Assessment of the Implementation of the International Health Regulations during the COVID-19 Pandemic: Portugal as a Case Study

INTRODUCTION

The International Health Regulations (IHR) were developed to prepare countries to deal with public health emergencies. The spread of SARS-CoV-2 underlined the need for international coordination, although few attempts were made to evaluate the integrated implementation of the IHR's core capacities in response to the COVID-19 pandemic. The aim of this study was to evaluate whether IHR shortcomings stem from non-compliance or regulatory issues, using Portugal as a European case study due to its size, organization, and previous discrepancies between self-reporting and peer assessment of the IHR's core capacities.

METHODS

Fifteen public health medical residents involved in contact tracing in mainland Portugal interpreted the effectiveness of the IHR's core capabilities by reviewing the publicly available evidence and reflecting on their own field experience, then grading each core capability according to the IHR Monitoring Framework. The assessment of IHR enforcement considered efforts made before and after the onset of the pandemic, covering the period up to July 2021.

RESULTS

Four out of nine core IHR capacities (surveillance; response; risk communication; and human resource capacity) were classified as level 1, the lowest. Only two were graded level 3 (preparedness; and laboratory), the highest. The remaining three) (national legislation, policy & financing; coordination and national focal point communication; and points of entry) were classified as level 2.

CONCLUSION

Portugal exemplifies the extent to which implementation of the IHR was not fully achieved, which has resulted in the underperformance of several core capacities. There is a need to improve preparedness and international cooperation in order to harmonize and strengthen the global response to public health emergencies, with better political, institutional, and financial support.

P1166Women as candidates for CRT: Are they less but better?

Introduction

 Women have been under-represented in trials of cardiac resynchronization therapy (CRT).  Most available data suggest that CRT has a greater clinical benefit in women than in men. However, further studies are needed to investigate the exact reasons for these results.

Purpose

To compare the prognostic impact and response rate of CRT in women and man.

Methods

Prospective study, single-center study that included pts undergoing CRT implant from 2015 to 2019. Clinical and echocardiographic evaluation were made before CRT implant and between 6-12 months post-implant. Pts with EF elevations≥10% or LV end-systolic volume (ESV) reductions≥15% were classified as responders. Patients with EF elevations ≥ 20% or ESV reductions≥30% were classified as super-responders. All the parameters were compared between women and man. Prognostic impact of CRT was evaluated as total mortality by the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 561 patients were submitted to CRT implant with a follow-up duration of 18.9 ± 15.8 months. From these 148 (26.4%) were female (mean age 72.2 ± 10 years, 22.4% ischemic, LVEF < 30% in 70.2%). The cardiovascular risk factors and comorbidities were similar in both populations (women and men). In the female group, dilated cardiomyopathy was more frequent than in men (71% vs 50.8%, p < 0.01), with ischemic heart disease being the second most frequent etiology of heart failure.

The frequency of LBBB was similar in both groups (63.9% in women and 57.0% in men, p = NS) however the QRS duration was higher in women (164 ± 17 vs 160 ± 24, p = 0.017). The baseline mean EF was similar (30.5 ± 10.3ms in women and 30.3 ± 11.4ms in men) but the ESV was lower (109.7 ± 59.9 vs 138.4 ± 64.6, p < 0.001).

The prevalence of complications and need for surgical revision were similar in both groups.

The rate of CRT responders was similar in both groups, although tendentially higher in women (64.3% in women vs 55.2% in men, p = NS). On the other hand, super-responder rate was statistically significant (38% in women vs 25.1% in men, p = 0.004). The long-term survival was similar in both groups.

Conclusion

The rate of super-responders was higher in women than in men. This may be explained by the higher prevalence of dilated cardiomyopathy in this subgroup of patients and by the fact that women have smaller hearts and a larger QRS duration at baseline, most likely to have a real LBBB. Long-term mortality of CRT was not gender related

Abstract Figure. Long-term survival by gender

P1162Atrial fibrillation and Cardiac resynchronization therapy - is this combination truly bad?

Introduction

 

Cardiac resynchronization therapy (CRT) significantly reduces mortality and hospitalizations in patients with heart failure and reduced ejection fraction (EF). Atrial fibrillation (AF) is a very common comorbidity in these patients, however, CRT benefit in AF patients has been controversial.

Purpose

 

To compare the prognostic impact of CRT in patients (pts) with and without AF.

Methods

Prospective, single-center study that included pts undergoing CRT implantsince 2015. Clinical and echocardiographicevaluation were made before CRT implant and between 6-12 months post-implant. Pts with EF elevation ≥10% or LV end-systolic volume (ESV) reduction ≥15% were classified as responders. Patients with EF elevation ≥ 20% or ESV reduction ≥30% were classified as super-responders. All the parameters were compared between patients with and without AF.Prognostic impact of CRT was evaluated by comparing total mortality using the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). From these patients, 166 patients (31%) had AF (73.5% males, mean age 72.2 ± 10.2 years, 37.3% ischemic, LVEF < 30% in 65.5%). The cardiovascular risk factors and comorbidities were similar in both populations (with and without AF), except for chronic kidney disease which was more frequent in AF pts(28% vs 17%, p = 0.012). 

The prevalence of complications and surgical revision were similar in both groups.

The CRT response rate was similar in both groups (50% in AF group vs 59.6%, p = NS) as was the super-response rate (22.4% in FA pts vs 31.5%, p = NS).

The 4-year survival rate of patients with AF was similar to non-AF (83.7% vs 84.3%). 

