundational to designing effective ART interventions among African American PLWH.

P1449Anti-thrombotic management for electrophysiological procedures: results of the European Heart Rhythm Association (EHRA) young investigators survey

Funding Acknowledgements

none

Background

Electrophysiological studies (EPS), with or without ablation, require percutaneous introduction of catheters into the heart to record local electrical activity. Instrumentation of catheters within the blood causes activation of the clotting cascade, increasing the risk of thrombus formation. To date, the electrophysiological community lacks international guidelines on the use of anti-thrombotic therapies before, during and after EPS.

Purpose

To survey the current practice regarding the use of anti-thrombotic therapies across member countries of the European Heart Rhythm Association (EHRA).

Methods

The survey was conducted in February 2019. Electrophysiologists from EHRA member countries were contacted to complete the survey by e-mail, utilizing the EHRA Young EP network. They were asked to answer a questionnaire containing information on anti-thrombotic and anticoagulation management before, during and after left-sided EPS and ablation: atrial tachycardia (AT), accessory pathway (AP) and ventricular tachycardia (VT).

Results

We obtained 41 answers responses from 40 centers in 15 European EHRA member countries. Regarding of antiaggregation, the most used antiplatelet is aspirin (100% before, during and after ablation). The most used anticoagulant was novel oral anticoagulants (NOAC) before ablation (47.1%), during hospitalization (85.2%) and at discharge (70.3%). The administration of anti-thrombotic therapy depended on the procedure time only in 10 cases (24.4%).

For AP, before ablation, only 4 centers (9.7%) administered anti-platelets and 2 (4.9%) anticoagulants. During ablation, heparin was used by 85.4% of respondents maintaining ACT target 300-350 s in 36.6% of cases. At discharge, antiaggregation therapy was prescribed by 22 colleagues (53.7%) and anticoagulation only by one (2.4%).

In patients with AT, before ablation, antiaggregation prophylaxis was prescribed by only 4 centers (19.5%) and anticoagulation by 11 (26.8%). During procedure, almost all centers (40, 97.6%) used heparin with ACT target 300-350 s in 58.5% of cases. At discharge, antiplatelet therapy was recommended by 12 colleagues (29.3%) and anticoagulation by 24 (58.5%).

Regarding VT, before procedure, 8 centers (19.5%) prescribed antiaggregation and 5 (12.2%) anticoagulation prophylaxis. During ablation, all centers used heparin, maintaining ACT target 300-350 s in 58% of cases. The use of antiaggregation or anticoagulation depended on the left ventricle (LV) access in 15 centers (37.5%) and on LV ejection fraction in 11 (26.8%). At discharge, anti-thrombotic therapy was recommended by 16 colleagues (39%) and anticoagulation by 13 (31.7%).

Conclusion

Our survey showed that there is considerable variation in the management of anti-thrombotic therapy surrounding left-sided EPS and ablation. Further studies are necessary to evaluate the right approach to these procedures.

THU0053 CONTRIBUTION OF DEFECTIVE NON-APOPTOTIC FAS SIGNALING TO IMMUNE DYSREGULATION IN AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME (ALPS)

Background:

ALPS patients show impaired generation of humoral memory for T independent antigens whereas they generate memory for self-antigens due to impaired FAS-dependent removal of autoreactive germinal center B cells. It is known that FAS signaling via caspase activation results in cell apoptosis. However, FAS ligation may also initiate or modulate non-apoptotic signaling as shown for example by its ability to activate NF-κB. Recent data implicate a regulatory role of FAS in the modulation of mTOR signaling in ALPS double-negative T cells. Moreover, a recently described C194V FAS mutation disturbs its post-translational modification leading to impaired apoptosis induction while non-apoptotic signalling is still intact. Consequently, C194V FAS protects from the autoimmune phenotype in the murine ALPS system. This supports the view that FAS may prevent autoimmunity with other mechanisms than inducing apoptosis.

Objectives:

We hypothesize that FAS mutations impair this modulatory signaling, leading to hyper-activation of B cells. Therefore we aim to investigate non apoptotic FAS signaling in B cells derived from healthy individuals and ALPS patients.

Methods:

We studied resting and activated B cells in ALPS patients in presence or absence of FAS ligand by flow cytometry analysing relevant molecules to the CD40 signaling pathway. We used mass cytometry to perform functional phenotyping of B cells isolated from secondary lymphoid organs. Proteomic studies were performed to identify potential signaling circuits and RNA sequencing to study the consequences of FAS signaling on B cell fate.

