Case Report of a Hidden Intruder-Extremely Rare Presentation of Hydatidosis as a Nuchal Tumoural Mass

Introduction: The parasitic tapeworm impersonated by the larvae of Echinococcus granulosus represents the aetiology of the hydatid pathology. The predilect site of invasion is the liver, but there are other cases of different localization all over the body, regardless of the type of invaded tissue. Soft tissue hydatidosis can be a real challenge for the clinician in terms of the diagnosis, and it might generate various complications such as anaphylactic shock. The aim of the present work is to illustrate a unique case of primary hydatidosis located in the nuchal region. Case Report: We report the case of a 68-year-old male patient, a zootechnic, who presented at the hospital with a tumoural mass (dimension: about 12/10 cm) located in the nuchal region. The complex approach needed consisted of surgical therapy along with histopathological confirmation of the diagnostic and antiparasitic medication, which led to a complete recovery with a low probability of recurrence. Discussion: Encounters with patients with primary soft tissue hydatidosis are exceptionally rare, but the surgeon must take into consideration this clinical diagnosis, especially for patients located in an endemic region with occupations that might have exposed the patient to this type of parasite.

Cardiopulmonary long-term effects in patients after hospitalization due to COVID-19 infection

Background

Multiple studies have described acute effects of the Covid-19 infection on the heart, but little is known about the long-term cardiac and pulmonary effects and complications after recovery. The aim of this analysis was to deliver a comprehensive report of symptoms and possible long-term impairments after hospitalization because of Covid-19 infection as well as to try to identify predictors for Long-Covid.

Methods

This was a prospective, multicenter registry study. Patients with verified Covid-19 infection, who were treated as in-patients at our dedicated Covid hospital (Clinic Favoriten), have been included in this study. In all patients, testing was performed approximately 6 months post discharge. During the study visit the following tests and investigations were performed: detailed patient history and clinical examination, transthoracic echocardiography, electrocardiography, cardiac magnetic resonance imaging (MRI), chest computed tomography (CT) scan, lung function test and a comprehensive list of laboratory parameters including cardiac bio markers.

Results

Between July 2020 and October 2021, 150 patients were recruited. Sixty patients (40%) were female and the average age was 53.5±14.5 years. Of all patients, 92% had been admitted to our general ward and 8% had a severe course of disease, requiring admission to our intensive care unit. Six months after discharge the majority of patients still experienced symptoms and 75% fulfilled the criteria for Long-Covid. Only 24% were completely asymptomatic (figure 1).

Echocardiography detected reduced global longitudinal strain (GLS) in 11%. Cardiac MRI revealed pericardial effusion in 18%. Furthermore, cardiac MRI showed signs of former peri- or myocarditis in 4%. Pulmonary CT scans identified post-infectious residues, such as bilateral ground glass opacities and fibrosis in 22%. Exertional dyspnea was associated with either reduced forced vital capacity measured during pulmonary function tests in 11%, with reduced GLS and/or diastolic dysfunction, thus providing evidence for a cardiac and/or pulmonary cause.

Independent predictors for Long-Covid were markers of a more severe disease course like length of in-hospital stay, admission to an intensive care unit, type of ventilation as well as higher NT-proBNP and/or troponin levels.

Conclusion

Even 6 months after recovery from Covid-19 infection, the majority of previously hospitalized patients still suffer from at least one symptom, such as chronic fatigue and/or exertional dyspnea. While there was no association between fatigue and cardiopulmonary abnormalities, impaired lung function, reduced GLS and/or diastolic dysfunction were significantly more prevalent in patients presenting with exertional dyspnea. On chest CT approximately one fifth of all patients showed post infectious changes in chest CT including evidence for myo- and pericarditis as well as accumulation of pericardial effusions.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Major fund

Improving the Pharmacists’ Response to Public Health Emergencies—Documentary Research on Online Resources Provided by National Pharmacists’ Associations

Objectives: Given the expanding role of pharmacists during COVID-19 pandemic, we aimed to investigate the approach of professional associations to supporting their practice and to find ways to improve their response to public health emergencies.

Methods: We conducted documentary research on websites of seven national pharmacists’ associations, submitted the findings to a comparative thematic analysis, and made proposals of specific good practices.

Results: Many great resources were provided by pharmacists’ associations in Australia, France, Spain, and the US. The similarities include scientific information on COVID-19 tests, treatments and vaccines, legal issues, and wellbeing management. The main differences were in developing medication management programs, supporting hospital pharmacists, helping families, or advocating for an equitable vaccination. In Finland, Hungary and Romania, the focus was on updating emerging information. Considering the need for better managing public health emergencies at organizational level, we suggested good practices regarding training and communication.

Conclusion: Professional associations should develop preparedness and response plans for public health emergencies. Practical training and effective communication could improve the resilience of pharmacists and patients during pandemics, which could save lives.

The effect of 100-200 nm ZnO and TiO2 nanoparticles on the in vitro-grown soybean plants

Engineered nanomaterials are increasingly used in everyday life applications and, in consequence, significant amounts are being released into the environment. From soil, water, and air they can reach the organelles of edible plants, potentially impacting the food chain and human health. The potential environmental and health impact of these nanoscale materials is of public concern. TiO2 and ZnO are among the most significant nanomaterials in terms of production amounts. Our study aimed at evaluating the effects of large-scale TiO2 (~100 nm) and ZnO (~200 nm) nanoparticles on soybean plants grown in vitro. The effect of different concentrations of nanoparticles (10, 100, 1000 mg/L) was evaluated regarding plant morphology and metabolic changes. ZnO nanoparticles showed higher toxicity compared to TiO2 in the experimental set-up. Overall, elevated levels of chlorophylls and proteins were observed, as well as increased concentrations of ascorbic and dehydroascorbic acids. Also, the decreasing stomatal conductance to water vapor and net CO2 assimilation rate show higher plant stress levels. In addition, ZnO nanoparticle treatments severely affected plant growth, while TEM analysis revealed ultrastructural changes in chloroplasts and rupture of leaf cell walls. By combining ICP-OES and TEM results, we were able to show that the nanoparticles were metabolized, and their internalization in the soybean plant tissues occurred in ionic forms. This behavior most likely is the main driving force of nanoparticle toxicity.

