Venomous snakes of medical importance in the Brazilian state of Rio de Janeiro: habitat and taxonomy against ophidism

Snakebite envenoming is a major global health problem that kills or disables half a million people in the world's poorest countries. Identifying the biting snake and its habitat use is key to understanding snakebite eco-epidemiology and optimizing its clinical management. To prevent and combat the neglected snakebite disease, we characterize the morphology, geographic distribution, habitat use, and snakebites of medically important venomous snakes in the state of Rio de Janeiro (Brazil). Despite Philodryas spp. not being considered of medical importance by the Brazilian Ministry of Health, we also explore their data once the bites may require medical intervention, may cause death, and their consequences are underestimated. Methods: We assessed taxonomy and geographic data from specimens housed in scientific collections, the literature, and the Notifiable Diseases Information System. Our data revealed fragility in the morphological characters recommended to distinguish Bothrops jararaca from B. jararacussu, identify the subspecies of Crotalus durissus and distinguish the species of Philodryas. To help identify these species, we present an identification key to the venomous snake species from Rio de Janeiro based on the morphological data collected. We record the genera Bothrops and Micrurus in all mesoregions of the state. Here, we provide the first record of C. durissus in the Serrana region, supporting the hypothesis of geographic expansion of the species in the state. The crotalic antivenom must not be missing in Médio Paraíba, Centro-Sul Fluminense, and Serrana, where the rattlesnake C. durissus occurs. Bothrops bilineatus and Lachesis muta have historical records presented for the first time herein. However, these species are likely endangered or extinct in the state. There were 7,483 snakebites reported between 2001 and 2019, with an annual average of 393.8 cases. The Bothrops genus is responsible for the majority of accidents. The highest number of cases occurred in the Serrana region, the largest pole of family agriculture in Rio de Janeiro. We improve the identification of venomous snake species, better delimit their distribution, and update the number of cases of snakebites, thus providing greater precision in the attention to this problem in Rio de Janeiro. We emphasize the importance of clinical studies to test using bothropic-crotalic antivenom and heparin in all mesoregions to treat B. jararacussu envenomation; and mechanical ventilation, atropine, and anticholinesterases in the emergency health centers in the Metropolitana and Norte Fluminense regions due to the occurrence of the coral M. lemniscatus in these areas.

Psychological impact of COVID-19 containment on CADASIL patients

INTRODUCTION

COVID-19 restrictive containment was responsible for major psychological distress and alteration of quality of life (QoL) in the general population. Their impact in a group of patients having cerebral small vessel disease (SVD) and at high risk of stroke and disability was unknown.

OBJECTIVE

We aimed to determine the potential psychological impact of strict containment during the COVID-19 pandemic in a sample of CADASIL patients, a rare SVD caused by NOTCH3 gene mutations.

METHODS

Interviews of 135 CADASIL patients were obtained just after the end of the strict containment in France. Depression, QoL and negative subjective experience of the containment were analysed, as well as predictors of posttraumatic and stressor-related manifestations, defined as an Impact Event Scale-Revised score ≥ 24, using multivariable logistic analysis.

RESULTS

Only 9% of patients showed a depressive episode. A similar proportion had significant posttraumatic and stressor-related disorder manifestations independently associated only with socio-environment factors, rather than clinical ones: living alone outside a couple (OR 7.86 (1.87-38.32), unemployment (OR 4.73 (1.17-18.70)) and the presence of 2 or more children at home (OR 6.34 (1.35-38.34).

CONCLUSION

Psychological impact of the containment was limited in CADASIL patients and did not appear related to the disease status. About 9% of patients presented with significant posttraumatic and stressor-related disorder manifestations which were predicted by living alone, unemployment, or exhaustion related to parental burden.

Physical activity and heart failure: a forgotten indicator

Introduction

Low physical activity may be associated with comorbidities, sedentary lifestyle or clinical worsening in heart failure (HF) patients. Cardiovascular implantable electronic devices (CIEDs) detect and analyse physical activity data that is often integrated in multifactorial algorithms for predicting HF decompensations, but its potential is probably underestimated.

Purpose

We hypothesized that low physical-activity levels, obtained from remote monitoring of CIEDs, help predict clinical outcomes in HF patients, independently from multifactorial algorithms.

Methods

We retrospectively evaluated consecutive patients with HF and CIEDs through clinical assessments and remote monitoring (two monitoring systems were used). Low activity was defined as <1 hour/day of physical activity and two groups of patients were defined: patients with low activity alerts (group 1) and patients without low activity alerts (group 2). Primary outcome was defined as death by all causes and secondary outcome as HF hospitalizations and sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) episodes.

Results

From 121 patients with RPM, physical activity data was obtained in 104 (85,9%). Mean age was 63,98±12,44 years, 70,2% were males and follow-up was 59,19±38,491 months. Fifty-four (51,9%) had implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D), 46 (44,2%) transvenous implantable cardioverter defibrillator (ICD), and 4 (3,8%) CRT pacemaker (CRT-P). The aetiology was idiopathic in 42,5% and ischemic in 40,2%. Mean left ventricular ejection fraction was 34,08±11,40% and mean physical activity duration was 2,25±1,84 hours/day. Forty-eight (53,7%) had low activity alerts (group 1) and 56 (46,3%) had no low activity alerts (group 2). In group 1 mean period of low activity was 52,978±15,75 days/year. Patients from group 1 were older (p=0,001), had more oncological disease (p=0,041) and peripheral artery disease (p=0,028). Three deaths occurred in total, all in group 1 (p=0,039) and HF hospitalizations were more frequent in group 1 (1,68±2,59 vs 0,69±1,32, p=0,005). Low activity burden was also associated with atrial fibrillation burden (r=0,473, p<0,05) and number of episodes of VT or VF (r=0,267, p=0,007). A decrease of 50% or more in mean duration of physical activity, but above 1 hour/day, was associated with increase HF hospitalizations (1,83±2,13 vs 1,05±1,95, p=0,006).

