Detection of enteric viruses and SARS-CoV-2 in beach sand

Beach sand harbors a diverse group of microbial organisms that may be of public health concern. Nonetheless, little is known about the presence and distribution of viruses in beach sand. In this study, the first objective was to evaluate the presence of seven viruses (Aichi virus, enterovirus, hepatitis A virus, human adenovirus, norovirus, rotavirus, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) in sands collected at public beaches. The second objective was to assess the spatial distribution of enteric viruses in beach sand. To that end, 27 beach sand samples from different beaches in Portugal were collected between November 2018 and August 2020 and analyzed for the presence of viruses. At seven beaches, samples were collected in the supratidal and intertidal zones. Results show that viruses were detected in 89 % (24/27) of the sand samples. Aichi virus was the most prevalent (74 %). Noroviruses were present in 19 % of the samples (norovirus GI - 15 %, norovirus GII - 4 %). Human adenovirus and enterovirus were detected in 48 % and 22 % of the samples, respectively. Hepatitis A virus and rotavirus were not detected. Similarly, SARS-CoV-2 in beach sand collected during the initial stages of the pandemic was also not detected. The detection of three or more viruses occurred in 15 % of the samples. Concentrations of viruses were as high as 7.2 log copies (cp)/g of sand. Enteric viruses were found in higher prevalence in sand collected from the supratidal zone compared to the intertidal zone. Human adenovirus was detected in 43 % of the supratidal and 14 % in the intertidal samples and Aichi virus in 57 % and 86 % of the intertidal and supratidal areas, respectively. Our findings suggest that beach sand can be a reservoir of enteric viruses, suggesting that it might be a vehicle for disease transmission, particularly for children, the elderly, and immunocompromised users.

Bactericide Activity of Cellulose Acetate/Silver Nanoparticles Asymmetric Membranes: Surfaces and Porous Structures Role

The antibacterial properties of cellulose acetate/silver nanoparticles (AgNP) ultrafiltration membranes were correlated with their integral asymmetric porous structures, emphasizing the distinct features of each side of the membranes, that is, the active and porous layers surfaces. Composite membranes were prepared from casting solutions incorporating polyvinylpyrrolidone-covered AgNP using the phase inversion technique. The variation of the ratio acetone/formamide and the AgNP content resulted in a wide range of asymmetric porous structures with different hydraulic permeabilities. Comprehensive studies assessing the antibacterial activity against Escherichia coli (cell death and growth inhibition of bacteria in water) were performed on both membrane surfaces and in E. coli suspensions. The results were correlated with the surface chemical composition assessed by XPS. The silver-free membranes presented a generalized growth of E. coli, which is in contrast with the inhibition patterns displayed by the membranes containing AgNP. For the surface bactericide test, the growth inhibition depends on the accessibility of E. coli to the silver present in the membrane; as the XPS results show, the more permeable membranes (CA30 and CA34 series) have higher silver signal detected by XPS, which is correlated with a higher growth inhibition. On the other hand, the inhibition action is independent of the membrane porous structure when the membrane is deeply immersed in an E. coli inoculated suspension, presenting almost complete growth inhibition.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Comparing the long-term prognosis of myocardial infarction with non-obstructive coronary arteries to myocardial infarction with obstructive coronary artery disease

Background

The long-term survival rates of myocardial infarction with non-obstructive coronary arteries (MINOCA) patients is lower than in the general population. Nevertheless, there are conflicting results regarding the prognosis of MINOCA patients in comparison to myocardial infarction with obstructive coronary artery disease (MI-CAD) patients.

Purpose

The aim of this study was to assess the long-term all-cause mortality of MINOCA patients and compare it to MI-CAD patients.

Methods

Retrospective analysis of 2443 consecutively admitted patients for acute myocardial infarction (AMI), in a single coronary intensive care unit. Only patients with 5 years of follow-up and those who died before the 5-year mark were considered. Patients were divided into two groups according to the presence or absence of obstructive coronary artery disease on angiography (≥50% stenosis). Demographic characteristics, symptoms at presentation, past medical history, laboratory characteristics and medication at discharge were compared using the Mann-Whitney U or χ2 test (according to variable type) to ensure comparability between groups. Five-year all-cause mortality was the target endpoint. Five-year survival was modelled through the Cox proportional hazard regression model. The variable of interest (MINOCA vs MI-CAD) and possible confounders that displayed statistically significant differences in the initial demographic analysis were included in univariable Cox regressions, and those with statistically significant associations were included in a multivariable model. Those that displayed non-significant associations in the multivariable model were subsequently removed until we were left with significant associations only, giving us an adjusted hazard ratio.

Results

Comparison between groups is presented in table 1. MINOCA patients were younger and more often women. They were less likely to have smoking habits, diabetes, or a previous history of AMI. They had a lower Killip class, as well as lower troponin I, serum creatinine and low-density lipoprotein cholesterol at admission. On the other hand, they had higher left ventricular ejection fractions. They were also less likely to have beta-blockers or aspirin prescribed at discharge.

All-cause mortality at 5 years was 13.1% among MINOCA patients and 28.3% among MI-CAD patients, with an unadjusted hazard ratio (HR) of 0.421 (95% CI 0.322–0.550), p<0.001. Adjusting for known confounders, the HR was 0.461 (95% CI 0.261–0.816), p=0.008.

Conclusions

Compared with MI-CAD patients, those with MINOCA were slightly younger and had fewer comorbidities. In spite of having a worse long-term prognosis when compared to the general population, MINOCA patients have a significantly higher 5-year survival rate than MI-CAD patients, even after adjustment of confounding factors.

Funding Acknowledgement

Type of funding sources: None.

Malnutrition: a mascaraed and underused prognostic marker in coronary patients

Funding Acknowledgements

Type of funding sources: None.

Background

Malnutrition had been associated with worse prognosis in heart failure (HF) patients, especially in elder. However, this association wasn’t demonstrated in coronary patients, after a ST-segment elevation myocardial infarction (STEMI). We want to evaluate the prognosis value of malnutrition, in elder patients, after a STEMI.

Methods

We conducted a retrospective, observational study of 200 elderly patients (365 years) consecutively admitted with STEMI between 2016 and 2017. At discharge, we applied a validated formula who evaluate nutritional status: "Prognostic Nutritional Index" (PNI), [10 x serum albumin at discharge (g/dL) + 0.005 x total lymphocytes at discharge], whose lowest values were associated with malnutrition. At 1 year follow-up, we evaluated the relation between PNI and major adverse cardiac events (MACE): myocardial infarction (MI), HF hospitalization, cardiovascular (CV) and all-cause death.

Results

Mean age was 74±8 years, 71% (n=149) were male and with multiples risks factors (75% hypertense, 63% with dyslipidemia, 33% diabetes and 11% smokers). At discharge, patients had a mean Left Ventricular Ejection Fraction (LVEF) of 47±8% and a mean PNI of 37±5. Low PNI values (malnutrition) were significant associated with MACE at 1-year [OR 0.87 (95% CI 0.78 to 0.97, p=0.01)], after adjusting for age, sex and LVEF. When evaluated individually, low PNI was associated with more incidence of 1-year HF hospitalization [OR 0.88 (95% CI 0.78 to 0.99, p=0.03)] and all-cause death [OR 0.84 (95% CI 0.75 to 0.95, p=0.004)], after adjusting for age, sex and LVEF, but not with MI and CV death.

Conclusion

Malnutrion associated with other comorbidities inherent to elderly people were associated with MACE, 1-year after STEMI, in this type of population. Thus, we want to draw attention to the importance of evaluating the nutritional status during hospitalization for STEMI, allowing to initiate measures that contribute to its improvement.

Discrimination and surveillance of infectious severe acute respiratory syndrome Coronavirus 2 in wastewater using cell culture and RT-qPCR

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA has been extensively detected in raw wastewater in studies exploring wastewater-based epidemiology (WBE) for early warning purposes. Nonetheless, only a few limited studies investigated the presence of SARS-CoV-2 in treated wastewaters to determine the potential health risks across the water cycle. The detection of SARS-CoV-2 has been done mostly by RT-qPCR and ddPCR, which only provides information on the presence of nucleic acids rather than information on potential infectivity. In this study, we set to develop and evaluate the use of viability RT-qPCR for the selective discrimination and surveillance of infectious SARS-CoV-2 in secondary-treated wastewater. Enzymatic (nuclease) and viability dye (Reagent D) pretreatments were applied to infer infectivity through RT-qPCR using porcine epidemic diarrhea virus (PEDV) as a CoV surrogate. Infectivity tests were first performed on PEDV purified RNA, then on infectious and heat-inactivated PEDV, and finally on heat inactivated PEDV spiked in concentrated secondary-treated wastewater. The two viability RT-qPCR methods were then applied to 27 secondary-treated wastewater samples positive for SARS-CoV-2 RNA at the outlet of five large urban wastewater treatment plants in Portugal. Reagent D pretreatment showed similar behavior to cell culture for heat-inactivated PEDV and both viability RT-qPCR methods performed comparably to VERO E6 cell culture for SARS-CoV-2 present in secondary-treated wastewater, eliminating completely the RT-qPCR signal. Our study demonstrated the lack of infectious SARS-CoV-2 viral particles on secondary-treated wastewater through the application of two pretreatment methods for the rapid inference of infectivity through RT-qPCR, showing their potential application in environmental screening. This study addressed a knowledge gap on the public health risks of SARS-CoV-2 across the water cycle.