Efficiency of platelet-rich plasma therapy for healing sports injuries in young athletes

In recent years, platelet-rich plasma (PRP) therapy has been a subject of controversy in orthopedics field. Our objective was to assess the efficiency of PRP therapy for patients who have suffered grade 2 meniscal lesions and grade 2 anterior cruciate ligament (ACL) lesions, graded by magnetic resonance imaging (MRI). A retrospective observational study was conducted, which included 72 young recreational athletes who had been diagnosed with grade 2 meniscal injury, graded using MRI, that benefited from PRP therapy as an enhancement of the primary treatment, after cast immobilization. The Lysholm score, the pain intensity and the resuming of the physical activity before the PRP treatment and one month after were analyzed. Our study revealed that patients had an improved subjective perception of pain after PRP therapy and an improvement of the Lysholm score. Concurrently, 83.3% of patients could return to sports and daily physical activity. It can be concluded that PRP therapy is a safe, easy to manage treatment, efficient for pain relief and in resuming of sports activities for young recreational athletes who have sustained partial meniscal or ACL tears. In terms of pain relief, it appears that the PRP therapy could be more efficient for young patients with ACL injuries.

Evaluating the Functional Outcomes and the Quality of Life for Pediatric Patients with Osteogenesis Imperfecta after Fracture Treatment with Intramedullary Rodding

BACKGROUND AND OBJECTIVES

Osteogenesis imperfecta is a rare pathology involving the bones and the connective tissues, generating alterations that lead to frequent fractures during childhood. When fractures occur at birth, they are associated with an impairment of walking and the quality of life. Although surgical techniques have significantly improved in recent years, functional outcomes and the quality of life for pediatric patients that benefited from surgical management with telescopic rods have been less evaluated. This study aimed to measure functional results and determine the factors that influence the quality of life for the pediatric population diagnosed with Osteogenesis imperfecta and surgically treated using the telescopic rod approach after suffering a fracture or severe deformity.

MATERIALS AND METHODS

We conducted a cohort study that consisted of 15 patients diagnosed with Osteogenesis imperfecta (average age of 11.6 years). All individuals possessed at least one intramedullary telescopic rod as a result of the surgical treatment.

RESULTS

We observed that the pain, both acute and chronic, impairs the quality of life and interferes with daily living activities, for instance, self-care tasks.

CONCLUSIONS

Osteogenesis imperfecta is associated with a severely damaged level of walking. All of the aspects of the pediatric patient's daily life activity seem to be affected. Furthermore, these patients, especially those residing in rural areas, have a poor quality of life.

Increased symmetric dimethyl-arginine is a predictor factor of decreased platelet reactivity and increased bleeding risk in patients with acute coronary syndrome

Background

One of the promising biomarkers in CVD are asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA), which are products of L-arginine methylation and are both involved in endothelial dysfunction. ADMA, SDMA and L-homoarginine, have emerged as biomarkers linked to cardiovascular outcomes [1].

Purpose

To investigate the association of SDMA with platelet reactivity and bleeding risk in patients with acute coronary syndrome (ACS) treated with potent P2Y12 inhibitors prasugrel and ticagrelor.

Methods

Our prospective observational study enrolled 292 patients with ACS undergoing percuteneus coronary intervention [2]. Plasma concentrations of SDMA were measured during the hospitalization for ACS. Impedance aggregometry was used. The primary study endpoint was the concentration of metabolites and platelet reactivity. The primary clinical outcome endpoint was the incidence of Thrombolysis in Myocardial Infarction (TIMI) bleeding events (major, minor and minimal). The efficacy endpoint was the composite of major adverse cardiac events (MACE: stent thrombosis, myocardial infarction, stroke and cardiac death).

Results

There was an inverse correlation between SDMA serum levels and platelet reactivity (r=−0.25; p<0.000). The ADP+PGE1-induced platelet reactivity was 33% lower among patients with the highest SDMA quartile (4th) as compared to those with the 1–3rd SDMA quartile (8 [0–29] vs 12 [0–126] U; p<0.001). The AA-induced platelet reactivity was 56% lower among patients with the highest SDMA quartile (4th) as compared to those with the 1–3rd SDMA quartile (4 [0–48] vs 9 [0–133]; p<0.001). In a multivariate model, the highest SDMA (4th) quartile was found to be an independent predictor of the lowest ADP+PGE1 and AA induced platelet aggregation (OR: 2.666, 95% CI [1.184–5.999], p=0.018).

Conclusions

Our study shows that high plasma concentration of SDMA, but not ADMA, is independently associated with low platelet reactivity to ADP and AA and is associated with major and minor bleeding events in patients with ACS on potent antiplatelet therapies. Therefore, SDMA might have a potential to be further evaluated as a blood biomarker for individualization of duration and potency of antiplatelet therapies in an ACS population at high risk of bleeding complications.

Acknowledgment

I-COMET research team

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

High concentrations of plasma trimethylamine-n-oxide is associated with long-term cardiovascular mortality in patients with acute coronary syndrome

Background

Acute coronary syndrome (ACS) remains a leading cause of mortality worldwide [1]. Patients who experienced ACS are at high risk of future cardiovascular events and death [2–4]. Identification of reliable predictive tools could potentially improve the risk stratification [5]. Numerous studies revealed that intestinal microbial organisms (microbiota) and its metabolites, as TMAO (trimethylamine-N-oxide) may play a pathogenic role in a cardiovascular disease (CVD) and ACS [6]. Elevated concentration of circulating TMAO has been associated with increased risk of CVD and major adverse cardiac events (MACE), including myocardial infarction (MI), stroke, major bleeding and all-cause mortality [7].