Conclusion

Low physical activity data obtained from CIEDs was associated with HF hospitalizations, arrhythmic events and death by all causes, independently of multifactorial algorithms. A decrease in basal activity even above alert threshold, was associated with HF hospitalizations and may be an even earlier sign of HF decompensations.

Funding Acknowledgement

Type of funding sources: None.

Lower rate limit in cardiac resynchronization therapy defibrillators

Background

There is few data about programmed lower rate limit (LRL) in real world heart failure (HF) patients with cardiac resynchronization therapy–defibrillators (CRT-Ds) and its influence in clinical outcomes. Heart rate score (HRS) is the percentage of all atrial-paced and sensed events in the single tallest 10 beats/min device histogram bin and may indicate impaired heart rate variability.

Purpose

We hypothesized that higher LRL programming is associated with worse clinical outcomes as arrhythmic events and HF decompensations in chronic HF patients with CRT-Ds.

Methods

LRL was evaluated and HRS was calculated from remote monitoring in 126 HF patients with CRT-D. Primary outcome was defined as HF hospitalizations and related admissions to the emergency department and secondary outcome as number of device therapies, sustained ventricular tachycardia (VT) and ventricular fibrillation (VF).

Results

Mean age was 69,03±10,39 years, 81 (64,3%) were males and mean follow-up was 53,72±46,13 months. Mean left ventricular ejection fraction was 30,31±8,33% and 29 (23,0%) were in NYHA III–IV. HF aetiology was idiopathic in 39 (43,3%), ischemic in 32 (25,4%) and alcoholic cardiomyopathy in 8 (6,3%). Thirty-seven (29,4%) patients had atrial fibrillation and 33 (26,2%) coronary disease. LRL ranged from to 40 to 80 bpm and mean LRL was 52,64±9,64 and mean HRS 49,60±23,17%. Programmed LRL was higher in women (p=0,014), patients with atrial fibrillation (AF) (p=0,012) and coronary disease (p=0,015). Higher LRL correlated with HF hospitalizations and related admissions to the emergency department (ED) (r=0,541, p=0,001), VT or VF episodes (r=0,337, p=0,005) and CRT-D number of therapies (r=0,342, p=0,004) and higher HRS (r=0,547, p<0,05).

Conclusion

Higher LRL programming was associated with higher HRS, HF decompensations with hospitalization or admission to the emergency department, VT or VF episodes and CRT-D therapies in a real world population. More studies are required but lower LRL may be preferred in HF patients.

Funding Acknowledgement

Type of funding sources: None.

Biventricular or left univentricular pacing in heart failure patients: is there a better strategy

Background

Cardiac resynchronization therapy (CRT) is a cornerstone in treatment of heart failure (HF) with reduced left ventricular ejection fraction (LVEF) and ventricular dyssynchrony. Biventricular (BiV) pacing is often the preferred method and corrects electrical and mechanical dyssynchrony but Left ventricular (LV) preferential pacing is may preserve conduction via the right bundle branch, preventing deleterious effects from right ventricular. The evidence is sparse and there is doubts whether which programming strategy is better.

Purpose

We hypothesized that BiV is non-inferior to preferential LV pacing in HF patients with reduced LVEF and CRT devices in cardiovascular death and HF hospitalizations.

Methods

We retrospectively evaluated 147 patients with HF patients with reduced LVEF and CRT devices. Two groups were defined: LV pacing (group 1) and BiV pacing (group 2). Primary outcome was defined as cardiovascular death and secondary outcome as HF hospitalizations and NYHA class after CRT.

Results

Mean age was 70,26±10,6 years, 68,1% were males and follow-up was 52,22±44,51 months. One hundred and twenty six (85,7%) patients had implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D) and 21 (14,3%) CRT pacemaker (CRT-P). Mean LVEF was 31,1±8,5% and mean QRS duration before CRT implantation was 149,5±48,6 ms. Thirty-nine (36,4%) patients were in NYHA III–IV. HF aetiology was idiopathic in 51 (47,2%), ischemic in 36 (33,3%) and alcoholic cardiomyopathy in 9 (8,3%). Forty-five (40,5%) patients had atrial fibrillation and 37 (35,6%) coronary disease. Patients in group 2 were more frequently males than group 1 patients (46 (78,0%) vs 32 (56,1%) respectively, p=0,012). There were no differences in regard to age, LVEF, HF aetiology or other comorbidities between groups. In 57 (49,1%) CRT was programming in preferential LV pacing and 50 (50,9%) in BiV pacing. There were 2 deaths in group 1 and 3 in group 2 (OR 0.80, 95% CI 0.27–2.40). There were 0,98±3,17 hospitalizations per patient and there were no differences in HF hospitalizations between groups (OR 1.01, 95% CI 0.92–1.18) or NYHA after 6 months of CRT (p=0,364).

Conclusion

BiV pacing was not inferior to LV-only pacing in regard to cardiovascular death, HF hospitalizations and NYHA class improvement. There was no clear advantage for one pacing strategy over the other but more studies are still required.

Funding Acknowledgement

Type of funding sources: None.

Suboptimal coronary flow after PCI in STEMI patients: clinical implications and predictors

Background

Even in experienced angioplasty centers, percutaneous coronary intervention (PCI) in the acute setting of ST-elevation myocardial infarctions (STEMI) is associated with a low, but still significant rate of suboptimal coronary flow. Identification of its clinical impact and potential modifiable risk factors is important.

Purpose

To evaluate the clinical impact of suboptimal coronary flow after PCI in STEMI patients and to access potential predictors of suboptimal coronary flow.

Methods

We retrospectively evaluated 103 hospitalized patients with acute STEMI who were admitted to our center between 2018 and 2019 and underwent PCI. Coronary flow was accessed using the Thrombolysis in myocardial infarction (TIMI) Flow Grading System. Patients were divided into suboptimal patency of the culprit-vessel, defined as TIMI flow ≤2 (group 1, n=8 (7,8%)) and optimal patency of the culprit-vessel defined as TIMI flow 3 (group 2, n=95 (92,2%)). Glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) formula.