Recovery of SARS-CoV-2 from large volumes of raw wastewater is enhanced with the inuvai R180 system

Wastewater-based epidemiology (WBE) for severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) is a powerful tool to complement syndromic surveillance. Although detection of SARS-CoV-2 in raw wastewater may be prompted with good recoveries during periods of high community prevalence, in the early stages of population outbreaks concentration procedures are required to overcome low viral concentrations. Several methods have become available for the recovery of SARS-CoV-2 from raw wastewater, generally involving filtration. However, these methods are limited to small sample volumes, possibly missing the early stages of virus circulation, and restrained applicability across different water matrices. The aim of this study was thus to evaluate the performance of three methods enabling the concentration of SARS-CoV-2 from large volumes of wastewater: i) hollow fiber filtration using the inuvai R180, with an enhanced elution protocol and polyethylene glycol (PEG) precipitation; ii) PEG precipitation; and iii) skimmed milk flocculation. The performance of the three approaches was evaluated in wastewater from multiple wastewater treatment plants (WWTP) with distinct singularities, according to: i) effective volume; ii) percentage of recovery; iii) extraction efficiency; iv) inhibitory effect; and v) the limits of detection and quantification. The inuvai R180 system had the best performance, with detection of spiked control across all samples, with average recovery percentages of 68% for porcine epidemic diarrhea virus (PEDV), with low variability. Mean recoveries for PEG precipitation and skimmed milk flocculation were 9% and 14%, respectively. The inuvai R180 enables the scalability of volumes without negative impact on the costs, time for analysis, and recovery/inhibition. Moreover, hollow fiber ultrafilters favor the concentration of different microbial taxonomic groups. Such combined features make this technology attractive for usage in environmental waters monitoring.

The role of process mining tools in STEMI networks: where should we build a new primary PCI centre?

Background

In ST-segment elevation myocardial infarction (STEMI), time delay between symptom onset and treatment is critical to improve outcome. The expected transport delay between patient location and percutaneous coronary intervention (PCI) centre is paramount for choosing the adequate reperfusion therapy. The “Centre” region of Portugal has heterogeneity in PCI assess due to geographical reasons.

Purpose

We aimed to explore time delays between regions using process mining (PM) tools.

Methods

We retrospectively assessed the Portuguese Registry of Acute Coronary Syndromes for patients with STEMI from October 2010 to September 2019, collecting information on geographical area of symptom onset, reperfusion option, and in-hospital mortality. We used a PM toolkit (PM4H – PMApp Version) to build two models (one national and one regional) that represent the flow of patients in a healthcare system, enhancing time differences between groups. One-way analysis of variance was employed for the global comparison of study variables between groups and post hoc analysis with Bonferroni correction was used for multiple comparisons.

Results

Overall, 8956 patients (75% male, 48% from 51 to 70 years) were included in the national model (Fig. 1A), in which primary PCI was the treatment of choice (73%), with the median time between admission and primary PCI <120 minutes in every region; “Lisboa” and “Centro” had the longest delays, (orange arrows). Fibrinolysis was performed in 4.5%, with a median time delay <1 hour in every region. In-hospital mortality was 5%, significantly higher for those without reperfusion therapy compared to PCI and fibrinolysis (10% vs. 4% vs. 4%, P<0.001). In the regional model (Fig. 1B) corresponding to the “Centre” region of Portugal divided by districts (n=773, 74% male, 47% from 51 to 70 years), only 61% had primary PCI, with “Guarda” (05:04) and “Castelo Branco” (06:50) showing significant longer delays between diagnosis and reperfusion treatment (orange and red arrows, respectively) than “Coimbra” (01:19) (green arrow); only 15% of patients from “Castelo Branco” had primary PCI. Fibrinolysis was chosen in 10% of patients, mostly in “Castelo Branco” (53%), followed by “Guarda” (30%), with a median time delay of 39 and 48 minutes, respectively. Regarding mortality, PCI and fibrinolysis groups had similar death rates while those patients without reperfusion had higher mortality (5% vs. 3% vs. 13%, P=0.001).

Conclusion

Process mining tools help to understand referencing networks visually, easily highlighting inefficiencies and potential needs for improvement. The “Centre” region of Portugal has lower rates and longer delay to primary PCI partially due to the geographical reasons, with worse outcomes in remote regions. The implementation of a new PCI centre in one of these districts, is critical to offer timely first-line treatment to their population.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Elucidation of fecal inputs into the River Tagus catchment (Portugal) using source-specific mitochondrial DNA, HAdV, and phage markers

Determining the source of fecal contamination in a water body is important for the application of appropriate remediation measures. However, it has been suggested in the extant literature that this can best be achieved using a 'toolbox' of molecular- and culture-based methods. In response, this study deployed three indicators (Escherichia coli (EC), intestinal enterococci (IE) and somatic coliphages (SC)), one culture-dependent human marker (Bacteroides (GB-124) bacteriophage) and five culture-independent markers (human adenovirus (HAdV), human (HMMit), cattle (CWMit), pig (PGMit) and poultry (PLMit) mitochondrial DNA markers (mtDNA)) within the River Tagus catchment (n = 105). Water samples were collected monthly over a 13-month sampling campaign at four sites (impacted by significant specific human and non-human inputs and influenced by differing degrees of marine and freshwater mixing) to determine the dominant fecal inputs and assess geographical, temporal, and meteorological (precipitation, UV, temperature) fluctuations. Our results revealed that all sampling sites were not only highly impacted by fecal contamination but that this contamination originated from human and from a range of agricultural animal sources. HMMit was present in a higher percentage (83%) and concentration (4.20 log GC/100 mL) than HAdV (32%, 2.23 log GC/100 mL) and GB-124 bacteriophage with the latter being detected once. Animal mtDNA markers were detected, with CWMit found in 73% of samples with mean concentration of 3.74 log GC/100 mL. Correlation was found between concentrations of fecal indicators (EC, IE and SC), CWMit and season. Levels of CWMit were found to be related to physico-chemical parameters, such as temperature and UV radiation, possibly as a result of the increasing presence of livestock outside in warmer months. This study provides the first evaluation of such a source-associated 'toolbox' for monitoring surface water in Portugal, and the conclusions may inform future implementation of surveillance and remediation strategies for improving water quality.

Late diagnosis of intraplacental choriocarcinoma co-existing with fetomaternal haemorrhage causing fetal demise: A case report

Intraplacental choriocarcinoma (IC) is a rare disease, occurring in approximately 1 in 50,000 pregnancies. A 33-year-old woman, gravida 2 para 0, sustained an intrauterine fetal death due to fetomaternal haemorrhage (FMH) at 36 weeks of gestation after presenting with decreased fetal movements in the days prior. The placenta macroscopically appeared normal. However, histological examination revealed an intraplacental choriocarcinoma. Assessment of this woman's quantitative beta human chorionic gonadotropin (bHCG) level was negative and a computerized tomography scan of her chest, abdomen and pelvis revealed no metastatic disease yet a bulky uterus. After discussion at a multidisciplinary tumour board meeting, the patient had endometrial curettings to rule out any uterine pathology and serial bHCG tests until one year post-partum. Following this, the patient successfully carried and delivered a live female term infant. Although FMH is a rare clinical manifestation of IC it should always alert clinicians to investigate the cause further, through urgent and careful histopathological examination of the placenta. This will allow for appropriate management with chemotherapy if indicated and a reduction in maternal morbidity and mortality.

Characterization of Stormwater Runoff Based on Microbial Source Tracking Methods

Rainfall and associated urban runoff have been linked to an increased deterioration of environmental waters, carrying several pollutants including pathogenic microorganisms. Such happens because fecal matter is washed into storm drainage pipes that are afterward released into environmental waters. Stormwater has not been extensively characterized as it is, because most studies are performed either on drainage pipes that are often impacted by sewage leakage or directly in environmental waters following a rain event. In this study, stormwater collected directly from the streets, was monitored for the presence of fecal indicator bacteria (FIB) and three potential important sources of fecal contamination in urban environments (human, cats, and dogs) in three distinct basins in Lisbon, Portugal. Stormwater was collected in sterilized plastic boxes inserted in the storm drains, therefore collecting only runoff. High concentration of fecal contamination was detected with a high percentage of the samples displayed at least one source of contamination. A strong relationship was found between the number of detected sources and the precipitation levels. Although no statistical correlation was found between the locations and the presence of FIB or source markers, the results show a trend in geographical information on the type of urban use in each basin. To the best of our knowledge, this is the first study analyzing the runoff collected directly from the streets. This study suggests that, in urban areas, stormwater runoff is highly impacted by fecal matter, not only from domestic animals but also from human origin, before any cross-contamination in the drainage system and may, by itself, pose a high risk to human health and the environment, particularly if water reuse of this water without further disinfection treatment is the final goal.