Purpose

To investigate the association of liver metabolite TMAO with cardiovascular disease (CV)-related and all-cause mortality in patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention.

Methods

Our prospective observational study enrolled 292 patients with ACS. Plasma concentrations of TMAO were measured during the hospitalization for ACS. Observation period lasted 7 years in the median. Adjusted Cox-regression analysis was used for prediction of mortality.

Results

ROC curve analysis revealed that increasing concentrations of TMAO levels assessed at the time point of ACS significantly predicted the risk of CV mortality (c-index=0.78, p<0.001). The cut-off value of >4 μmol/L, labeled as high TMAO level (23% of study population), provided the greatest sum of sensitivity (85%) and specificity (80%) for the prediction of CV mortality and was associated with a positive predictive value of 16% and a negative predictive value of 99%. A multivariate Cox regression model revealed that high TMAO level was a strong and independent predictor of CV death (HR=11.62, 95% CI: 2.26–59.67; p=0.003). High TMAO levels as compared with low TMAO levels were associated with the highest risk of CV death in a subpopulation of patients with diabetes mellitus (27.3% vs 2.6%; p=0.004). Although increasing TMAO levels were also significantly associated with all-cause mortality, their estimates for diagnostic accuracy were low.

Conclusions

High TMAO level is a strong and independent predictor of long-term CV mortality among patients presenting with ACS. TMAO concentration of 4 μmol/L may be a cut-off value for prognosis of ACS patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Kaplan-Meier curvesTable 1

Research on developing environmental ethics in pharmacists' activities

BACKGROUND

Authors of various backgrounds are preoccupied with the meaning of environmental ethics, which refers to specific values, norms, attitudes, and practices with respect to all beings and elements of nature. Many international organizations have adopted important documents proclaiming the ethical obligation to protect the environment in all professional activities. At the national level, professional associations should include and develop this obligation in their codes of conduct. This study aimed to analyze and compare elements of environmental protection included in codes of conduct for pharmacists, to find ways to integrate environmental ethics into their activities.

METHODS

Seven codes of conduct for pharmacists were analyzed using the comparative method and methods of legal interpretation. Based on acknowledged values and principles of environmental ethics, a framework model for developing environmental protection in pharmacists' activities was created via an iterative process of reflection and discussion.

RESULTS

Explicit provisions for environmental ethics were found in codes in force in three countries and in a Romanian project. These provisions refer, in general, to an ethical duty of environmental protection in pharmacists' activities. Regarding the other codes, the study could only interpret stipulations of public health ethics to deduce an ethical environmental obligation. Considering the need for developing such provisions, an ethical framework was proposed as a model for professional associations of pharmacists.

CONCLUSIONS

The studied codes demonstrate a preoccupation of the professional associations with environmental protection in pharmacists' activities, with different degrees of interest in developing environmental ethics. To this end, the codes of conduct for pharmacists should include environmental values, principles, and ethics guidelines. Those guidelines should indicate the ethical attitude in relation to the environment for each activity. Further research is needed to stimulate, shape, and develop an environmental ethical behavior in pharmacists' practice.

COVID-19 pandemic and chaos theory

The dynamics of COVID-19 is investigated with regard to complex contributions of the omitted factors. For this purpose, we use a fractional order SEIR model which allows us to calculate the number of infections considering the chaotic contributions into susceptible, exposed, infectious and removed number of individuals. We check our model on Wuhan, China-2019 and South Korea underlying the importance of the chaotic contribution, and then we extend it to Italy and the USA. Results are of great guiding significance to promote evidence-based decisions and policy.

A contemporary definition of periprocedural myocardial injury after percutaneous coronary intervention of chronic total occlusions

Background

Coronary chronic total occlusion (CTO) recanalization represents the most technically challenging percutaneous coronary interventions (PCI). The complexity harbours a significant increased risk risk for complications with CTO PCI as compared to non-CTO PCI. However there are evidenced biomarker cut-off levels that help to identify those patients at risk for an unfavorable clinical outcome.

Objective

This study aimed to assess the prognostic impact of postprocedural troponin T increase and mortality in patients undergoing CTO-PCI in order to define the threshold, where procedural related myocardial injury drives mortality.

Methods

We enrolled a total of 3712 consecutive patients undergoing PCI for at least one CTO lesion and performed comprehensive troponin Tmeasurements 6, 8, and 24 hours after the procedure. All-cause mortality was defined as the primary study endpoint.

Results

Using spline curve analysis, we observed that a more than 18-fold increase of troponin above the upper reference limit (URL) is significantly associated with mortality. In the Cox regression analysis we observed a crude hazard ratio (HR) of 2.32 (95% CI 1.83–2.93, P<0.001) for a ≥18fold increase compared to patients with post-procedural troponin increase <18-fold of the URL.Results remained virtually unchanged after bootstrap- or clinical confounder-based adjustment.

Conclusion

This large-scale outcome study demonstrates for the first time the prognostic value of post-procedural troponin T elevation after PCI in CTO patients. We could define a threshold for procedure related myocardial injury in CTO patients that differ non- CTO patients and may help guide the postprocedural clinical care in this high risk patient population.

Figure 1

Funding Acknowledgement

Type of funding source: None

The Impact of COVID-19 on Emergent Large-Vessel Occlusion: Delayed Presentation Confirmed by ASPECTS

BACKGROUND AND PURPOSE

Our hypothesis is that the COVID-19 pandemic led to delayed presentations for patients with acute ischemic stroke. This study evaluates the impact of the coronavirus disease 2019 pandemic on presentation, treatment, and outcomes of patients with emergent large-vessel occlusion using data from a large health system in the Bronx, New York.