Results

Mean age 58,15±12,6 years and 85,4% were males. Seventy-eight patients (75,7%) had history of smoking, 45 (43,7%) dyslipidemia, 20 (19,4%) previous acute coronary syndrome, 18 (17,5%) diabetes, 17 (15,5%) were obese and 4 (3,9%) had chronic kidney disease. The revascularization strategy was primary PCI in 55 (54,4%) patients and fibrinolytic therapy with facilitated PCI in 48 (46,6%) patients. Infarct-related artery was the left anterior descending artery in 45 (45,5%) and multivessel disease was present in 38 (38,0%). Angiographic no-reflow after PCI was 3,0%. Intrahospital cardiovascular death occurred in 4 (3,9%) patients and was significantly associated with suboptimal flow (p=0,036) and there was no association with stent thrombosis. Predictors of suboptimal flow were higher blood urea nitrogen, creatinine and GFR at hospital admission (p=0,017 and p=0,012), peak creatinine (p=0,012) and stent length (p=0,038). Suboptimal flow was associated with higher Zwolle score (p=0,010) and ischemic Paris score (p=0,036).

Conclusion

Failure to achieve optimal culprit-vessel patency after PCI in STEMI patients, although infrequent, is associated with increased hospital cardiovascular death. Longer stents could be and important modified risk factor. Renal dysfunction is an important comorbidity that should be promptly identified and could be partially improved with medical treatment.

Funding Acknowledgement

Type of funding sources: None.

Acute ST-elevation myocardial infarction: are men and women particular cases of STEMI ?

Funding Acknowledgements

Type of funding sources: None.

Background

ST-segment elevation myocardial infarction (STEMI) has high levels of morbidity and mortality. Multiple risk factors may contribute to clinical outcomes and some studies demonstrate gender-related differences in baseline characteristics and in-hospital management.

Purpose

To access the difference in clinical characteristics and prognostic outcomes between men and women who were admitted in our Cardiac Intensive Care Unit with STEMI diagnosis.

Methods

We retrospectively analyzed 121 non-consecutive patients with STEMI during a mean follow-up period 135 ± 31 weeks.

We accessed baseline characteristics and time course of events (symptom onset-to-door admission; time to first EKG; time to fibrinolytic therapy; door-to-cath lab time and time from fibrinolytic therapy to PCI (for patients transferred from another centers).

Primary endpoint (PE) was a composite of in-hospital cardiovascular death, arrhythmic events or STEMI evolution in Killip-Kimbal III or IV.

Secondary endpoint (SE) was in-hospital major bleeding events, considered intracerebral hemorrhage, cases of hemodynamic compromise or requiring a blood transfusion.

Tertiary endpoint (TE) included admissions to the emergency department or hospitalization by heart failure decompensation, acute or chronic coronary syndromes and all-cause mortality.

Results

Of the 121 patients, 102 were male (84.3%) and 19 (15.7%) female. The mean age was 58.3 ± 12.7 years and women had a superior mean age (69.8 ± 12.2 years) vs. Men mean age 56 ± 11.6 years.

Hypertension was more prevalent in women (84.2% vs. 47.1%, respectively; p 0.003) and also diabetes – 36.8% of women had type 2 diabetes (vs 10.8% of men) and 5.3% of these female patients requires insulin therapy (vs 2% of men; p 0.021).

According to Charlson Comorbidity Index (CCI), women had a higher disease burden with 73.7% of them included into the moderate or severe group of mortality risk, compared to 42.2% of men (p 0.014).

Conversely, less women smoke (31.6% vs. 82.2%; p <0.001) and less frequently chest pain was the onset symptom (78.9% vs. 95.1%; p 0.04).

Time since symptom onset to door admission was estimated on 510 ± 1149 minutes and the mean women delay was superior (557 ± 858 minutes).

Regarding to in-hospital hemorrhagic events (secondary endpoint), female patients had a statistically significant higher risk (22.2% vs. 7.1%, p 0.045), independently of hypertension, diabetes or anticoagulant therapy (r=0.249; ANOVA p-value < 0.005), but it was associated with higher CCI (p 0.033). No other gender differences in outcomes or survival function were observed.

Conclusion

Our study demonstrates gender-related differences among patients with STEMI. Indeed, women were older, had more clinical cardiovascular risk factors and tend to delay hospital admission after symptoms onset. Secondary endpoint was statistically more frequent in women, but no other differences in outcomes were observed.

Risk scores in predicting adverse events after an acute coronary syndrome

Funding Acknowledgements

Type of funding sources: None.

Introduction

ST-segment elevation myocardial infarction (STEMI) is a serious event that usually occur in patients with cardiovascular risk factors and is associated with great morbidity and mortality.

PARIS ischemic risk score and TIMI score were validated to evaluate ischemic risk in STEMI patients who underwent percutaneous coronary intervention (PCI) and to estimate mortality, respectively.

Despite these specific purposes, the usefulness of these scores in predicting adverse cardiovascular events (ACE) is unknown.

Objectives

To assess the prognostic value of PARIS and TIMI scores for cardiovascular events, coronary ischemic events and mortality in patients after STEMI.

Methods

Retrospective single center cohort study enrolled 103 patients with STEMI diagnosis between 2018 and 2019, during a mean follow-up period 30.30 ± 6.46 months and patients were included regardless of the reperfusion strategy.

Primary endpoint (PE) was a composite of acute coronary events (ACE), admissions to the emergency department by heart failure (HF) decompensation or chronic coronary syndrome and HF hospitalization. Secondary endpoint (SE) was ACE. Cardiovascular and non-cardiovascular death was determined.

PARIS ischemic risk score was calculated and patients were stratified into low (0-2), intermediate (3-4) or high (≥ 5) ischemic risk categories. TIMI score was also assessed.