Myocardial infarction in young adults: are the risk profile and mortality outcomes different from older patients?

Funding Acknowledgements

Type of funding sources: None.

Introduction

The incidence of acute myocardial infarction (AMI) among young patients is increasing. The YOUNG-MI Registry reported that those under 40 years had similar risk profiles and outcomes compared to those aged 41 to 50. We aimed to evaluate cardiovascular risk factors and mortality outcomes in two age cohorts from southern European.

Methods

We retrospectively evaluated 4758 patients admitted to our coronary intensive care unit between 2004 and 2017 with AMI. We only included patients <60 years in two subgroups: cohort A < 50 years and cohort B 50-60 years. 

Results

From the 1233 patients included (mean age 50.5 ± 6.5 years, 82.2% male), 53% had STEMI. Cohort B had higher rates of hypertension (59.8 vs. 42.9%, p < 0.001), diabetes (41.8 vs. 28.9%, p < 0.001), and dyslipidemia (59.4 vs. 46.4%, p < 0.001), while cohort A had higher rates of familial premature coronary artery disease (20.9 vs. 13.2%, p < 0.001) and smoking habits (54.4 vs. 40.0%, p < 0.001). Regarding coronary angiography, cohort B had higher rates of obstructive disease in each epicardial artery, except for left main involvement and non-obstructive disease (Fig. 1). Cohort A had lower all-cause mortality rates at the index hospitalization (1.3 vs. 3.2%, p = 0.045), 6-months (2.9 vs.5.4, p = 0.038), 1-year (3.1 vs. 6.3%, p = 0.014), and 3-years (3.6 vs 8.4, p = 0.001). After multivariable adjustment, we found no relationship between age cohorts and all-cause mortality for any follow-up timing: HR 1.57 (95% CI 0.56-4.37), 1.37 (95% CI 0.50-3.74), and 0.92 (95% CI 0.35-2.39) at 6-months, 1-year, and 3-years, respectively.

Conclusion

Among patients who suffer AMI, those under 50 years old have a different risk profile, compared to the 50-60 years cohort. However, there is no significant difference in all-cause mortality.

Abstract Figure.

Bacteriophages Are Good Estimators of Human Viruses Present in Water

The detection of fecal viral pathogens in water is hampered by their great variety and complex analysis. As traditional bacterial indicators are poor viral indicators, there is a need for alternative methods, such as the use of somatic coliphages, which have been included in water safety regulations in recent years. Some researchers have also recommended the use of reference viral pathogens such as noroviruses or other enteric viruses to improve the prediction of fecal viral pollution of human origin. In this work, phages previously tested in microbial source tracking studies were compared with norovirus and adenovirus for their suitability as indicators of human fecal viruses. The phages, namely those infecting human-associated Bacteroides thetaiotaomicron strain GA17 (GA17PH) and porcine-associated Bacteroides strain PG76 (PGPH), and the human-associated crAssphage marker (crAssPH), were evaluated in sewage samples and fecal mixtures obtained from different animals in five European countries, along with norovirus GI + GII (NoV) and human adenovirus (HAdV). GA17PH had an overall sensitivity of ≥83% and the highest specificity (>88%) for human pollution source detection. crAssPH showed the highest sensitivity (100%) and specificity (100%) in northern European countries but a much lower specificity in Spain and Portugal (10 and 30%, respectively), being detected in animal wastewater samples with a high concentration of fecal indicators. The correlations between GA17PH, crAssPH, or the sum of both (BACPH) and HAdV or NoV were higher than between the two human viruses, indicating that bacteriophages are feasible indicators of human viral pathogens of fecal origin and constitute a promising, easy to use and affordable alternative to human viruses for routine water safety monitoring.

Integrated efforts to promote mental health care during the SARS-CoV-2 pandemic: Reflecting on the experience of a university helpline

Introduction

The SARS-CoV-2 pandemic is affecting numerous dimensions of our society since the beginning of the outbreak. A significant increase in emotional distress was expected in the general population, particularly among the high-risk groups such as the oldest, chronic patients, healthcare professionals, and psychopathology vulnerable people. There was an urgent need to adapt and create solutions to promote mental health. Given the recommendations to minimize face-to-face interactions, several helplines were widely developed.

Objectives

In this work, we aim to reflect on the experience of a university helpline, that integrated efforts with the regional mental health care services.

Methods

A University helpline was created to give support to the regional community outside academia. The team was created on an online teamwork platform, to communicate through the chat, carry videoconference meetings, and store useful files. A Manchester screening decision tree was adopted, to define a set of guidelines to provide support to the callers, based mainly on the guidelines defined by the Order of Portuguese Psychologists. Liaison with the mental health care services, including other specific helplines, was established.

Results

Notwithstanding all the efforts, the number of received calls was scarce, similarly to helplines created by other national universities and by other entities.

Conclusions

A new approach to psychological intervention in crisis is needed, maintaining integrated efforts, and taking advantage of the opportunity to foster personalized mental health care in the digital era. It is important to continuously assess the value of integrated efforts in patient care and to the healthcare system.

Left atrial functional assessment and mortality in patients with severe aortic stenosis

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe. Both symptoms and systolic dysfunction can appear late in the course of the disease, being often synonym of irreversible damage to the myocardium when found. Thus, there is a necessity to find other sensitive markers present at an earlier stage of the disease. 

Purpose

Our primary aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up.

Methods

We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated all 3 left atrial (LA) functional phases (reservoir, conduit and pump) by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and own patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up.

Results

After exclusion criteria, a total of 451 patients were included in the analysis (aged 74 ±11years, 54% male) and were followed during a median period of 73 months (interquartile range 44.5). A total of 55.8% of patients underwent AVR and 45,5% of patients registered the primary outcome. Left atrial emptying fraction (LAEF) was the best LA functional parameter in discriminating primary outcome (AUC 0.840, p < 0.001), even when compared to left ventricular ejection fraction, aortic valve area, aortic mean pressure gradient and aortic Vmax. Patients in the lower tercile of LAEF were older, had greater comorbidities, had greater AS severity, with greater degree of diastolic disfunction. After adjustment for clinical and demographic variables, cumulative survival of patients with LAEF <37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (adjusted HR 19.04, 95% CI 8.30-43.67, P < 0.001 and adjusted HR 4.09, 95% CI 1.85-9.06, P = 0.001). Survival was also higher in patients with LAEF 37 to 53% when compared to patients with LAEF <37% (adjusted HR 0.22, 95% CI 0.13-0.37, P < 0.001). All associations remained true after adjustment for AVR (LAEF <37% versus LAEF 37 to 53% and LAEF ≥54%, respectively, adjusted HR 3.97, 95% CI 1.80-8.78, P = 0.001 and adjusted HR 13.95, 95% CI 5.98-32.54, P < 0.001, respectively)

Conclusion(s) In patients with a first diagnosis of severe AS in hospital setting, LA function assessed by volumetric parameters is an independent predictor of all-cause mortality. Compared to classical severity parameters, different LA functional parameters were found to be more potent predictors of death. These data can be useful in clinical practice for risk stratification and therefore for decision of timing for AVR.

Abstract Figure. Survival of patients stratified by group

Organization of intensive cardiac care units in Europe: Results of a multinational survey

Background:

The present survey aims to describe the intensive cardiac care unit organization and admission policies in Europe.

Methods:

A total of 228 hospitals (61% academic) from 27 countries participated in this survey. In addition to the organizational aspects of the intensive cardiac care units, including classification of the intensive cardiac care unit levels, data on the admission diagnoses were gathered from consecutive patients who were admitted during a two-day period. Admission policies were evaluated by comparing illness severity with the intensive cardiac care unit level. Gross national income was used to differentiate high-income countries (n=13) from middle-income countries (n=14).

Results:

A total of 98% of the hospitals had an intensive cardiac care unit: 70% had a level 1 intensive cardiac care unit, 76% had a level 2 intensive cardiac care unit, 51% had a level 3 intensive cardiac care unit, and 60% of the hospitals had more than one intensive cardiac care unit level. High-income countries tended to have more level 3 intensive cardiac care units than middle-income countries (55% versus 41%, p=0.07). A total of 5159 admissions were scored on illness severity: 63% were low severity, 24% were intermediate severity, and 12% were high severity. Patients with low illness severity were predominantly admitted to level 1 intensive cardiac care units, whereas patients with high illness severity were predominantly admitted to level 2 and 3 intensive cardiac care units. A policy mismatch was observed in 12% of the patients; some patients with high illness severity were admitted to level 1 intensive cardiac care units, which occurred more often in middle-income countries, whereas some patients with low illness severity were admitted to level 3 intensive cardiac care units, which occurred more frequently in high-income countries.