MATERIALS AND METHODS

We performed a retrospective cohort study of 2 cohorts of consecutive patients with emergent large-vessel occlusion admitted to 3 Montefiore Health System hospitals in the Bronx from January 1 to February 17, 2020, (prepandemic) and March 1 to April 17, 2020 (pandemic). We abstracted data from the electronic health records on presenting biomarker profiles, admission and postprocedural NIHSS scores, time of symptom onset, time of hospital presentation, time of start of the thrombectomy procedure, time of revascularization, presenting ASPECTS, TICI recanalization score, mRS, functional outcomes, and mortality.

RESULTS

Of 179 patients admitted with ischemic stroke during the study periods, 80 had emergent large-vessel occlusion, of whom 36 were in the pandemic group. Patients in the pandemic group were younger (66 versus 72 years, P < .061) and had lower ASPECTS (7 versus 9, P < .001) and took longer to arrive at the hospital (361  versus 152 minutes, P < .004) with no other major differences. There was a decreased rate of thrombolysis administration (22% versus 43%, P < .049) and a decreased number of patients treated with mechanical thrombectomy (33% versus 61%, P < .013).

CONCLUSIONS

The pandemic led to delays in patients arriving at hospitals, leading to decreased patients eligible for treatment, while in-hospital evaluation and treatment times remain unchanged.

Heterocycles 51: Liphophilicity investigation of some thiazole chalcones and aurones by experimental and theoretical methods

Reversed-phase thin-layer chromatography and reversed-phase high-performance liquid chromatography were used for lipophilicity determination of a library of 30 thiazole chalcones and aurones previously synthetized in our laboratory. The experimental lipophilicity data have been compared with theoretical lipophilicity parameters estimated by various computational methods. Good correlations between the experimental and calculated lipophilicity parameters have been found for both investigated classes of compounds. Correlations between the lipophilicity of the thiazole chalcones and aurones and their antiproliferative activity were discussed. The methodologies and data gathered in this study will contribute to the lipophilicity studies of chalcones and aurones derivatives, two important classes of compounds in medicinal chemistry.

Current Pharmacological Treatment of Painful Diabetic Neuropathy: A Narrative Review

Background and Objectives: Distal symmetrical polyneuropathy (DSPN) is one of the most common chronic complications of diabetes mellitus. Although it is usually characterized by progressive sensory loss, some patients may develop chronic pain. Assessment of DSPN is not difficult, but the biggest challenge is making the correct diagnosis and choosing the right treatment. The treatment of DSPN has three primary objectives: glycemic control, pathogenic mechanisms, and pain management. The aim of this brief narrative review is to summarize the current pharmacological treatment of painful DSPN. It also summarizes knowledge on pathogenesis-oriented therapy, which is generally overlooked in many publications and guidelines. Materials and Methods: The present review reports the relevant information available on DSPN treatment. The search was performed on PubMed, Cochrane, Semantic Scholar, Medline, Scopus, and Cochrane Library databases, including among others the terms "distal symmetrical polyneuropathy", "neuropathic pain treatment", "diabetic neuropathy", "diabetes complications", "glycaemic control", "antidepressants", "opioids", and "anticonvulsants". Results: First-line drugs include antidepressants (selective serotonin reuptake inhibitors and tricyclic antidepressants) and pregabalin. Second- and third-line drugs include opioids and topical analgesics. While potentially effective in the treatment of neuropathic pain, opioids are not considered to be the first choice because of adverse reactions and addiction concerns. Conclusions: DSPN is a common complication in patients with diabetes, and severely affects the quality of life of these patients. Although multiple therapies are available, the guidelines and recommendations regarding the treatment of diabetic neuropathy have failed to offer a unitary consensus, which often hinders the therapeutic options in clinical practice.

552 Natural history of bivalvular functional regurgitation

Introduction

Bivalvular functional regurgitation (BVFR) defined as concomitant mitral and tricuspid insufficiency has not been described or systematically assessed before. The present study therefore sought to define incidence, impact and natural history of BVFR in heart failure with reduced ejection fraction (HFrEF) to provide the foundation for risk assessment and directions for potential treatment strategies.

Methods

We enrolled 1021 consecutive patients with HFrEF under guideline-directed medical therapy and performed comprehensive echocardiographic and neurohumoral profiling. Mitral and tricuspid regurgitation was quantified by an integrated approach comprising valve morphology, width of the proximal regurgitant jet, proximal flow convergence, and pulmonary venous flow. All-cause mortality during a five-year follow up served as the primary endpoint.

Results

Thirty percent of patients suffered from moderate or severe BVFR. Long-term mortality increased with the presence and severity of FR with severe BVFR representing the highest risk-subset (P &lt; 0.001). Severe BVFR patients were more symptomatic and displayed an adverse remodeling and neurohumoral activation pattern (all P &lt; 0.05). Severe BVFR was associated with excess mortality (Figurel 1, Panel A) independently of clinical (adj.HR 1.52, 95%CI 1.39-1.84;P &lt; 0.001) and echocardiographic (adj.HR 1.31, 95%CI 1.11-1.54;P = 0.001) confounders, guideline-directed medical therapy (adj. HR 1.55, 95%CI 1.35-1.79;P &lt; 0.001) and neurohumoral activation (adj.HR 1.31, 95%CI 1.07-1.59;P = 0.009). Moderate BVFR (n = 99) comprised equal baseline characteristics and similar risk as isolated severe FR. (Figure 1, Panel B) (HR 0.95, 95%CI 0.69-1.30;P = 0.73).