Results

Out of 103 patients with STEMI diagnosis, the median age was 58.15 ± 12.6 years and 85,4% were male. Fifty-seven patients (55.3%) had hypertension, 45 (43.7%) dyslipidemia, 18 (17.5%) diabetes, 17 (15.5%) were obese and seventy-eight patients (75.7%) had history of smoking. Twenty (19.4%) patients had a previous acute coronary syndrome and 15 underwent PCI.

Twenty-five (24.3%) patients were included in low PARIS ischemic risk category, 53 (51.5%) in intermediate risk and 20 (19.4%) in high risk category.

PE occurred in 16 patient (15.5%) and SE in 7 patients (6.8%).

Eight patients died during the follow-up period (7.8%), 4 of cardiovascular causes (50%), 3 of non-cardiovascular causes (37.5%) and 1 of unknown cause.

PARIS ischemic risk score showed prognostic value for PE, with an area under the curve (AUC) of 0.65, 95% confidence interval (CI) 0.506-0.806 and p-value 0.039.

PARIS score also had predictive value for SE (AUC 0.816, 95% CI 0.604-1.000; p 0.004) as well as TIMI score (AUC 0.738, 95% CI 0.560 – 0.917; p 0.032).

Both scores showed a good prognostic value in evaluating all-cause mortality, with a slightly better predictive value for TIMI score (AUC 0.91, 95% CI 0.802 – 1.00) when compared to PARIS score (AUC 0.84, 95% CI 0.685 – 0.987).

Conclusion

This study revealed that PARIS and TIMI scores have a good discriminatory power to predict prognosis in STEMI patients. According to our study results, these scores could be an interesting tool to determine the likelihood of fatal and non-fatal outcomes, including ACS.

Hemorrhagic risk scores in hospitalized patients with acute coronary syndrome: can they (only) predict bleeding events?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Acute coronary syndrome (ACS) is a life-threatening condition and its therapeutic approach increases the risk of important bleeding events which are associated with a worse prognosis. Along with hemorrhagic events, a drop on hemoglobin level not related to bleeding or the development of anemia could have a negative impact on prognosis.

Both CRUSADE and PARIS bleeding risk scores are used to evaluate and to stratify the risk of major bleeding in ACS. However their actual predictive value has been questioned and validity of these scores in predicting in-hospital mortality (IHM) is not established.

Objectives

To evaluate the actual prognostic value of CRUSADE and PARIS bleeding scores in ACS patients during their hospitalization stay.

Methods

Retrospective single center cohort study including 103 hospitalized patients after an acute ST-segment elevation myocardial infarction (STEMI) regardless of its reperfusion strategy.

In-hospital major hemorrhagic events (IHMHE), considered intracerebral hemorrhage, those resulting in hemodynamic compromise or requiring a blood transfusion, were assessed. Data on hemoglobin levels (HL) at hospital admission and at the time of hospital discharge were also collected and a composite endpoint (CE) of IHMHE and a drop in HL  ≥ 3g/dL were elaborated.

Both scores were calculated for each patient, its predictive value and their impact on IHM were determined.

Results

Out of 103 patients enrolled, the median age was 58.15 ± 12.6 years and 85.4% were male.

Two IHMHE occurred, twenty patients (19.4%) had anemia at the time of hospital discharge and 16 of these patients (15.5%) were not anemic at the time of hospital admission. Nine (8.7%) patients had a drop in their HL of at least 3g/dL.

The five bleeding risk categories defined by CRUSADE investigators were used, with 48 (46.6%) patients in the very low risk category, 9 (8.7%) and 6 (5.8%) in the high and very high risk category, respectively.

Hospitalization length stay was 5.6 ± 4.1 days with an overall in-hospital mortality (IHM) of 5.8%.

Receiver operating characteristic curve (ROC) analysis showed that CRUSADE score had an excellent discriminatory power for the CE (AUC 0.927, 95% CI 0.854-1.000) and the PARIS score had an acceptable discriminatory value (AUC 0.775, 95% CI 0.616-0.935).

Both CRUSADE and PARIS bleeding scores also had prognostic value in evaluating IHM (AUC 0.929, 95% CI 0.856-1.000 and AUC 0.788, 95% CI 0.634-0.942, respectively).

No specific and independent predictors of IHMHE were found, neither related to individual characteristics nor to therapeutic approach.  

Conclusion

The presenting study showed that CRUSADE and PARIS scores still have discriminatory power to assess CE and to assess IHM in ACS patients. Their addition to stratification tools could be of interest.

High Cell Density Culture of Dairy Propionibacterium sp. and Acidipropionibacterium sp.: A Review for Food Industry Applications

The dairy bacteria Propionibacterium sp. and Acidipropionibacterium sp. are versatile and potentially probiotic microorganisms showing outstanding functionalities for the food industry, such as the production of propionic acid and vitamin B₁₂ biosynthesis. They are the only food grade microorganisms able to produce vitamin B₁₂. However, the fermentation batch process using these bacteria present some bioprocess limitations due to strong end-product inhibition, cells slow-growing rates, low product titer, yields and productivities, which reduces the bioprocess prospects for industrial applications. The high cell density culture (HCDC) bioprocess system is known as an efficient approach to overcome most of those problems. The main techniques applied to achieve HCDC of dairy Propionibacterium are the fed-batch cultivation, cell recycling, perfusion, extractive fermentation, and immobilization. In this review, the techniques available and reported to achieve HCDC of Propionibacterium sp. and Acidipropionibacterium sp. are discussed, and the advantages and drawbacks of this system of cultivation in relation to biomass formation, vitamin B₁₂ biosynthesis, and propionic acid production are evaluated.

STEMI treatment in remote areas – challenges of the only interventional angioplasty center located in an archipelago

Background

In remote islands lack of specialized medical facilities, long distance transfer and emergency medical system organization remains a challenge and fibrinolysis is necessary to achieve revascularization in optimal timing in ST-elevation myocardial infarction (STEMI) patients. Our angioplasty center is the only one located in an archipelago composed of nine islands, six of which do not have hospital facilities and only have small family health care units.

Purpose

To evaluate the reality and outcomes of our interventional angioplasty center and compare cardiovascular outcomes between STEMI patients from the main island and remote islands.