Results:

In CD40L activated B cells, FAS signaling results in specific modulation of the mTOR signaling pathway. This modulation is absent in ALPS derived B cells. In line with these data germinal center B cells and plasmablast from secondary lymphoid organs of ALPS patients show hyperactive mTOR signaling pathway. Proteomic studies identify a circuit that links FAS to the phosphatase PTEN via DAXX and the deubiquitinase USP7.

Conclusion:

We describe a new role of FAS in the regulation of B cell activation. Defects in FAS signaling in ALPS contribute to dysregulation of the mTOR signaling pathway and disturbed B cell development.

Disclosure of Interests:

None declared

Technical Note: Flattening filter free beam from Halcyon linac: Evaluation of the profile parameters for quality assurance

INTRODUCTION

The use of flattening filter free (FFF) beams generated by standard linear accelerators is increasing in the clinical practice. The radiation intensity peaked toward the beam central axis is properly managed in the optimization process of treatment planning through intensity modulation. Specific FFF parameters for profile analysis, as unflatness and slope for FFF beams, based on the renormalization factor concept has been introduced for quality assurance purposes. Recently, Halcyon, an O-ring based linear accelerator equipped with a 6 MV FFF beam only has been introduced by Varian.

METHODS

Renormalization factors and related fit parameters according to Fogliata et al. ["Definition of parameters for quality assurance of FFF photon beams in radiation therapy," Med. Phys. 39, 6455-6464 (2012)] have been evaluated for the 6 MV FFF beam generated by Halcyon units. The Halcyon representative beam data provided by Varian were used. Dose fall-off at the field edges was matched with an unflattened beam generated by a 6 MV from a TrueBeam linac. Consistency of the results was evaluated against measurements on a clinical Halcyon unit, as well as a TrueBeam 6 MV FFF for comparison.

RESULTS

The five parameters in the analytical equation for estimating the renormalization factor were determined with an R² of 0.997. The comparison of the unflatness parameters between the Halcyon representative and hospital beam data was consistent within a range of 0.6%. Consistently with the computed parameters, the Halcyon profiles resulted in a less pronounced peak than TrueBeam.

CONCLUSION

Renormalization factors and related fit parameters from the 6 MV FFF beam generated by the Varian Halcyon unit are provided.

Trust in Physicians and Regional Brain Volumes: A Population-Based Study

Objective

Trust, a fundamental part of human interpersonal relationships, is known to be associated with specific brain regions and demographic characteristics. Level of trust in medical professionals can alter population health outcomes and influence the nature of the doctor-patient relationship. This study utilized structural magnetic resonance imaging (MRI) and trust data from the Dallas Heart Study (DHS), a large community-based study, to determine brain regions associated with degree of trust in physicians and the medical profession. The first phase of the DHS was conducted from 2000 to 2002 and the second phase from 2007 to 2009.

Methods

The MRI data were analyzed as part of the DHS using automated FreeSurfer software. Forward stepwise binary logistic regression was performed to investigate the association between measures of trust and bilateral brain region volumes and thickness followed by confirmatory multiple regressions of significant brain regions. A total of 1,596 participants were included in the final analysis.

Results

Left caudal anterior cingulate cortex (ACC) thickness was inversely correlated with trust of physicians (P < .01). There were no significant associations between trust in physicians and age, race or ethnicity, or education.

Conclusions

The ACC is an integral part of the salience network, the brain network responsible for communication and social behavior. Trust in physicians did not appear to be influenced by demographic characteristics. The findings suggest there are neuroanatomical correlates of trust in physicians.

P1899Heparin and low-molecular-weight heparin switch associated with an increase in bleeding complications in patients on apixaban undergoing catheter ablation: The AMPER ABLATION study

Background

The aim of this study was to identify the factors associated with bleeding complications in patients taking apixaban and undergoing a catheter ablation in everyday clinical practice.

Methods

AMPER ABLATION is a multicenter, observational, prospective study of patients with non valvular atrial fibrillation (AF) undergoing a catheter ablation. Eligible patients had been taking apixaban (2.5 or 5 mg twice daily) for ≥3 weeks before the procedure, and were followed for 30 days afterwards.