Conclusion

This long-term outcome study shows the multi-faceted nature of FR and defines BVFR as an important clinical entity associated with impaired functional class, adverse cardiac remodeling and excess risk of mortality. Moderate BVFR conveys similar risk as isolated severe FR reflecting the deleterious impact of the global regurgitant load on the failing heart and the need of an integrated understanding for risk-assessment.

Abstract 552 Figure 1 (Panel A and B)

P1764 A unifying concept for the quantitative definition of functional mitral regurgitation

Background

Diverging guideline definitions for the quantitative assessment of severe secondary mitral regurgitation (sMR) reflect the lacking link of the sMR spectrum to mortality and has introduced a source of uncertainty and continuing debate.

Objectives

The current study aimed to define improved risk-thresholds specifically tailored to the complex nature of sMR that provide a unifying solution to the ongoing guideline-controversy.

Methods

We enrolled 423 heart failure patients under guideline directed medical therapy and assessed sMR by effective regurgitant orifice area (EROA), regurgitant volume (RegVol) and regurgitant fraction (RegFrac).

Results

Measures of sMR severity were consistently associated with 5-year mortality with a HR for a 1-SD increase of 1.42 (95%CI 1.25-1.63, P &lt; 0.001) for EROA, 1.37 (95%CI 1.20-1.56, P &lt; 0.001) for RegVol and 1.50 (95%CI 1.30-1.73, P &lt; 0.001) for RegFrac. Results remained statistically significant after bootstrap- or clinical confounder-based adjustment. Spline-curve analyses (Figure 1A-C) showed a linearly increasing risk enabling to stratify in low-risk (EROA &lt; 20mm2 and RegVol &lt; 30ml), intermediate-risk (EROA 20-30mm2 and RegVol 30-45ml) and, high-risk (EROA≥30mm2 and RegVol≥45ml). In the intermediate-risk group, a RegFrac ≥50% as indicator for hemodynamic severe sMR was associated with poor outcome (P = 0.017). A unifying concept based on combined assessment of the EROA, the RegVol, and the RegFrac (Figure 1D) showed a significantly better discrimination compared to the currently established algorithms (Table 1).

Conclusions

Risk-based thresholds tailored to the pathophysiological concept of sMR provide a unifying solution to the ongoing guideline controversy. An algorithm based on the combined assessment of the unifying cut-offs for EROA, RegVol and RegFrac improves risk prediction compared to currently established grading.

Table 1 Definition of severe sMR Cox regression analysis ROC analysis IDI analysis HR (95%CI) P-Value ROC P-Value-for-comparison IDI P-Value Unifying concept 3.76 (2.71-5.23) &lt;0.001 0.63 –- –- –- ACC/AHA definition 3.20 (2.14-4.78) &lt;0.001 0.57 &lt;0.001 0.06 &lt;0.001 ESC/EACTS definition 1.52 (1.10-2.09) 0.01 0.55 &lt;0.001 0.13 &lt;0.001 ACC/ASE expert consensus 1.89 (1.40-2.56) &lt;0.001 0.59 0.04 0.08 &lt;0.001 Comparison of the unifying concept with the ACC/AHA, ESC/EACTS and ACC/ASE expert consensus definitions of sMR by Cox regression, ROC, and IDI demonstrated the most powerfull prediction by the unifying concept with significantly higher ROC area under the curve and better discriminatory power by IDI.

Abstract P1764 Figure 1 A-D

P4736The Prognostic Impact of Volume Substitution on Cardiac Strain and the Development of Postoperative Atrial Fibrillation after Cardiac Surgery

Background

Postoperative atrial fibrillation (POAF) represents a common complication after cardiac valve or coronary artery bypass surgery. Etiologically, multifactorial causes such as the patients' age, weight, comorbidities or local remodeling proved a strong association with this common arrhythmia. While strain of atrial tissue is known to induce atrial fibrillating impulses, less attention has been paid to potentially strain-promoting values during the peri- and post-operative period. Therefore, we aimed to determine the association of peri- and post-operative volume substitution on markers of cardiac strain and subsequently its impact on the promotion and development of POAF.

Methods

In this prospective observational study 271 patients undergoing elective cardiac surgery in our Medical University were enrolled (median age: 69 years [IQR: 60–75 years]; 195 [72%] male gender). Intra- and post-operative data was collected from anesthesiologic and intensive care unit protocols. Multivariate binary logistic regression analysis was used to identify the prognostic value of volume substitution on the development of POAF.

Results

A total of 123 (45.4%) individuals developed POAF. The average intra-operative transfusion volume was significantly elevated in the POAF subgroup (605.6ml [POAF] vs. 227.1ml [non-POAF]; p<0.001). Moreover, the fluid balance within the first 24 hours after surgery was significantly higher in patients developing POAF (+1129.6 ml [POAF] vs. +544.9 ml [non-POAF]; p=0.044). We found that N-terminal pro brain natriuretic peptide (NT-proBNP) values were significantly elevated in patients that received any volume substitution (2860.0 pg/mL [Transfusion] vs. 1486.5 pg/mL [no-Transfusion]; p=0.002). In line with those results, the postoperative fluid balance was also found to have a direct and significant correlation with postoperative NT-ProBNP values (r=0.287, p=0.002). Of note, the amount of substituted volume proved to be a strong and independent predictor for POAF with an adjusted odds-ratio (OR) per one standard deviation (1-SD) of 2.49 (95% CI: 1.25–4.96; p=0.009).

Conclusion

Within the present analysis we were able to demonstrate that substitution of larger transfusion volumes presents a strong and independent predictor for the development of POAF. Via the observed distinct association with NT-proBNP values, it can reasonably be assumed that post-operative atrial fibrillating impulses are triggered via volume-induced cardiac strain.