Conclusion:

More than one-third of the admitted patients were considered intermediate or high risk. Although patients with higher illness severity were mostly admitted to high-level intensive cardiac care units, an admission policy mismatch was observed in 12% of the patients; this mismatch was partly related to insufficient logistic intensive cardiac care unit capacity.

Incidence of enterococci resistant to clinically relevant antibiotics in environmental waters and in reclaimed waters used for irrigation

Treated wastewater discharged into the environment or reused in different activities can be a major vehicle for the transmission of antibiotic-resistant bacteria and antibiotic-resistance genes. In this study, environmental and wastewater samples, collected at different stages of treatment, were studied to identify the possibility of a positive selection of antibiotic-resistant organisms in wastewater treatment plants (WWTPs). Enterococci were isolated, characterized into the main human species, and subjected to the Kirby-Bauer test using seven antibiotics (five classes): ampicillin, chloramphenicol, ciprofloxacin, gentamicin, linezolid, tetracycline, and vancomycin. Furthermore, vancomycin-resistant enterococci (VRE), a major cause of nosocomial infection, was identified, and the genes vanA and vanB detected directly in the samples and in all confirmed VRE. Data showed that WWTPs were able to reduce the levels of antibiotic resistance, although 72% of the disinfected wastewaters still presented antibiotic-resistant enterococci. VRE were detected in 6% of the samples, including in reclaimed waters. UV disinfection was not effective at removing VRE and multiple antibiotic-resistant (MAR) enterococci, most commonly Enterococcus faecalis. The use of reclaimed water containing VRE and MAR enterococci in crop production, irrigation of urban gardens, and street cleaning increases immensely the potential risk to human health.

Organization of intensive cardiac care units in Europe: Results of a multinational survey

Background:

The present survey aims to describe the intensive cardiac care unit organization and admission policies in Europe.

Methods:

A total of 228 hospitals (61% academic) from 27 countries participated in this survey. In addition to the organizational aspects of the intensive cardiac care units, including classification of the intensive cardiac care unit levels, data on the admission diagnoses were gathered from consecutive patients who were admitted during a two-day period. Admission policies were evaluated by comparing illness severity with the intensive cardiac care unit level. Gross national income was used to differentiate high-income countries (n=13) from middle-income countries (n=14).

Results:

A total of 98% of the hospitals had an intensive cardiac care unit: 70% had a level 1 intensive cardiac care unit, 76% had a level 2 intensive cardiac care unit, 51% had a level 3 intensive cardiac care unit, and 60% of the hospitals had more than one intensive cardiac care unit level. High-income countries tended to have more level 3 intensive cardiac care units than middle-income countries (55% versus 41%, p=0.07). A total of 5159 admissions were scored on illness severity: 63% were low severity, 24% were intermediate severity, and 12% were high severity. Patients with low illness severity were predominantly admitted to level 1 intensive cardiac care units, whereas patients with high illness severity were predominantly admitted to level 2 and 3 intensive cardiac care units. A policy mismatch was observed in 12% of the patients; some patients with high illness severity were admitted to level 1 intensive cardiac care units, which occurred more often in middle-income countries, whereas some patients with low illness severity were admitted to level 3 intensive cardiac care units, which occurred more frequently in high-income countries.

Conclusion:

More than one-third of the admitted patients were considered intermediate or high risk. Although patients with higher illness severity were mostly admitted to high-level intensive cardiac care units, an admission policy mismatch was observed in 12% of the patients; this mismatch was partly related to insufficient logistic intensive cardiac care unit capacity.

Epicardial fat tissue: a new tool for identification of coronary artery disease patients?

Introduction

Epicardial fat (EF), the true visceral fat depot of the heart, has been strongly correlated with both coronary artery disease (CAD) incidence and severity. However, the methods for its measurement were not always affordable. Its measurement by echocardiography is fast, accessible and easily reproducible, turning it into a promising clinical tool for assessing cardiovascular risk to predict the incidence of CAD.

Purpose

To determine the correlation between EF tissue dimensions measured by transthoracic echocardiography and the presence of CAD.

Methods

We prospectively analysed data from 196 consecutive patients admitted for acute coronary syndrome in our coronary care unit. All patients underwent diagnostic coronary angiography and echocardiogram during stay. EF dimensions were obtained with transthoracic echocardiography by measuring maximum EF diameter (mm) at the basal right ventricular free wall (PLAXB) level and mid-right ventricular free wall (PLAXM) level [in paraesternal long-axis view (PLAX)] and maximum right-ventricle free wall EF diameter at basal (PSAXB) level and papillary-muscle (PSAXM) level [in paraesternal short-axis view (PSAX)]. All measures were taken at end-systole. Patients were divided in 2 groups according to the presence of significant CAD (sCAD) or not (nCAD), defined as having at least 1 diseased epicardial vessel with a stenosis >50%.

Results

One-hundred and sixty-three (83.2%) had significant CAD. 22 patients (11.2%) were admitted for unstable angina, 60 patients (30.6%) for non-ST elevation myocardial infarction and 93 patients (47,4%) for ST-elevation myocardial infarction. Mean EF diameters were as follows: PLAXB (19,3±5.1 mm), PLAXM (11.3±2.6), PSAXB (10,6±2.8), PSAXM (10.5±2.8). We found a direct correlation between number of diseased epicardial coronary vessels and epicardial fat thickness in PLAXB (r=0.506, p<0.001), PLAXM (r=0.372, p<0.001), PSAXB (r=0.445, p<0.001) and PSAXM (r=0.372, p<0.001). EF was significantly different between groups: PLAXB (20,6±4.4 vs. 13.8±3,8, p<0.001), PLAXM (11.8±2.5 vs. 9.0±1.9, p<0.001), PSAXB (11.1±2.7 vs. 8.3±2.3, p<0.001) and PSAXM (11.0±2.6 vs. 8.2±4, p<0.001). Receiver operating characteristic curve analysis showed that the predictive value of mean right ventricular EF [(PLAXB+PSAXB)/2] for significant CAD was 0.895 (AUC=0.895, CI 95% 0.818–0,972, p<0.001). For a [(PLAXB+PLAXM)/2] value of 12.57 mm, sensitivity was 86.3% and specificity was 79.3%.

Conclusions

In a population of high suspicion of acute coronary syndromes, echocardiographic EF is a sensitive and specific marker of the presence of significant coronary disease and could become an important tool for coronary risk prediction.

Figure 1

Funding Acknowledgement

Type of funding source: None

Inequalities after STEMI in National Health Service: is there really a postcode lottery?

Background and purpose

Failure to address the impact of social determinants of health attenuates efficacy of proven prevention recommendations, namely because important considerations related to socioeconomic disadvantage are not captured by existing cardiovascular disease (CDV) risk stratification methods. We aimed to assess how socioeconomic determinants influence recurrent MI and all-cause death after myocardial infarction (MI) in Portugal.

Methods

We conducted a retrospective, observational cohort study, including all patients with a ST-elevation MI (STEMI) admitted to and discharged alive from an intensive cardiac care unit between 2004 and 2017 (n=1809). The median (interquartile range) follow-up was 6 (4–9) years. We used survival models to assess the relationship between their municipal (i) income by purchasing power per capita (PPC), (ii) geographical accessibility to health care, (iii) illiteracy, iv) residential socioeconomic deprivation and recurrent MI and all-cause mortality. To assess residential socioeconomic deprivation, each individual's residential postcode was matched to the recently validated Portuguese version of European Deprivation Index (EDI). The index was categorized into quintiles (Q1-least deprived to Q5-most deprived).

Results

The mean age was 64±14 years; 74% were male. Regarding individual socioeconomic variables, PPC (HR 1.19; 95% CI 0.97–1.47 for Tertile 1 vs Tertile 2; HR 1.28; 95% CI 1.04–1.56 for Tertile 1 vs Tertile 3 and HR 1.07; 95% CI 0.85–1.34 for Tertile 2 vs Tertile 3) and medical appointments in primary health centers per inhabitant (HR 0.90; 95% CI 0.75–1.09 for Tertile 1 vs Tertile 2; HR 1.23; 95% CI 0.95–1.61 for Tertile 1 vs Tertile 3 and HR 1.37; 95% CI 1.06–1.76 for Tertile 2 vs Tertile 3) were predictors of all-cause mortality, but not recurrent MI; however, in multivariate analysis adjusted for sex, age and ejection fraction, this association was no longer significant (HR 1.00; 95% CI 0.99–1.00 and, HR 1.00; 95% CI 0.89–1.17, respectively). Additionally, no evident association between illiteracy and all-cause mortality or MI was present. Concerning EDI, demographic data was similar among the quintiles (Table 1). Although EDI quintiles were not associated with all-cause mortality (HR 1.17; 95% CI 0.82–1.66 for Q5 vs Q1), the EDI was an independent predictor of recurrent MI (Figure 1). On multivariate analysis, adjusted for age, sex, hypertension, diabetes and LDL cholesterol, the HR for the most deprived (Q5) to the least deprived (Q1) quintile was 1.91 (95% CI 1.05–3.49) for MI.