Results

A total of 595 patients (65 [interquartile range 59, 72] years, 67% male, mean CHA2DS2-VASc score 1.85±1.37) were enrolled at 25 academic/nonacademic centers in France; 524 patients (88%) were receiving apixaban 10 mg/day and 71 (12%) 5 mg/day. 323 patients (54%) underwent an AF ablation, and 272 (46%) an atrial flutter (AFL) ablation. The most prevalent concomitant disorders were hypertension (51% of patients), diabetes (15%) and vascular disease (10%). Mean creatinine concentration was 1.06±0.28 mg/dL, median weight was 83±18 kg and mean creatinine clearance (Cockcroft-Gault) was 82±34 mL/min. The management of apixaban in the periprocedural period was left to the investigator's preference. Overall, 264 patients were switched to unfractionated heparin or enoxaparin (238 for AF ablations and 26 for AFL ablations). The median duration of switch was 29 hours. Complications were reported at 30 days, and included 12 bleeding events (1 tamponade needing drainage, 1 pericardial effusion without drainage, 7 International Society on Thrombosis and Haemostasis [ISTH] non major bleedings for AF ablations and 1 pericardial effusion without drainage, and 2 ISTH non major bleedings for AFL ablations) and 1 embolic event (non disabling stroke for an AF ablation). Comparing patients with and without a bleeding event revealed a higher rate of heparin or low-molecular-weight heparin (LMWH) switching in patients with a bleeding event (60% vs 35%; p=0.02). A switch to heparin or LMWH was the only factor associated with an increase rate of bleeding (odds ratio 2.5; [CI 95%; 1.1, 7.1]; p=0.01).

Conclusion

Heparin or LMWH switch in the periprocedural AF and AFL-ablation period is associated with an increased rate of bleeding complications at 30 days.

Acknowledgement/Funding

Financial support from BMS

2404The use of wearable cardioverter defibrillator in France

Background

The wearable cardioverter defibrillator (WCD) has been shown to be useful during transient periods of high sudden cardiac death risk, and the issue of compliance recently pointed out. This Registry was designed to provide real-world data on WCD use in France, in terms of compliance, potential adverse events, as well as efficacy.

Methods and results

Multicenter evaluation (WEARIT FRANCE Registry) was conducted in France between January 2017 and March 2018. Overall, 1,157 patients were analyzed: 950 with ischemic heart disease (82%, including 647 patients after myocardial infarction), 119 after ICD explant (10%), and 88 pre-transplant (8%). The median age was 61 years; the median ejection fraction was 25%. Median WCD wear time was 62 days, with median daily use of 23.4 hours. Less than 1% of patients did not wear WCD at least 4 hours per day. During follow-up, a total of 42 sustained ventricular tachyarrhythmias (VT/VF) occurred in 36 patients, of whom 50% (n=18) received appropriate WCD shocks, giving an incidence of appropriate therapy of 1.56%. The rate of all VT/VF episodes were 3.1% among patients with ischemic cardiomyopathy (n=29/950) versus 3.4% for the others (n=7/207). Of the ischemic patients wearing beyond 30 days (N=784), 5 received appropriate therapy of VT/VF episodes. Overall shock survival was 100%. At the end of the WCD period, 586 patients (51%) were implanted with an implantable cardioverter defibrillator. Eight patients (0.69%) received inappropriate WCD shocks. Regarding the apparent very low proportion of women considered for WCD therapy, we aimed to appreciate in which extent

Conclusions

In this multicenter nationwide WCD evaluation, 3.1% of patients presented with sustained VT/VF with 47% of those patients developing VT/VF after 30 days. The incidence of inappropriate therapy was low. The compliance to WCD in this real life evaluation was very high. These data suggest that the WCD, when worn appropriately, may be helpful in the arsenal to protect high-risk patients against SCD, especially in case of transient risk situations.

Acknowledgement/Funding

Zoll

Relationship between trust in neighbors and regional brain volumes in a population-based study

Trust is a fundamental part of human interpersonal relationships, and among other complex factors it is shown to be linked with demographic characteristics and specific regions of the brain. The authors utilized a large, community-based database gathered from the Dallas Heart Study to determine specific brain regions associated with an individual's trust in neighbors. A trust questionnaire was taken and regional brain volumes were determined from structural magnetic resonance imaging. Two analyses using logistic regressions in a training set and validation set were performed to investigate the association between measures of trust and bilateral brain region volumes and thickness. A total of 1527 participants were included in the final analysis. Right caudal anterior cingulate cortex thickness and left caudate volume were inversely correlated with neighbor trust, while left amygdala volume was positively correlated with neighbor trust. Greater age and higher level of education were positively correlated with neighbor trust. African Americans showed less neighbor trust than Caucasians and Hispanics. Anterior cingulate cortex, caudate, and amygdala are all integral parts of the salience network; thus, results of this study suggest that the salience network, the brain network responsible for functions such as communication and social behavior, may play a role in the formation of interpersonal trust.