P52 Prescription of patient’s regular medications on admission to neurosurgical unit

Objectives

Timely and correct prescription of patients’ regular medications on admission to neurosurgical unit is noticed not to be fully compliant with set standards. This audit aims to review the practice of medication prescription by junior doctors during patient admission to a national neurosurgical unit, and to identify areas of improvement for prompt and accurate prescription.

Design

Prospective clinical audit.

Subjects

130 patients admitted to the neurosurgical unit in 2 weeks.

Methods

Prescription of patient’s regular medications on admission was audited. The prescription practice was compared against the set standards, and between different settings (in-hour vs. out-of-hour, emergency vs. elective, experienced vs. new SHOs).

Results

18% of patients had no regular medications prescribed by clerking doctors, the majority of which were elective admissions during in-hour clerking and performed by experienced SHOs. Of the patients who had their regular medications prescribed on admission, 29% were prescribed inaccurately, and 16% in wrong doses. Total percentage of missed and error prescription was 46%, in which only 18% were corrected within 24 hours and 21% corrected up to 48 hours after admission.

Conclusions

Areas of improvement identified: prescription practice of experienced SHOs during elective admissions, medication and dose check on prescription in both elective and emergency settings, medication reconciliation within 24 hours and thereafter. Changes (e.g. an alert system) are being implemented and re-audit is in plan.

TM3-5 Venous sinus stenting for IIH: what are the long-term outcomes?

Objectives

Idiopathic intracranial hypertension (IIH) is associated with dural venous sinus stenosis (DVSS). This is increasingly treated with endovascular insertion of stents. Clinical and manometric improvements after stent placement have been described. However, there is little data reporting further need for CSF diversion, complication rates and sustained improvements in ICP.

Design

Single centre case series.

Subjects

Twenty-four IIH patients underwent stent insertion on discovery of DVSS with medical management ongoing.

Methods

Clinical notes, radiographic reports and 24 hour ICP monitoring data before and after stent placement was collected.

Results

After 1089.2±107.1 days, 6 patients remained symptomatic and went onto require CSF diversion, 75.0% did not require CSF diversion. One patient developed stent thrombosis requiring VKA anticoagulation for 3 months, this patient also developed new stenosis proximal to the stent at 2 years. A second patient developed in-stent stenosis requiring balloon angioplasty at 2 years and subsequent repeat stenting at 3 years. Eleven patients had 24 hour ICP monitoring at baseline and a mean of 231.9±129.5 days after DVSS stent placement. The mean reduction in ICP was 7.92±1.80 mmHg (p<0.01) and PA was 2.84±0.84 mmHg (p<0.01).

Conclusions

DVSS stenting is a viable endovascular therapy for IIH with modest long-term patency and ICP reduction. However, a quarter of stented patients required subsequent CSF diversion to manage their symptoms.

TM3-4 The effect of acetazolamide on intracranial pressure: primary study with prolonged continuous intracranial pressure monitoring

Objectives

Acetazolamide has frequently been used as a first-line treatment for idiopathic Intracranial Hypertension (IIH) and other disorders which lead to a non-acute rise in intracranial pressure (ICP). The effect of acetazolamide has been observed through lumbar puncture, however the effect of acetazolamide on ICP has not been studied in continuous ICP measurement.

Design

A retrospective study of a prospectively built ICP database

Subjects

All patients with continuous ICP monitoring demonstrating 24 hours on and 24 hours off acetazolamide were included in the study.

Methods

Patients median ICP and median pulse amplitude over 24 hour monitoring period on and off Diamox was assessed.

Results

12 patients (9F, 3M) underwent ICP monitoring with data collected during the same admission. 8 patients had IIH, 1 Chiari Malformation, 3 new diagnostic ICP procedures. 10 patients saw a reduction in ICP while on acetazolamide. Overall, patients experienced a Median reduction of 1.14 mmHg (Mean 1.16 mmHg, Range 4.24 to −4.445 mmHg). Patients (n9) who were on ≥1 g of acetazolamide per day experienced a median reduction in ICP of 1.595 mmHg (Mean 1.91 mmHg, Range 4.24–0.5 mmHg).

Conclusions

Our data suggests acetazolamide can reduce ICP quickly following commencement, however this reduction was relatively small. The effect seems greater with a higher dose. Larger numbers of patients are required to gain a greater understanding into the significance of acetazolamide on ICP, particularly the affect at larger doses.

WP1-8 Radiographic markers of disturbances in CSF dynamics: correlating imaging with 24-hour ICP monitoring

Objectives

Disorders with chronically elevated ICP have salient imaging findings associated with the sella turcica and optic nerves. We aim to quantify the degree of correlation between imaging features and ICP.

Design

Prospective case-cohort study.

Subjects

One-hundred and twenty-six patients (35M:91F) underwent ICPM with recent MR imaging.

Methods

T1-saggital views for sella volume, optic nerve vertical tortuosity, then T2-axial views for optic nerve sheath distension were blindly reviewed against respective median ICP and pulse amplitudes (PA). Imaging was triple reviewed for discordant values.

Results

The mean ICP of four sella morphologies (full/flat/concave/empty) were 1.2, 4.8, 8.4 and 16.7 mmHg respectively (p<0.01). AUROC for sella morphology predicting ICP was 0.81. This measurement was able to detect minimum ICP of 5.3 mmHg with 73.0% sensitivity and specificity, 73.0% PPV and 69.8% NPV. The mean PA values were 4.0, 5.2, 6.1 and 9.6 mmHg respectively (p<0.01). AUROC for sella morphology predicting PA was 0.78. This measurement was able to detect minimum PA of 5.47 mmHg with 76.3% sensitivity, 79.5% specificity, 63.5% PPV and 81.0% NPV. Mean PA values for vertical tortuosity (nil/uni/bi) were 5.2, 7.1 and 7.0 mmHg respectively (p<0.05). Mean ICP values for rail tracking (nil/uni/bi) were 4.5, 7.5 and 15.7 mmHg respectively (p<0.01). Mean PA values were 5.2, 5.8 and 8.0 mmHg respectively (p<0.0001).