Conclusions

Our study shows clear socioeconomic differentials in cardiovascular outcomes in patients with STEMI which suggests that accounting for socioeconomic deprivation might improve risk prediction and therefore disease prognosis.

Funding Acknowledgement

Type of funding source: None

A real world analysis of NSTE-ACS in more than 4000 patients: accuracy of GRACE and TIMI scores in mortality prediction

Introduction

The TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) risk scores identify high-risk patients with Non-ST elevation acute coronary syndrome (NSTE-ACS) who can benefit from an early invasive strategy.

Purpose

We aimed to compare both scores predictive accuracy for mortality in a real-world cohort of patients presenting with NSTE-ACS.

Methods

We retrospectively evaluated 4264 patients admitted to our coronary intensive care unit between 2004 and 2017 with a diagnosis of NSTE-ACS. The TIMI and GRACE scores were calculated for each patient, and all-cause mortality was recorded during hospitalization, at one month and one year. To better characterize global troponin release, we defined Total Troponin (TT) as the sum of initial and discharge troponin. We used the area under the receiver operating characteristic curve (AUC) to compare the predictive value of both scores for mortality during hospitalization, at one month and one year.

Results

Mean patient age was 67.6±12.4 years and 66.4% were male (n=2833). Mean GRACE score was 124.6±35.8 and mean TIMI score was 2.7±1.6. There was a weak correlation between GRACE and TIMI score (r=0.3, p<0.001). In-hospital mortality was 2.8%: the GRACE score showed higher AUC (0.845, 95% CI 0.805–0.804, p<0.001) compared to TIMI (0.581, 95% CI 0.519–0.643, p=0.009) (Figure 1). Mortality at one month was 5.1%: the GRACE score showed higher AUC (0.842, 95% CI 0.814–0.869, p<0.001) compared to TIMI (0.586, 95% CI 0.541–0.630, p<0.001). Mortality at one year was 11.4%: the GRACE score showed higher AUC (0.811, 95% CI 0.789–0.822, p<0.001) compared to TIMI (0.591, 95% CI 0.560–0.622, p<0.001) (Fig. 1). Analyzing Unstable Angina and Non-ST segment elevation myocardial infarction separately, the GRACE score also showed higher AUC compared to TIMI. Exploratory analyses revealed a combined indicator (GRACE score + TT) which had higher AUC (0.876, 95% CI 0.844–0.907, p<0.001) compared to GRACE score (0.855, 95% CI 0.823–0.887, p<0.001) for one month mortality and for one year mortality (0.818, 95% CI 0.792–0.844, p<0.001 vs. 0.813, 95% CI 0.788–0.839, p<0.001).

Conclusion

In patients with NSTE-ACS, GRACE risk score is a better predictor of in-hospital, one month and one-year mortality, compared to TIMI risk score. TT, as a measure of ischemia burden, might improve accuracy of GRACE score in predicting short and long-term mortality.

Figure 1

Funding Acknowledgement

Type of funding source: None

Process mining tools: where should we build another PCI centre to reduce STEMI mortality?

Introduction

The expected delay of transport between patient location and percutaneous coronary intervention (PCI) centre is paramount for choosing the adequate reperfusion therapy in ST-segment elevation myocardial infarction (STEMI). The central region of Portugal has heterogeneity in PCI assess due to geographical reasons. However, this data is usually presented numerically without providing a visual distribution of patients.

Purpose

We aimed to analyse the impact of distance to PCI centres on mortality in patients with STEMI through visual maps of patients' flow by using an experimental process mining tool, integrated in EIT Health's project PATHWAYS.

Methods

Using the Portuguese Registry of Acute Coronary Syndromes (ProACS), we retrospectively assessed patients with an established diagnosis of STEMI, geographical presentation specified, reperfusion option identified (PCI, fibrinolysis or no reperfusion), short-term outcomes defined as discharge or in-hospital death. With the 2 317 patients that fulfilled the criteria, we used a process mining tool to build national and regional models that represent the flow of patients in a healthcare system, enhancing differences between groups.

Results

Colour gradient in nodes and arrows changes from green to red, with green representing a lower number of patients as opposed to red. In the national model, most patients from all regions had PCI. Mortality was similar between PCI and fibrinolysis groups (4%) but higher in those without reperfusion (9%). In the central region model, one third of the patients were more than 120 minutes away from a PCI centre. Despite that, almost one third of these patients had PCI instead of fibrinolysis. In this model, fibrinolytic therapy had higher in-hospital survival rate than PCI (98% vs. 94%). Overall mortality was higher in the central model compared with the national model (6.92% vs. 5%). Central region had less PCI (53% vs. 73%), more fibrinolysis (15% vs. 7%) and more patients with no reperfusion (32% vs. 20%).

Conclusion

In the ProACS registry, mortality was higher in the central region compared with national data. Even though global interpretation of these findings is limited by underrepresentation from certain central areas, process mining offers an easily understandable view of patients flow. With its statistical upgrade and continuous development, this tool will facilitate the analysis of big data and comparison between groups.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): EIT Health

Parenteral anticoagulation in non-ST segment elevation acute coronary syndromes: which option to pick?

Background

According to the 2015 European Society of Cardiology's non-ST segment elevation acute coronary syndrome (NSTE-ACS) clinical practice guideline, fondaparinux is the parenteral anticoagulant with the most favorable efficacy/safety profile. Thus, it is recommended over enoxaparin, for instance, in that setting. However, its use and performance in a contemporary portuguese cohort has not been fully described.

Purpose

To assess fondaparinux utilization degree and to compare its in-hospital efficacy and safety profiles with those of enoxaparin, in a contemporary portuguese cohort of NSTE-ACS patients.

Methods

Patients consecutively admitted with NSTE-ACS, between October 2010 and January 2019, were retrospectively identified from a national registry of acute coronary syndromes and were further divided in two groups, as per parenteral anticoagulation strategy (fondaparinux vs. enoxaparin). Key exclusion criteria were specific contraindications to both agents, recent hemorrhagic stroke and indications for anticoagulation other than ACS. The primary efficacy endpoint was a composite of in-hospital reinfarction and mortality, whereas the primary safety endpoint was moderate-to-severe bleeding, as defined by the GUSTO criteria.

Results

A total of 5843 NSTE-ACS patients (mean age 65±13 years, 72.4% males) were included. Of these, 89.2% had a myocardial infarction, while the remaining 10.8% were diagnosed with unstable angina. The most frequent cardiovascular comorbidities were hypertension (71.3%), dyslipidemia (63.0%) and diabetes mellitus (31.7%). Fondaparinux was the anticoagulant of choice in 27.5% of patients, whereas the remainder were treated with enoxaparin. Compared with patients receiving enoxaparin, those in the fondaparinux group were younger, had less hypertension or diabetes mellitus and exhibited a less severe presentation; nonetheless, they had more often a previous history of coronary artery disease or hemorrhagic events. An invasive approach in terms of revascularization was adopted in 87.7% of the cohort (79.1% in the fondaparinux group vs. 90.9% in the enoxaparin group, p<0.001). The primary efficacy and safety endpoints occurred in 2.4% and 4.7% of patients, respectively. After adjustment for relevant covariates, the use of fondaparinux was independently associated with a lower rate of both the primary efficacy (OR 0.56 [0.32–0.95], p=0.034) and the primary safety endpoints (OR 0.37 [0.23–0.59], p<0.001).

Conclusion

In a contemporary portuguese cohort of NSTE-ACS patients, fondaparinux was underused but still independently associated with a lower risk of both a composite of in-hospital reinfarction or mortality event and major hemorrhage.

Funding Acknowledgement

Type of funding source: None

An invasive strategy is associated with improved short- and long-term outcomes in acute myocardial infarction independently of frailty status and GRACE score: a nationwide analysis of 12144 episodes

Introduction

Frailty is common among patients presenting with acute myocardial infarction (MI), who have conflicting risks regarding benefits and harms of invasive procedures.

Purpose

To assess the clinical management and prognostic impact of invasive procedures in frail MI patients in a real-world scenario.