Methods

We retrospectively evaluated 103 patients with STEMI admitted to our center between 2018 and 2019. Patients from the main island where the center is located underwent primary percutaneous coronary intervention (PCI) (group 1, n=55) and patients from remote islands underwent fibrinolytic therapy followed by transference to our center with facilitated or rescue PCI (group 2, n=48). A subanalysis of the far remote islands without hospital facilities was also performed. Primary outcome was defined as cardiovascular death or re-infarction at two years and secondary outcome as intrahospital haemorrhagic complications.

Results

Mean age was 58,15±12,6 years, 85,4% were males and follow up period was 30,30±6,46 months. Seventy-eight patients (75,7%) had history of smoking, 45 (43,7%) dyslipidemia, 20 (19,4%) previous acute coronary syndrome, 18 (17,5%) diabetes and 17 (15,5%) were obese. Troponin I peak was 117,42±129,06 ug/L and 14 (13,6%) were in Killip Class III/IV. Infarct-related artery was the left anterior descending artery in 45 (45,5%) and multivessel disease was present in 38 (38,0%). In group 1 reperfusion after PCI was obtained in 91,5%. In group 2, 73,5% met criteria for reperfusion after fibrinolysis and 23,6% after rescue PCI. Mean time from fibrinolysis to PCI was 558±349 minutes. Rates of successful revascularization did not differ between groups, as well as complete patency of the culprit-vessel defined as thrombolysis in myocardial infarction (TIMI) flow 3 (91,5% vs. 97,2% and 90,0% vs. 93,0% respectively for group 1 and 2). Cardiovascular death at two years occurred in 4 (3,9%) patients and re-infarction in 11 (10,7%) and were similar between groups (3 (5,5%) vs. 1 (2,1%) and 8 (14,5%) vs. 3 (6,3%) respectively) as well as haemorrhagic complications (1 (1,8%) vs. 5 (10,4%) respectively). Nineteen (18,4%) patients were from far remote islands without hospital facilities and when comparing these patients with the others there was also no difference in primary outcome.

Conclusion

Even in remote islands, an organized STEMI network with attempted fibrinolytic treatment and coordinated transference of patients for facilitated or rescue PCI can provide successful revascularization with cardiovascular outcomes similar to those submitted to primary PCI.

Funding Acknowledgement

Type of funding sources: None.

Non-ST elevation myocardial infarction in patients with previous CABG: what is the best treatment option?

Background

Current European Society of Cardiology guidelines recommend an invasive strategy (IS) for the treatment of non-ST elevation myocardial infarction (NSTEMI) patients, but the clinical trials that support this recommendations included only a few patients with previous coronary artery bypass graft (CABG).

Purpose

To characterize NSTEMI patients with previous CABG who underwent medical and invasive management and to evaluate the prognostic impact of the type of strategy used.

Methods

Retrospective analysis of a cohort of patients from a multicenter national registry diagnosed with NSTEMI with a previous history of CABG between 2010 and 2021. Patient's baseline demographics, medical history and in-hospital management data was collected. Outcomes of in-hospital and six months follow-up all-cause mortality were accessed.

Results

A total of 890 patients were included in the analysis. Of these, 470 were medically managed (MM) – this group included 249 patients (53.1%) who underwent coronary angiography but did not perform any further revascularization. The remaining 420 underwent an invasive strategy (IS) and performed additional revascularization, mainly percutaneous (only 1 patient submitted to reCABG). Mean age was similar (MM 72±10 vs IS 71±10 years, p=0.147) and most patients were male (MM 81.5% vs IS 83.8%, p=0.362). MM patients had more chronic kidney disease (16.7% vs 9.9%, p=0.003), peripheral artery disease (20.5% vs 15.0%, p=0.003) and heart failure (20.5% vs 11.9%, p<0.001). Main presenting symptom was chest pain in both groups, however it was more frequent in the IS group (89.4% vs 94.5%, p=0.006) and dyspnea in the MM patients (6.3% vs 3.1%). Mean left ventricle ejection fraction was similar between groups (MM 49±12% vs IS 50±11%, p=0.290). Although the GRACE risk score was available for only 124 patients, high risk patients (GRACE score >140) were equally distributed among the two groups (55.9% vs 48.2%, p=0.395). An IS was associated with significant lower in-hospital mortality (4.5% vs 1.7%, OR 0.37, 95% CI 0.15–0.87, p=0.018). At six months follow-up an IS was also associated with lower mortality (6.6% vs 2.4%, HR 0.18, 95% CI 0.06–0.52, p=0.002), even after adjusting for the baseline differences (HR 0.41, 95% CI 0.20–0.85, p=0.016).

Conclusions

In this cohort of patients with NSTEMI and previous CABG, an IS was linked to better outcomes during hospitalization and during six months follow-up. Randomized clinical trials are needed to address this issue.

Funding Acknowledgement

Type of funding sources: None.

Impact of COVID-19 pandemic on ST-elevation myocardial infarction: data from two Portuguese centers

Introduction

Recently during the COVID-19 pandemic there was a general belief in a reduction of hospital admissions due to non-infectious causes, namely cardiovascular diseases.

Objectives

To evaluate the impact of the pandemic in the admissions by ST elevation acute myocardial infarction (STEMI), during the first pandemic wave.

Methods

Multicentric and retrospective analysis of consecutive patients presenting in two Portuguese hospital centers with STEMI in two sequential periods – P1 (1st March to 30th April) and P2 (1st May to 30th June). A comparison of patient's clinical and hospital outcomes data was performed between the year 2020 and 2017 to 2019 for both periods.