Conclusions

Combined radiological features of ICP are promising non-invasive markers for raised ICP.

WP1-10 Prevalence of normal pressure hydrocephalus in falls clinic patients

Objectives

Patients with idiopathic Normal Pressure Hydrocephalus (iNPH) present with Hakim Adams triad and radiological findings suggestive of iNPH. We compare the presence of clinical and radiological signs of iNPH present in patients presenting to falls clinic at a District General Hospital with the general population.

Design

Retrospective analysis of patients referred to falls clinic (January 2017 to December 2017) and interpretation of CT or MRI head imaging with Evans index.

Subjects

Falls clinic patients presenting to a District General Hospital outpatient clinic.

Methods

Retrospective cohort of patients admitted to a single District General Hospital with falls and recent CT or MRI head. An Evans Index above 0.35 was used as an indicator of hydrocephalic ventricular enlargement.

Results

371 patients were seen in one year. 216 had previous CT or MRI head. 6.75% of all patients seen in falls clinic (11.6% who have had brain imaging) have hydrocephalic ventricular enlargement. This is compared to 4.5% in a study of patients aged 70 and over in a normal population.1

Conclusions

Patients seen in Falls clinic have an increased probability of having radiological signs consistent with idiopathic normal pressure hydrocephalus.

Reference

Jaraj D, Marlow T, Jensen C, Skoog I, Wikkelso C. Prevalence of idiopathic normal-pressure hydrocephalus. Neurology2014April 22;82(16):1449–1454.

Green pharmacy - a narrative review

Introduction

Active pharmaceutical ingredients are present in various sections of the environment, because of both the human and veterinary use of medicinal products. Ways of minimizing the risk of environmental contamination should be observed during all pharmaceutical activities (research, manufacturing, prescribing, dispensing and disposal of medicinal products).

Methods

For the present study we searched specific literature on this subject, using the main international databases (Thomson Reuters – Web of Science, SCOPUS and Science Direct).

Results

This narrative review focuses on the main aspects concerning environmental contamination with medicinal products. Consequently, the present study is structured on four different topics: environmental research on medicinal products, minimizing environmental contamination, waste disposal management and towards a greener community pharmacy.

Conclusion

Waste management activities are important for reducing the presence of active pharmaceutical ingredients in the environment. Pharmacists should inform patients on proper pharmaceutical waste disposal and organize collection programs for unused and expired medicines, in order to develop a greener pharmacy for the future.

Sporadic pedunculated duodenal adenomas. Clinical presentations and endoscopic management: a case series

The prevalence of sporadic duodenal polyps is estimated to be 0.3%-4.6% in patients referred for an upper endoscopy. Most of patients are asymptomatic (66-80%) at the time of diagnosis though bleeding, anemia and abdominal pain are the most commonly reported symptoms. These are related to the polyp's size, location and histological characteristics. We describe three cases of big, pedunculated nonampullary sporadic duodenal polyps (tubulovillous low-grade dysplasia adenomas) located in the second part of the duodenum and characterized by different clinical presentations, managed in our Endoscopic Unit within one year (between 2016 and 2017). Polypectomies were performed, either piece-meal or en-bloc using various endoscopic instruments. In one of our patients (case 1), a delayed bleeding (36 hours after the procedure) occurred eventually managed conservatively with two units of blood transfusion. In the same patient, in the following months after polypectomy, the pre-procedural state of anemia misclassified as Mediterranean anemia has improved with a significant rise of hemoglobin value (14.1g/dl). In a patient who previously underwent a renal transplant (case 2), endoscopy was indicated, based on the positive fecal occult blood test. In another patient (case 3), a big polyp induced pancreatitis since it exerted a strong traction on the duodenal wall during peristaltic movements. The removal of the polyp has led to the resolution of pancreatitis and associated symptoms.

Boosting infrared energy transfer in 3D nanoporous gold antennas

The applications of plasmonics to energy transfer from free-space radiation to molecules are currently limited to the visible region of the electromagnetic spectrum due to the intrinsic optical properties of bulk noble metals that support strong electromagnetic field confinement only close to their plasma frequency in the visible/ultraviolet range. In this work, we show that nanoporous gold can be exploited as a plasmonic material for the mid-infrared region to obtain strong electromagnetic field confinement, co-localized with target molecules into the nanopores and resonant with their vibrational frequency. The effective optical response of the nanoporous metal enables the penetration of optical fields deep into the nanopores, where molecules can be loaded thus achieving a more efficient light-matter coupling if compared to bulk gold. In order to realize plasmonic resonators made of nanoporous gold, we develop a nanofabrication method based on polymeric templates for metal deposition and we obtain antenna arrays resonating at mid-infrared wavelengths selected by design. We then coat the antennas with a thin (3 nm) silica layer acting as the target dielectric layer for optical energy transfer. We study the strength of the light-matter coupling at the vibrational absorption frequency of silica at 1240 cm^-1 through the analysis of the experimental Fano lineshape that is benchmarked against identical structures made of bulk gold. The boost in the optical energy transfer from free-space mid-infrared radiation to molecular vibrations in nanoporous 3D nanoantenna arrays can open new application routes for plasmon-enhanced physical-chemical reactions.