Methods

We analysed 5422 episodes of ST-elevation MI (STEMI) and 6692 of Non-ST-elevation MI (NSTEMI) recorded from 2010–2019 in a nationwide registry. A validated deficit-accumulation model was used to create a frailty index (FI), comprising 22 features [BMI >25kg/m2, myocardial infarction, angina, heart failure, percutaneous coronary intervention (PCI), coronary artery bypass graft surgery (CABG), valvular disease, bleeding, pacemaker/implantable cardioverter defibrillator, chronic kidney disease (creatinine >2.0mg/dL), dialysis/renal transplant, stroke/transient ischaemic attack, diabetes, hypertension, dyslipidaemia, smoking, peripheral vascular disease, dementia, chronic lung disease, malignancy, polymedication (>3 cardiovascular drugs), admission haemoglobin <10g/dL; not including age]. Episodes with missing data on any FI parameter were not included. Frailty was initially defined as FI>0.25 (i.e. ≥6 features).

Results

Overall, 511 (9.4%) STEMI and 1763 (26.4%) NSTEMI patients were considered frail. Angiography, PCI and CABG were less frequently performed in frail patients (p<0.001). Delayed angiography (>72h) was more common among NSTEMI frail patients (p<0.001), and radial access was less commonly used overall (p<0.001). Guideline-recommended in-hospital medical therapy, including aspirin (NSTEMI), dual-antiplatelet therapy (STEMI/NSTEMI), heparin/heparin-related agents (NSTEMI), beta-blockers (STEMI) and ACEIs/ARBs (STEMI), was less commonly used in frail patients; discharge medical therapy exhibited similar patterns. Frail patients had longer hospital stay and increased in-hospital all-cause and cardiovascular (CV) mortality, as well as 1-year all-cause and CV hospitalization and all-cause mortality (p<0.001). Using receiver-operator-characteristics curve analysis, FI cutoffs of 0.11 (STEMI) and 0.20 (NSTEMI) yielded the best accuracy to predict 1-year all-cause mortality (area under the curve: 0.629 and 0.702 respectively, p<0.001) – these cutoffs were subsequently used to define frailty. Although frailty attenuated in-hospital risk reductions from angiography (STEMI/NSTEMI) and PCI (NSTEMI only) (Wald test p<0.05), their 1-year prognostic benefit remained unaffected (Wald test p>0.05). Angiography and PCI were associated with improved in-hospital and 1-year outcomes, independently of frailty status or GRACE score (p<0.001).

Conclusion

Frail MI patients are less commonly offered standard therapy; however, angiography and PCI were associated with short- and long-term prognostic benefits regardless of frailty status or GRACE score. Increased adherence to current recommendations might improve post-MI outcomes in frail patients.

Invasive strategy and 1-year outcomes

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Portuguese Society of Cardiology

Improving medical emergency system: Results of a multi-professional questionnaire

OBJECTIVE

This study aimed to identify ways to improve the Medical Emergency System (MES) in its different components and infer Medical Emergency Team (MET) activation failure causes.

METHODS

A questionnaire regarding opinions and attitudes towards the MES was conducted, targeting all professionals at the hospital, which has an implemented MES with Basic Life Support (BLS) since 1998.

RESULTS

Thirty two percent (n=585) of hospital professionals answered, from these 37.8% were neither doctors nor nurses. In mean six years passed since the BLS certification, yet 102 professionals (17.4%) had not done it. A relevant percentage admitted to not being familiarized with the different components of the MES (activation criteria 16.4%, telephone number 4.1%, content of the resuscitation trolleys 42.4% and defibrillator-monitor 47.4%), percentages lessened among those had taken the BLS course. The majority highly valued MET, however 83 (23%) could not confirm that debriefingand 17 (4.4%) that allocation of tasks happened after and during activation, respectively. When activating MET 52 (18.1%) admitted fear of criticism and 38 (13.3%) agreed that they needed validation by another professional, factors not influenced by BLS course completion. Excessive workload as a barrier to recognize ill patients was pointed by 127 (45.7%) of the respondents.

CONCLUSION

Despite educational and auditing efforts, the MES is not fully integrated into hospital culture. BLS certification for all professionals and non-technical skills of MET were identified has major areas for MES improvement. Unfamiliarity with activation criteria, fear of criticism and excessive workload were identified as failure of activation causes.

Accessible communication in the transport of non-urgent people with communication impairments

Introduction Paramedics may find innumerous circumstances that require careful consideration of the patient’s clinical condition. Because of that, communication between paramedics and patients in a critical condition must be as clear and effective as possible.

Objectives This study aims to identify the communicative needs of ambulance’s crew members when transporting non-urgent people with communicative impairments and to create a tool that facilitates the communicative process.

Methodology A brainstorming was held at Associação de São Jorge to gather information regarding the needs and difficulties experienced by the ambulance’s crew members. An audio record of this meeting was collected and a qualitative analysis was carried out. Additionally, a questionnaire was fulfilled. Based on these results, a first version of the communicative tool was developed. A pluridisciplinary focus group was held to discuss it, regarding content, form and utility. After this focus group, the second version of the communicative tool was elaborated to be tested by the crew members of this association. As so, a dynamic of three hours was implemented to empower these professionals to use this tool and other communicative strategies.

Results The qualitative analysis of the first meeting collected data recognize as crew member’s needs: communicating basic and immediate needs at clinical level and at colloquial discourse. This data allowed to establish parameters for the construction of the first version of the communicative tool. The referred focus group identified the need to improve it, considering: format, content and also the need to complement this tool with other communicative facilitators (e.g. braille; gestures).

Conclusion This study shows the need of facilitating the communication in non-urgent transportation. Despite the modifications that have to be done, the communicative tool that was developed already shows a positive impact in the ambulance crew and in the community.

Efficiency of PEG secondary concentration and PCR for the simultaneous concentration and quantification of foodborne bacteria, viruses and protozoa

Fresh fruits are a potential source of many different pathogens, including bacteria, enteric viruses and protozoa that may pose serious health risks. The consumption of raspberries has been widely associated with large foodborne outbreaks and because of the low concentration at which most of these pathogens are found, sensitive and accurate detection methods are required. Methods that would allow for an accurate and sensitive simultaneous elution and concentration of the different classes of pathogens would decrease the time for analysis, the costs associated and the expertise necessary. In this study we explored the use of polyethylene glycol (PEG) secondary concentration to simultaneously concentrate bacteria, enteric viruses and protozoa from raspberries. PEG secondary concentration showed good recovery rates for all the organisms tested. This work indicates that PEG secondary concentration followed by quantitative (Reverse Transcription) Polymerase Chain Reaction (q(RT)PCR) may be a relevant alternative to standardized methods for the simultaneous concentration of bacteria, enteric viruses and protozoa.

Improving the identification of the source of faecal pollution in water using a modelling approach: From multi-source to aged and diluted samples

The last decades have seen the development of several source tracking (ST) markers to determine the source of pollution in water, but none of them show 100% specificity and sensitivity. Thus, a combination of several markers might provide a more accurate classification. In this study Ichnaea® software was improved to generate predictive models, taking into account ST marker decay rates and dilution factors to reflect the complexity of ecosystems. A total of 106 samples from 4 sources were collected in 5 European regions and 30 faecal indicators and ST markers were evaluated, including E. coli, enterococci, clostridia, bifidobacteria, somatic coliphages, host-specific bacteria, human viruses, host mitochondrial DNA, host-specific bacteriophages and artificial sweeteners. Models based on linear discriminant analysis (LDA) able to distinguish between human and non-human faecal pollution and identify faecal pollution of several origins were developed and tested with 36 additional laboratory-made samples. Almost all the ST markers showed the potential to correctly target their host in the 5 areas, although some were equivalent and redundant. The LDA-based models developed with fresh faecal samples were able to differentiate between human and non-human pollution with 98.1% accuracy in leave-one-out cross-validation (LOOCV) when using 2 molecular human ST markers (HF183 and HMBif), whereas 3 variables resulted in 100% correct classification. With 5 variables the model correctly classified all the fresh faecal samples from 4 different sources. Ichnaea® is a machine-learning software developed to improve the classification of the faecal pollution source in water, including in complex samples. In this project the models were developed using samples from a broad geographical area, but they can be tailored to determine the source of faecal pollution for any user.

Water safety plan enhancements with improved drinking water quality detection techniques

Drinking water quality has been regulated in most European countries for nearly two decades by the drinking water directive 98/83/EC. The directive is now under revision with the goal of meeting stricter demands for safe water for all citizens, as safe water has been recognized as a human right by the United Nations. An important change to the directive is the implementation of a risk-based approach in all regulated water supplies. The European Union Framework Seventh Programme Aquavalens project has developed several new detection technologies for pathogens and indicators and tested them in water supplies in seven European countries. One of the tasks of the project was to evaluate the impact of these new techniques on water safety and on water safety management. Data were collected on risk factors to water safety for five large supplies in Denmark, Germany, Spain and the UK, and for fifteen small water supplies in Scotland, Portugal and Serbia, via a questionnaire aiming to ascertain risk factors and the stage of implementation of Water Safety Plans, and via site-specific surveys known as Sanitary Site Inspection. Samples were collected from the water supplies from all stages of water production to delivery. Pathogens were detected in around 23% of the 470 samples tested. Fecal contamination was high in raw water and even in treated water at the small supplies. Old infrastructure was considered a challenge at all the water supplies. The results showed that some of the technique, if implemented as part of the water safety management, can detect rapidly the most common waterborne pathogens and fecal pollution indicators and therefore have a great early warning potential; can improve water safety for the consumer; can validate whether mitigation methods are working as intended; and can confirm the quality of the water at source and at the tap.