Results

A total of 347 consecutive STEMI patients were included in this study. The patient's baseline characteristics and cardiovascular risk factors were similar across the considered periods. During P1 of 2020, in comparison with previous years, a reduction in the number of STEMI patients was observed (26.0±4.2 vs 16.5±4.9 cases per month; p=0.033), contrary to what was observed during P2 (19.5±0.7 vs 20.5±0.7 cases per month; p=0.500). Percutaneous coronary interventions in the setting of failed thrombolysis were more frequent (1.9% vs 9.1%; p=0.033). A global trend in longer delays in time-key bundles of STEMI care was noted, namely pain to first medical contact, door to needle, door to wire crossing and symptoms to wire crossing times, however without statistical significance. Mortality rate was six-fold higher during P1 comparing to previous years (1.9% vs 12.1%; p=0.005), and also an increase in the number of mechanical complications (0.0% vs 3.0%; p=0.029) was observed.

Conclusions

During the first COVID-19 pandemic wave there were fewer patients presenting with STEMI at catheterization laboratory for coronary angioplasty. These patients presented more mechanical complications and higher mortality rates.

Funding Acknowledgement

Type of funding sources: None.

Early and long term prognostic accuracy of 4 acute pulmonary embolism mortality risk scores

Background

Acute pulmonary embolism (PE) is a frequent condition associated with significant morbidity and mortality. Multiple scores have been developed and validated to predict 30-day mortality risk, however accurate prognostic assessment remains a challenge in clinical practice.

Purpose

To compare the performance of PESI, simplified PESI, Hestia and Bova scores in predicting in-hospital, 30-day and 1-year mortality risk for acute PE.

Methods

We retrospectively assessed consecutive patients from a single center registry who were hospitalized with acute PE between January 2017 and October 2020. Discriminative power of each score was assessed by receiver operating characteristic curve analysis. Charlson comorbidity index (CCI) was also assessed for comparison.

Results

A total of 131 patients with a mean age of 67.6±15.3 years were included with a mean follow-up of 46.3±17.7 months. Thirty-six patients (27.5%) had a recent hospitalization or major surgery and 26 (19.8%) a medical history of cancer. Besides anticoagulation, 7 patients (5.3%) underwent fibrinolysis. Overall in-hospital mortality was 8.4%, 30-day mortality 12.2% and 1-year mortality 19.8%. All acute PE scores, except Bova score, were significantly higher in those patients who died during hospitalization and on 30-day and 1-year follow-up. CCI was also higher in those patients. Discriminative power for in-hospital mortality was higher for PESI (c-statistic 0.84, 95% CI 0.74–0.93, p=0.002), followed by sPESI (c-statistic 0.77, 95% CI 0.65–0.90, p=0.010) and Hestia (c-statistic 0.77, 95% CI 0.61–0.92, p=0.011). The Bova score showed a poor discriminative power for prediction of in-hospital mortality (c-statistic 0.61, 95% CI 0.43–0.78, p=0.325). For 30-day and 1-year mortality PESI score still maintained the best performance with acceptable discriminative power (c-statistic 0.73, 95% CI 0.61–0.85, p=0.007 for 30-day mortality; c-statistic 0.80, 95% CI 0.71–0.89, p<0.0001 for 1-year mortality). However at longer follow-up CCI had a better performance to predict worse outcomes (c-statistic 0.79, 95% CI 0.65–0.92, p=0.001 for 30-day mortality; c-statistic 0.83, 95% CI 0.74–0.92, p<0.0001 for 1-year mortality).

Conclusions

All scores, except Bova score, showed overall good performance in stratifying mortality for acute PE, however PESI score performed better in this population particularly at shorter follow-up. At longer follow-up, although PESI score maintained an acceptable performance, comorbidities seem to play a bigger role. The different performance of multiple scores highlights the complexity of this condition.

Funding Acknowledgement

Type of funding sources: None. ROC curves for mortality risk scores

New York Heart Association class change on heart failure patients with implantable devices: does it matters?

Background

Chronic heart failure (CHF) is a pathology with high prevalence and an important cause of morbidity and mortality. Benefits of implantable devices have been demonstrated in selected groups of patients with benefits on symptoms and heart failure hospitalization.

Purpose

To determine the clinical impact of New York Heart Association class change (NYHA) in patients with CHF and Cardiac Implantable Electric Devices (CIEDs).

Methods

We retrospectively enrolled 178 consecutive patients with CHF and CIEDs between November 2003 and January 2021, during a follow-up period of 51±43,9 months. Patients demographic characteristic and NYHA class change impact on occurrence of arrhythmic events, heart failure hospitalization (HFH) or long-term admission in an emergency department were assessed. Patients with NYHA class change were considered responders to therapy.

Results

Out of 178 patients enrolled in this study, sixty-seven (37,6%) had a reduction ≥1 in NYHA functional class and in this group, 61 patients (91,0%) had a cardiac resynchronization therapy (CRT) and 9% had an implantable cardioverter defibrillator. Mean age 68±11,3 years, 44 (65,7%) patients were male, 33 (49,2%) were in NYHA class II, 30 (44,8%) NYHA class III and 4 (6%) NYHA class IV. Mean QRS width 129,9±63,1 ms before CIEDs. Fifty-eight patients (86,6%) had an improvement in one NYHA functional class and 9 patients (13,4%) in two NYHA functional class.

Fourty NYHA responders patients (59,7%) had paroxistic or permanent atrial fibrillation and 31,9% had an epicardial coronary artery disease, that was a negative predictor of NYHA response (p=0,012).

A total of 35 (19,7%) enrolled patients experience non-sustained ventricular tachycardia (NSVT) and 74,3% were non-responders (p=0,019).

There was fifteen and twenty HFH at 2 and 5 years of follow-up, respectively, and we observed that an improvement in NYHA class was associated with a reduction in HFH at 2 years of follow-up (p=0,043; OR 0,029, 95% CI 0,050–1,06) and 5 years of follow-up (p 0,027, OR 0,252; 95% CI 0,069 – 0,915). Emergency department (ED) admission related to HF decompensations was significantly reduced at 2 years of follow-up (p=0,035, OR 0,22, 95% CI 0,048 – 1,0) and at 5 years of follow-up (p=0,001, OR 0,15, 95% CI 0,044 – 0,55).

There was no difference on cardiovascular or all-cause mortality.