Lenalidomide with or without erythropoietin in transfusion-dependent erythropoiesis-stimulating agent-refractory lower-risk MDS without 5q deletion

After failure of erythropoiesis-stimulating agents (ESAs), lenalidomide (LEN) yields red blood cell (RBC) transfusion independence (TI) in 20-30% of lower-risk non-del5q myelodysplastic syndrome (MDS). Several observations suggest an additive effect of ESA and LEN in this situation. We performed a randomized phase III study in 131 RBC transfusion-dependent (TD, median transfusion requirement six RBC units per 8 weeks) lower-risk ESA-refractory non-del5q MDS. Patients received LEN alone, 10 mg per day, 21 days per 4 weeks (L arm) or LEN (same schedule) + erythropoietin (EPO) beta, 60,000 U per week (LE arm). In an intent-to-treat (ITT) analysis, erythroid response (HI-E, IWG 2006 criteria) after four treatment cycles (primary end point) was 23.1% (95% CI 13.5-35.2) in the L arm and 39.4% (95% CI 27.6-52.2) in the LE arm (P=0.044), while RBC-TI was reached in 13.8 and 24.2% of the patients in the L and LE arms, respectively (P=0.13). Median response duration was 18.1 and 15.1 months in the L and LE arms, respectively (P=0.47). Side effects were moderate and similar in the two arms. Low baseline serum EPO level and a G polymorphism of CRBN gene predicted HI-E. Combining LEN and EPO significantly improves erythroid response over LEN alone in lower-risk non-del5q MDS patients with anemia resistant to ESA.

Plasmonic Moon: A Fano-Like Approach for Squeezing the Magnetic Field in the Infrared

Outstanding results have been achieved in the localization of optical electric fields via ultrasmall plasmonic cavities, paving the way to the subdiffractive confinement of local electromagnetic fields. However, due to the intrinsic constraints related to conventional architectures, no comparable squeezing factors have been managed yet for the magnetic counterpart of radiation, practically hindering the detection and manipulation of magneto-optical effects at the nanoscale. Here, we observe a strong magnetic field nanofocusing in the infrared, promoted by the induction of a coil-type Fano resonance. By triggering the coil current via a quadrupole-like plasmonic mode, we straightforwardly boost the enhancement of the infrared magnetic field and perform its efficient squeezing in localized nanovolumes.

Fano coil-type resonance for magnetic hot-spot generation

The possibility to develop nanosystems with appreciable magnetic response at optical frequencies has been a matter of intense study in the past few years. This aim was strongly hindered by the saturation of the magnetic response of "natural" materials beyond the THz regime. Recently, in order to overcome such limitation, it has been considered to enhance the magnetic fields through the induction of displacement currents triggered by plasmonic resonances. Here we investigate a nanoassembly supporting the hybridization of an electric and magnetic plasmonic mode in Fano resonance conditions. Taking advantage of the enhancement properties owned by such interferential resonance, we have been able to generate an intense and localized magnetic hot-spot in the near-infrared spectral region.

Hot-electron nanoscopy using adiabatic compression of surface plasmons

Surface plasmon polaritons are a central concept in nanoplasmonics and have been exploited to develop ultrasensitive chemical detection platforms, as well as imaging and spectroscopic techniques at the nanoscale. Surface plasmons can decay to form highly energetic (or hot) electrons in a process that is usually thought to be parasitic for applications, because it limits the lifetime and propagation length of surface plasmons and therefore has an adverse influence on the functionality of nanoplasmonic devices. Recently, however, it has been shown that hot electrons produced by surface plasmon decay can be harnessed to produce useful work in photodetection, catalysis and solar energy conversion. Nevertheless, the surface-plasmon-to-hot-electron conversion efficiency has been below 1% in all cases. Here we show that adiabatic focusing of surface plasmons on a Schottky diode-terminated tapered tip of nanoscale dimensions allows for a plasmon-to-hot-electron conversion efficiency of ∼30%. We further demonstrate that, with such high efficiency, hot electrons can be used for a new nanoscopy technique based on an atomic force microscopy set-up. We show that this hot-electron nanoscopy preserves the chemical sensitivity of the scanned surface and has a spatial resolution below 50 nm, with margins for improvement.

A generic framework for modeling brain deformation as a constrained parametric optimization problem to aid non-diffeomorphic image registration in brain tumor imaging

OBJECTIVES

In the present paper a novel computational framework for modeling tumor induced brain deformation as a biophysical prior for non-rigid image registration is described. More precisely, we aim at providing a generic building block for non-rigid image registration that can be used to resolve inherent irregularities in non-diffeomorphic registration problems that naturally arise in serial and cross-population brain tumor imaging studies due to the presence (or progression) of pathology.

METHODS

The model for the description of brain cancer dynamics on a tissue level is based on an initial boundary value problem (IBVP). The IBVP follows the accepted assumption that the progression of primary brain tumors on a tissue level is governed by proliferation and migration of cancerous cells into surrounding healthy tissue. The model of tumor induced brain deformation is phrased as a parametric, constrained optimization problem. As a basis of comparison and to demonstrate generalizability additional soft constraints (penalties) are considered. A back-tracking line search is implemented in conjunction with a limited memory Broyden-Fletcher-Goldfarb-Shanno (LBFGS) method in order to handle the numerically delicate log-barrier strategy for confining volume change.

RESULTS

Numerical experiments are performed to test the flexible control of the computed deformation patterns in terms of varying model parameters. The results are qualitatively and quantitatively related to patterns in patient individual magnetic resonance imaging data.

CONCLUSIONS

Numerical experiments demonstrate the flexible control of the computed deformation patterns. This in turn strongly suggests that the model can be adapted to patient individual imaging patterns of brain tumors. Qualitative and quantitative comparison of the computed cancer profiles to patterns in medical imaging data of an exemplary patient demonstrates plausibility. The designed optimization problem is based on computational tools widely used in non-rigid image registration, which in turn makes the model generally applicable for integration into non-rigid image registration algorithms.