Identification of Copy Number Variation by Array-CGH in Portuguese Children and Adolescents Diagnosed with Autism Spectrum Disorders

BACKGROUND

Autism spectrum disorders (ASD) affect many children with an estimated prevalence of 1%. Array-comparative genomic hybridization (CGH) offers significant sensitivity for the identification of submicroscopic chromosomal abnormalities and it is one of the most used techniques in daily practice. The main objective of this study was to describe the usefulness of array-CGH in the etiologic diagnosis of ASD.

METHODS

Two-hundred fifty-three patients admitted to a neurogenetic outpatient clinic and diagnosed with ASD were selected for array-CGH (4 × 180K microarrays). Public databases were used for classification in accordance with the American College of Medical Genetics Standards and Guidelines.

RESULTS

About 3.56% (9/253) of copy number variations (CNVs) were classified as pathogenic. When likely pathogenic CNVs were considered, the rate increased to 11.46% (29/253). Some CNVs apparently not correlated to the ASD were also found. Considering a phenotype-genotype correlation, the patients were divided in two groups. One group according to previous literature includes all the CNVs related to ASDs (23 CNVs present in 22 children) and another with those apparently not related to ASD (10 CNVs present in 7 children). In 18 patients, a next-generation sequencing (NGS) panel were performed. From these, one pathogenic and 16 uncertain significance variants were identified.

CONCLUSION

The results of our study are in accordance with the literature, highlighting the relevance of array-CGH in the genetic of diagnosis of ASD population, namely when associated with other features. Our study also reinforces the need for complementarity between array-CGH and NGS panels or whole exome sequencing in the etiological diagnosis of ASD.

Impact of beef extract used for sample concentration on the detection of Escherichia coli DNA in water samples via qPCR

There is increasing interest in methodologies for the simultaneous concentration and detection of multiple targets in individual samples. The aim of this study was to investigate the potential presence of E. coli DNA in beef extract powder used as part of a procedure to concentrate water samples for the simultaneous detection of bacteria, viruses and protozoa. DNA from E. coli was detected in five out of six beef extract lots tested, demonstrating the limitations of its inclusion when being used in assays that will be used for the detection of E. coli in water samples. Further work is required to clarify if this phenomenon also occurs for other microorganisms of interest in water.

P6404Myocardial infarction with nonobstructive coronary arteries: does aspirin have a place in the treatment of this entity?

Background

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is still a clinical enigma that is being increasingly recognised, as the number of coronary angiographies we perform in our centres also increase. However, the treatment for this entity is still a matter of important debate, not only due to the different causative mechanisms of this disease but also because there are no major trials regarding MINOCA treatment.

Purpose

To determine the association between acetylsalicylic acid (ASA) use after discharge and mortality after discharge in MINOCA patients admitted to a coronary care unit (CCU).

Methods

We analyzed data from 370 (11.7% of the global sample) patients admitted with MINOCA in our CCU. Patients with other final diagnoses, missing mortality data, previous acute myocardial infarction, contra-indications to aspirin and known heart failure before admission were excluded. All patients underwent transthoracic echocardiography and coronary angiography at any point during hospitalisation. After adjusting data for relevant comorbidities we then compared mortality after hospital discharge between the ASA group and the no-ASA group.

Results

Of all MINOCA patients admitted in our CCU, 84 (22.7%) were diagnosed with ST-elevation myocardial infarction (STEMI) and 286 (77.3%) with non-ST elevation myocardial infarction (NSTEMI). 296 (80%) patients received ASA after discharge. Both groups were homogeneous as we did not find any significant differences between groups regarding age (p=0.106), left ventricle ejection fraction (p=0.100), GRACE score at hospitalisation (p=0.150), Killip-Kimball class at hospitalisation (p=0.604), incidence of acute kidney injury (p=0.450), maximum c-reactive protein during stay (p=0.804) and low-density lipoprotein levels at hospitalization (p=0.055). There was also no difference in the incidence of diabetes (p=0.350), exposure to daily stress (p=0.767), active smoking (p=0.569), dyslipidemia (p=0.229), hypertension (p=0.057) and type of myocardial infarction (STEMI vs NSTEMI – p=0.215). In this MINOCA cohort (5 years follow-up) a total of 47 patients died (12.7%). ASA vs. no-ASA 1-month (3.1% vs. 0.0%, p=0.214), 6-month (4.5% vs. 1.4%, p=0.317), 1-year (5.9% vs 5.6%, p=0.900), 3-year (10.5% vs. 8.3%, p=0.668) and 5-year (13.3% vs. 12.5%, p=0.860) all-cause mortality was not significantly different. The same non-significant trend towards higher mortality with ASA was obtained when survival curves were taken into account.

Conclusions

MINOCA remains a challenging entity. In our study, the systematic use of ASA in all patients following MINOCA was not associated with better survival after long-term follow-up.

Bowel preparation for small bowel capsule endoscopy - The later, the better!

BACKGROUND

In small bowel capsule endoscopy (SBCE), the presence of residue may compromise diagnostic accuracy.

AIMS

To assess differences in quality of visualisation and diagnostic yield of SBCE using 3 different preparation protocols.

METHODS

Prospective, randomized, blind, pilot study. Protocol A:Clear liquids diet the day before the examination with fasting from 8p.m.; Protocol B:Protocol A + 2 pouches of Moviprep^®(polyethylene glycol electrolyte solution + sodium ascorbate) in 1 L of water from 8p.m. of the day before the examination; Protocol C: Protocol A + 2 pouches of Moviprep^® in 1 L of water consumed after real-time confirmation of capsule arrival at small bowel. Small bowel preparation was classified by two experienced physicians, considering the percentage of the examination during which mucosal observation was adequate: Excellent(>90%); Good(90-75%); Fair(75-50%); Poor(<50%).

RESULTS

101 patients randomized to the 3 protocols (A 37, B 31, C 33 patients). Protocol C had an excellent/good small bowel preparation in a higher percentage of examinations for both readers(Reader 1-A:37.8% vs B:45.2% vs C:78.8%, p = 0.002 and Reader 2 -A:37.8% vs B:41.9% vs C:75.8%, p = 0.003). Also, protocol C had a higher detection of angioectasia (A:5.4% vs B:9.7% vs C:27.3%, p = 0.022).

CONCLUSIONS

The administration of Moviprep^® after the capsule had reached the small bowel was associated with a better small bowel preparation and a higher detection of angioectasia.

Global phylogeography and ancient evolution of the widespread human gut virus crAssphage

Microbiomes are vast communities of microorganisms and viruses that populate all natural ecosystems. Viruses have been considered to be the most variable component of microbiomes, as supported by virome surveys and examples of high genomic mosaicism. However, recent evidence suggests that the human gut virome is remarkably stable compared with that of other environments. Here, we investigate the origin, evolution and epidemiology of crAssphage, a widespread human gut virus. Through a global collaboration, we obtained DNA sequences of crAssphage from more than one-third of the world's countries and showed that the phylogeography of crAssphage is locally clustered within countries, cities and individuals. We also found fully colinear crAssphage-like genomes in both Old-World and New-World primates, suggesting that the association of crAssphage with primates may be millions of years old. Finally, by exploiting a large cohort of more than 1,000 individuals, we tested whether crAssphage is associated with bacterial taxonomic groups of the gut microbiome, diverse human health parameters and a wide range of dietary factors. We identified strong correlations with different clades of bacteria that are related to Bacteroidetes and weak associations with several diet categories, but no significant association with health or disease. We conclude that crAssphage is a benign cosmopolitan virus that may have coevolved with the human lineage and is an integral part of the normal human gut virome.

P6420Can machine learning help us improve risk stratification of diabetic patients with acute coronary syndromes? The answer will blow your mind

Background

Risk stratification following an acute coronary syndrome (ACS) is of utmost importance, in order to identify patients at higher risk of subsequent cardiovascular events. Diabetic patients have a significantly worse prognosis, so new risk prediction tools are important to better identify and risk stratify high risk patients within this important ACS subpopulation.

Aim

The aim of this study was to identify the best predictors of a new ACS, in a single-center database of ACS, resorting to machine learning and artificial intelligence, and to compare the Global Registry of Acute Coronary Events (GRACE) risk score's relevance for risk discrimination in a general ACS population versus a subpopulation of diabetic patients.

Methods

In a single center, 5977 patients admitted due to ACS between 2004 and 2017 and alive at discharge were studied. In the subpopulation of diabetic patients (n=3429), each covariate present in the database was analyzed separately with a Cox proportional hazard model with three terms – subpopulation belonging indicator, covariate, interaction term. The p-value of the interaction term was used to rank variables. The more significant the interaction term, the stronger the change in relationship between patients in the subpopulation and the risk of a new ACS, compared to the one in the general population.