Conclusion

 

Despite the controversy about the efficacy of CRT in AF pts, in our population the long-term survival and CRT response rates were comparable between patients with and without AF.

Abstract Figure.

P541Cardiac resynchronization therapy: left or non-left bundle branch block? That is the question

Introduction

Cardiac resynchronization therapy (CRT) is associated with reduced mortality and improved quality of life in patients (pts) with low ejection fraction (EF) and conduction delays. Patients with left bundle branch block (LBBB) seem to be the ones who benefit the most from CRT and there is controversy about its efficacy in patients with non-LBBB.

Purpose

To compare the prognostic impact and the response rate to CRT in patients with LBBB and non-LBBB.

Methods

Prospective single-center study of patients who implanted CRT between 2015 and 2019. Clinical, electrocardiographic and echocardiographic evaluations were made before CRT implant and between 6-12 months post-implant. Patients with EF elevation ≥ 10% or left ventricle end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. All the parameters were compared between patients with or without LBBB. Prognostic impact of resynchronization therapy was evaluated by comparing total mortality using the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). From these patients, 59% had LBBB (69% males, mean age 71.6 ± 10.8 years, 34.5% ischemic, EF < 30% in 65.5%). The cardiovascular risk factors and comorbidities were similar in both populations (with and without LBBB), except for diabetes which was more frequent in non-LBBB patients (33% vs 50.6%, p = 0.007). Mean duration of QRS was similar between LBBB vs non-LBBB patients (163 ± 19ms vs 160 ± 22ms, p = NS) and baseline ejection fraction was also equivalent (29.8 ± 13.6% vs 27.9 ± 8.9%).

The prevalence of complications and surgical revisions were similar in both groups.

The response rate according to left ventricle remodelling criteria was higher in LBBB pts (65.9% vs 49.1%, p < 0.05), but the super-responders were similar in both groups (32.5% vs 26.4% p = NS).

The 4-year survival rate of patients with LBBB and non-LBBB was similar (86.5% vs 85.3%).

Conclusion

In our population the response rate to CRT was higher in LBBB pts. However, and despite the actual controversy about the efficacy of CRT in non-LBBB, the long-term mortality was similar in patients with or without LBBB.

Abstract Figure. lon-term survival

Intravenous immunoglobulin in lupus panniculitis

Systemic lupus erythematosus (SLE) is a disease of unknown cause that may involve one or many organ or systems. Skin involvement is a major feature in this disease, and a wide variety of skin conditions may be present. Lupus erythematosus panniculitis (LEP) constitutes a rare form of cutaneous lupus characterized by recurrent nodular or plaque lesions that can vary from a benign and mild course to a more disfiguring disease. Initial therapy includes corticosteroids, antimalarials, and azathioprine and, in refractory cases, two antimalarials in association, mycophenolate mofetil, or other immunomodulators. Intravenous immuglobulin (IVIG) is used in many autoimmune disorders, like in SLE, although clinical trials have not yet taken place. In this report, we review skin manifestations of SLE and their treatment, IVIG, and finally a case of LEP successfully treated with IVIG when other therapy modalities failed.

Autosomal recessive short stature, Robin sequence, cleft mandible, pre/postaxial hand anomalies, and clubfeet in male patients

We report on 2 unrelated Brazilian boys with the syndrome of autosomal recessive short stature, Robin sequence, cleft mandible, pre/postaxial hand anomalies, and clubfeet. This is the first report of male patients.

Newly recognized blepharofacioskeletal syndrome

A mother and daughter are described with similar facial and skeletal manifestations. The syndrome consists of blepharophimosis, malar hypoplasia, small thin lips, and long tapering fingers. The facial phenotype changes with age. Autosomal dominant inheritance is suggested.

Postaxial acrofacial dysostosis: report on two patients

We report on 2 patients with the postaxial acrofacial dysostosis (AFD) syndrome. One patient was an isolated case; the other had an equally affected brother previously described [Richieri-Costa and Guion-Almeida, 1989]. Recurrence in sibs suggests autosomal recessive inheritance.

Short stature, Robin sequence, cleft mandible, pre/postaxial hand anomalies, and clubfoot: a new autosomal recessive syndrome

We report on 5 unrelated Brazilian children with short stature, Robin sequence, cleft mandible, pre/postaxial hand anomalies, and clubfoot. Genetic aspects and phenotypic manifestations are compared with those of previous reports of acrofacial dysostoses and with other Robin sequence syndromes. We suspect that these patients present a previously undescribed autosomal recessive syndrome.

The effect of devascularization of the visual cortex on visual function in the rabbit

The role of the visual cortex in brightness and pattern vision was re-examined in the rabbit. Animals were trained on both a brightness and a horizontal-vertical striation discrimination. Bilateral removal of the dura mater overlying the entire visual cortex produced no impairments in either brightness or pattern vision. When the visual cortex was devascularized by removal of the pia mater bilaterally, total loss of pattern vision was found with no impairment of brightness discrimination ability. The significance of the finding that the effects of slowly developing degenerative lesions are the same as those of surgical ablation was discussed.

Angular acuity in normal and commissure-sectioned rabbits

Both normal and commissure-sectioned rabbits were examined over a variety of visual discrimination tasks. The visual displays were projected at various distances within the frontal visual field of the rabbit. The learning of either a black-white or a vertical-horizontal problem was found to be normal in commissure-cut animals. Furthermore, no deficit in angular acuity was observed. However, when they were tested with the patterns displayed at 25 cm distance, large impairments were found in the commissure-sectioned animals.