Conclusion

CHF patients with CIEDs and improving on NYHA class have less NSVT episodes, HFH and HF decompensations with ED admission, both at 2 and 5 years of follow-up.

Funding Acknowledgement

Type of funding sources: None.

Non-sustained ventricular tachycardia on remote patient monitoring in heart failure patients

Background

Non-sustained ventricular tachycardia (NSVT) is commonly found in patients with structural heart disease and was historically obtained from registers of external ambulatory monitoring. The advent of remote patient monitoring (RPM) in Cardiac implantable electronic devices (CIEDs) has made it possible to detect asymptomatic NSVT in Heart Failure (HF) patients more frequently, but its impact in real world is uncertain.

Purpose

To determine the clinical impact of NSVT detection in RPM in ischemic and non-ischemic chronic heart failure patients with reduced ejection fraction (HFrEF) and CIEDs.

Methods

We retrospectively enrolled 121 consecutive patients with HFrEF, CIEDs and RPM. Patients were evaluated through routine episodic CIEDs interrogation, routine clinical evaluations and continuous monitoring data obtained from CIEDs and transmitted remotely to the care team and divided into NSVT positive (Group 1) and negative groups (Group 2). Primary endpoint was admissions to the emergency department by HF decompensation and secondary endpoint was the occurrence of arrhythmic events. A sub-analysis of non-ischemic HF was also performed.

Results

NSVT was detected in 78 (72,2%) patients. The mean number of episodes of NSVT was 611,68±3271,25 during the follow-up period or 2,445±16,688 in 24 hours. Mean age was 62,40±13,218 years, 71,9% were males and mean follow-up period was 56,30±39,37 months. Fifty-eight patients (47,9%) had transvenous implantable cardioverter defibrillator (ICD), 48 (39,7%) implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D), 14 (11,6%) subcutaneous ICD (S-ICD) and 1 (0,8%) CRT pacemaker (CRT-P). Medium left ventricular ejection fraction (LVEF) was 34,70±12,53%, 25 (23,14%) were in NYHA III-IV and 46 (39,0%) were ischemic (29 (37,7%) in Group 1 and 11 (37,9%) in Group 2). NSVT was associated with the occurrence of sustained ventricular tachycardia (VT) (1,88±0,186episodes of VT in group 1 and 0,03±0,186 in group 2, p=0,012), ventricular fibrillation (VF) (1,44±5,325 episodes of VT in group 1 and 0,03±0,186 in group 2, p=0,011) and admissions to the emergency department by HF decompensation at 5 years (r=0,310, p=0,011). A sub-analysis in non-ischemic HF patients also showed correlation between NSVT and VT (r=0,602, p<0,05) and admissions to the emergency department by HF decompensation at 5 years (r=0,382, p=0,014).

Conclusions

On remote patient monitoring with CIEDs, NSVT in HF patients was associated with arrhythmic events and may serve as a predictor for HF decompensations.

Funding Acknowledgement

Type of funding sources: None.

Prognostic significance of non-sustained ventricular tachycardia on stored electrograms of heart failure patients with cardiovascular implantable electronic devices

Background

Non-sustained ventricular tachycardia (NSVT) is commonly found in patients with structural heart disease and was historically obtained from registers of external ambulatory monitoring. The advent of Cardiac implantable electronic devices (CIEDs) has made it possible to detect asymptomatic NSVT in Heart Failure (HF) patients more frequently, but its true impact in real world is uncertain, and often does not lead to a change in clinical intervention.

Purpose

To determine the prognostic significance of NSVT detection on stored electrograms of CIEDs in HF patients with systolic left ventricle dysfunction.

Methods

We retrospectively enrolled 132 consecutive HF patients (mean age 67,5±11,1 years, males 72,0%) with systolic left ventricle dysfunction and CIEDs (biventricular pacemakers with or without cardiac defibrillators). Patients were evaluated through CIEDs interrogation and clinical evaluations and divided into NSVT positive (Group 1) and negative groups (Group 2). Mean follow-up period was 62,8±7,1 months.

Results

NSVT was detected in 51 (38,6%) patients. 70 (53,0%) had implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D), 37 (28,0%) transvenous implantable cardioverter defibrillator (ICD), 13 (9,8%) CRT pacemaker (CRT-P) and 12 (9,1%) subcutaneous ICD (S-ICD). Medium left ventricular ejection fraction (LVEF) was 31,1±7,9%, 20,6% were in NYHA III-IV and 47,0% were ischemic (49% Group 1 and 45,7% Group 2, p=0,708). Dyslipidemia was more prevalent in Group 2 (p=0,042). In total 11 (8,3%) patients died, 2 (1,5%) from sudden cardiac death and 5 (3,8%) from cardiovascular death. NSVT was associated with CIEDs treatments (hazard ratio [HR]2,52; 95% confidence interval [CI]1,2–5,1; p=0,001), ventricular fibrillation (VF) (HR: 3,71, 95% CI: 1,19–11,58; p=0,018), sustained ventricular tachycardia (VT) (HR: 9,06, 95% CI: 2,82–29,12; p<0,05) and composite outcome of VT, VF, HF re-admissions and related admissions to emergency department (ED) and death by all causes (HR: 2,52; 95% CI: 1,20–5,10; p=0,011). NSVT at 1 year was associated with HF readmissions at 1 year (p=0,004).

Conclusions

On extended monitoring possible with CIEDs, NSVT in HF patients was associated with a worse prognosis and may serve as a predictor of significant arrhythmic events, HF hospitalizations and mortality. These findings enhances the importance of remote monitoring and optimization of therapeutic modalities in these patients along with a close supervision.

Funding Acknowledgement

Type of funding sources: None.

Early Cerebrovascular Ultrasonography as a Predictor of Hemorrhagic Transformation After Thrombectomy

OBJECTIVES

To determine the predictive value of early transcranial color-coded sonography (TCCS) for intracranial hemorrhage (ICH) in patients with large artery occlusion (LAO) stroke of carotid circulation, who were submitted to endovascular therapy (EVT) with successful reperfusion.