Results

During long term follow-up, 13% of patients (n=771) experienced a second event. Kaplan-Meier curve represents how ACS free-survival depends on the GRACE risk score and group of interest. In the general population and in the subpopulation of diabetic patients, the GRACE score was used to further divide patients into 3 terciles, of which only the lower and upper tercile are shown (GRACE ≤113 and GRACE >144, respectively). The solid lines represent Kaplan-Meier curves for diabetic patients, and the dotted lines in the general population. Pink or grey colour of the curves represent the stratification level of the covariate.

Conclusions

In our model, the GRACE risk score was found to be a better discriminator of risk of futher ACS in diabetic patients than in the general ACS population. Strikingly, a higher GRACE score predicts a lower rate of readmission, probably because many patients will die in the index hospitalization or out of hospital. This finding reinforces the usefulness of the GRACE score in high risk patients and may improve risk stratisfication in diabetic post-ACS patients, making sure that they are closely followed and submitted to optimal risk factor management, in order to improve their post-ACS prognosis.

Global phylogeography and ancient evolution of the widespread human gut virus crAssphage

Microbiomes are vast communities of microorganisms and viruses that populate all natural ecosystems. Viruses have been considered to be the most variable component of microbiomes, as supported by virome surveys and examples of high genomic mosaicism. However, recent evidence suggests that the human gut virome is remarkably stable compared with that of other environments. Here, we investigate the origin, evolution and epidemiology of crAssphage, a widespread human gut virus. Through a global collaboration, we obtained DNA sequences of crAssphage from more than one-third of the world's countries and showed that the phylogeography of crAssphage is locally clustered within countries, cities and individuals. We also found fully colinear crAssphage-like genomes in both Old-World and New-World primates, suggesting that the association of crAssphage with primates may be millions of years old. Finally, by exploiting a large cohort of more than 1,000 individuals, we tested whether crAssphage is associated with bacterial taxonomic groups of the gut microbiome, diverse human health parameters and a wide range of dietary factors. We identified strong correlations with different clades of bacteria that are related to Bacteroidetes and weak associations with several diet categories, but no significant association with health or disease. We conclude that crAssphage is a benign cosmopolitan virus that may have coevolved with the human lineage and is an integral part of the normal human gut virome.

P3122Complete versus culprit-vessel only revascularization for patients with acute coronary syndromes and multivessel disease

Background

Recent randomized clinical trials have suggested that complete revascularization (CR) instead of culprit-vessel only revascularization (CVO) strategies may take a stand in the optimal management of patients admitted for acute myocardial infarction (AMI) with multivessel (MV) disease undergoing primary percutaneous coronary intervention (P-PCI). However, despite the 2017 ST-elevation acute coronary syndrome (STEMI) guidelines update with a new class of recommendation for CR, it remains controversial whether this strategy leads to better outcomes.

Purpose

To compare CR versus CV strategies during hospitalization in patients presenting with AMI with multivessel disease at P-PCI.

Methods

We analyzed data from all patients admitted with non-ST acute myocardial infarction (NSTEMI) and STEMI in a portuguese coronary care unit (CCU), between 2007 and 2016. We then evaluated potential differences of CR versus CVO with PCI during hospitalization in AMI patients with multivessel disease, defined by at least 2 different diseased main coronary vessels, saphenous vein or mammary artery conduits. We used 1:1 ratio propensity score matching to study the impact of CR on patient mortality and adjusted data for relevant risk factors at admission time.

Results

A total of 4758 patients were admitted for AMI, 2690 NSTEMI (56.5%) and 2068 STEMI (43.5%). Access to PCI records was possible in 3162 (66.5%) patients, of which 1707 (54%) underwent CR versus 1455 (46%) who underwent CVO. CVO patients were older (67.9±11.8 vs. 63.5±13.1 years, p<0.001), more diabetic (56.5% vs. 47.1%, p<0.001), hypertensive (78.4% vs. 72.2%, p<0.001), dyslipidemic (82.1% vs. 75%, p<0.001), had greater GRACE score at admission (mean score 143.4±37.2 vs. 131.2±131.2, p<0.001), had more severe coronary disease (mean number of diseased vessels – 2.56±0.6 vs. 2.18±0.4, p<0.004), reached higher Killip class (mean – 1.42±0.9 vs. 1.26±0.7, p<0.001) and had lower left ventricular ejection fraction (48.07±11.6 vs. 51.25±10.5, p<0.001). No significant differences were found in peak troponin-I release between CR and CV (44.7±69 vs. 46.9±76, respectively, p=0.468). After propensity matching, we obtained 130 CR and 133 CVO patients. In this cohort all-cause mortality was lower in CR group at 6-month (RR 0.262, CI 95% 0.071–0.962, p=0.031) and 1-year (RR 0.340, CI 95% 0.119–0.973, p=0.036) follow-up. When comparing STEMI versus NSTEMI all-cause mortality was nonsignificantly lower in CR (RR 0.394 vs. 0.226, p=0.12 vs. p=0.16).

Conclusions

In patients presenting with AMI and MV disease, CR strategy during hospitalization leads to greater 6-month and 1-year survival when compared with CVO strategy. Despite not having found significant differences when STEMI was directly compared to NSTEMI, we believe this was due to the great loss of patient numbers after propensity matching, requiring larger trials to prove the effect.

P2655ST-elevation myocardial infarction in women: a more satisfactory outcome?

Background

Despite all the advances registered in the last decade regarding acute myocardial infarction with ST-segment elevation (STEMI) treatment, this entity remains prevalent and highly lethal. Women constitute a lower proportion of STEMI patients, however, they show important differences when compared to men. Thanks to the lower representation of women in STEMI trials, less is know about this patient subpopulation.

Purpose

To determine and understand gender differences in patients admitted with STEMI in a coronary care unit (CCU).

Methods

Observational retrospective study of patients admitted with STEMI in a CCU, between 2006 and 2017. Patients were split between groups according to gender and were assessed in terms of risk factors, diagnosis, treatment, complications and mortality.

Results

A total of 2516 patients were included in the study. 1833 were men (72.9%) and 682 were women (27.1%). Mean age was superior in women (73.3±13.2 vs. 64.1±12.8 years, p<0.001), and displayed a greater cardiovascular comorbidity burden such as hypertension (79.6% vs. 66.2%, p<0.001) and diabetes (55.8% vs. 45.3%, p<0.001). At admission time women registered a higher mean TIMI (2.79 vs. 2.62, p=0.009) and GRACE score (166.3 vs. 146.3, p<0.001) which did not reflect in a higher hospital stay (mean 4.75 vs. 5.29 days, p=0.043). Before admission women were less treated with aspirin (26.4% vs. 33.2%, p=0.014) and statins (36.8% vs. 46.5%, p=0.001). There were no differences regarding access to revascularization (98% vs. 96.5%, p=0.105) but women presented more normal coronary angiographies (10.2% vs. 3.6%, p<0.001). During hospital stay, women evolved more to Killip-Kimball (KK) class III (4.5% vs. 1.9%, p<0.001) and KK class IV (15.9% vs. 11.2%, p<0.001). Intra-hospital (13.9% vs. 8.2%, p<0.001), 1-month (18.4% vs. 13.2%, p<0.001), 6-month (22.2% vs. 16.1%, p<0.001) and 1-year mortality (25.7% vs. 17.8%, p<0.01) was superior in women. After multivariate analysis heart failure on admission (OR 9.2, CI 95% 6.7–12.8), intravenous amiodarone use (OR 3.5, CI 95% 2.5–4.8), diabetes (OR 2.3, CI 95% 1.8–2.8), female gender (OR 1.6, CI 95% 1.3–2.0) and peak serum creatinine during hospital stay (OR 1.7, CI 95% 1.6–1.9) were independent predictors of 1-year mortality. After adjustment for age, diabetes, hypertension, previous acute myocardial infarction and initial KK, female gender maintained its potency as a significant 1-year mortality predictor.

Conclusions

Women presenting with STEMI register poorer outcomes compared to men. In our study, female gender was considered a good independent predictor of short-term and long-term mortality.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Development of a novel digital RT-PCR method for detection of human sapovirus in different matrices

A new nanofluidic digital RT-PCR method was developed for sapovirus (SaV) using control material obtained according to standards for enteric viruses. Primers employed amplify a fragment of 112 bp of the polymerase capsid junction, allowing the detection of human genogroups I, II and IV. Analytical validation was performed in clinical, shellfish and environmental water samples. This novel protocol rendered great effectiveness and repetitiveness, as well as higher sensitivity than real time RT-PCR assay, with differences in quantification ranging from 0.1 to 2.6 log-units. The method described here can constitute a promising tool for standardizing SaV quantification.