MATERIALS AND METHODS

Retrospective study evaluating a cohort of consecutive stroke patients with LAO of the carotid circulation that were recanalyzed with EVT. We measured angle-corrected peak systolic velocities, end-diastolic velocities and mean flow velocities (PSV, EDV and MFV) of the symptomatic and asymptomatic middle cerebral artery (MCA). The ratio between MFV of the symptomatic MCA and MFV of the asymptomatic MCA (MCA-Ra) was calculated. Parenchymal hematoma in the 24 hours control CT was considered as ICH. Univariate associations and multivariate analyses were used to identify early independent predictors for ICH among TCCS findings.

RESULTS

We included 234 patients, mean age 72.5 (SD 12.6) years, 52.1% male. The mean time between recanalization and TCCS was 12.3 hours (range 3-22). Patients who developed postinterventional ICH showed a higher MCA-Ra (1.02 ± 0.26 vs 1.16 ± 0,21, p = 0.036). In multivariate analysis, only higher MCA-Ra remained independently associated with postinterventional ICH (OR: 6.778, 95%CI: 1.152-39.892, p = 0.034). A value of MCA-Ra ≥ 1,05 was associated with ICH, showing a sensitivity of 81.3% and a specificity of 65.9%; the AUC based of the ROC analysis was 0.688 (95% CI 0.570-0.806).

CONCLUSION

TCCS performed within the first 24 hours after stroke onset can help to predict hemorrhagic transformation in patients with LAO.

Antipsychotics in first-episode psychosis: Patterns of prescription in an inpatient unit

Introduction

The treatment of first-episode psychosis patients is different from those with multiple-episode schizophrenia: the response to antipsychotics is better, the required doses are lower and the sensitivity to side-effects is higher. As such, current guidelines recommend a “start slow, go slow” strategy and an active avoidance of side-effects.

Objectives/aims

To know the patterns of antipsychotic prescription in first-episode psychosis patients of our inpatient unit.

Methods

We retrospectively reviewed the clinical data of all non-affective first-episode psychosis patients admitted to the Inpatient Unit C of Hospital de Magalhães Lemos during 2015. The antipsychotics prescribed at admission and discharge were recorded, as well as the doses.

Results

A total of 29 patients were identified. The mean age was 36.6 and 65.5% were man. At admission, all patients were medicated with second-generation antipsychotics: 62.1% with risperidone, 27.6% with olanzapine, 6.9% with paliperidone and 3.4% with aripiprazol. The mean dose of risperidone was 3.5 mg/day. By the time of discharge, 34.5% of patients were prescribed a depot antipsychotic, half of them risperidone. Among those with oral medication only, 55.5% were prescribed risperidone, 22.2% paliperidone and the remainder 22.3% other antipsychotics (aripiprazol, olanzapine or quetiapine). The mean dose of risperidone was 3.7 mg/day.

Conclusions

Second-generation antipsychotics are clearly preferred. The mean dose by the time of discharge is similar to that used in clinical trials. However, antipsychotics are initiated at doses above the minimum effective dose. On discharge, an important proportion of patients are prescribed depot antipsychotics, which are known to improve medication adherence.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Microorganisms in the ticks Amblyomma dissimile Koch 1844 and Amblyomma rotundatum Koch 1844 collected from snakes in Brazil

Knowledge about ticks (Acari) and screening of ticks parasitizing various hosts are necessary to understand the epidemiology of tick-borne pathogens. The objective of this study was to investigate tick infestations on snakes (Reptilia: Squamata: Serpentes) arriving at the serpentarium at the Institute Vital Brazil, Rio de Janeiro. Some of the identified ticks were individually tested for the presence of bacteria of the genera Rickettsia (Rickettsiales: Rickettsiaceae), Borrelia (Spirochaetales: Spirochaetaceae), Coxiella (Legionellales: Coxiellaceae), Bartonella (Rhizobiales: Bartonellaceae), Ehrlichia (Rickettsiales: Anaplasmataceae), Anaplasma (Rickettsiales: Anaplasmataceae), and Apicomplexa protozoa of the genera Babesia (Piroplasmida: Babesiidae) and Hepatozoon (Eucoccidiorida: Hepatozoidae). A total of 115 hard ticks (Ixodida: Ixodidae) were collected from 17 host individuals obtained from four Brazilian states. Two species of tick were identified: Amblyomma dissimile Koch 1844 (four larvae, 16 nymphs, 40 adults), and Amblyomma rotundatum Koch 1844 (12 nymphs, 43 adults). Rickettsia bellii was found in A. rotundatum and A. dissimile ticks and Rickettsia sp. strain Colombianensi, Anaplasma-like and Hepatozoon sp. in A. dissimile ticks. Among the tested ticks, no DNA of Borrelia, Bartonella, Coxiella or Babesia was found. The present findings extend the geographic range of Rickettsia sp. strain Colombianensi in Brazil and provide novel tick-host associations.

Aspectos citoquímicos e morfológicos de elementos sanguíneos das serpentes dos gêneros Bothrops e Crotalus mantidas em cativeiro no serpentário do Instituto Vital Brasil

RESUMO A criação de serpentes peçonhentas em cativeiro vem se tornando prática cada vez mais difundida no país. Dessa forma, o conhecimento do manejo e da clínica de serpentes se torna prioritário, a fim de permitir maior sobrevida dos animais. No que concerne a serpentes peçonhentas, dados hematológicos já foram descritos na literatura, no entanto, apesar dos recursos utilizados, os dados analisados ainda são insipientes. Com o objetivo de caracterizar, morfologicamente, as células sanguíneas e de esclarecer diferenças morfológicas e funcionais, foram coletadas amostras de sangue de 50 serpentes pertencentes ao plantel do Instituto Vital Brasil. Foram confeccionados e analisados por microscopia óptica e citoquimicamente os esfregaços sanguíneos corados por métodos de Romanowsky e citoquímicos. Foi possível diferenciar as células, caracterizar e confirmar a existência de eosinófilo em B. atrox e C. durissus. Concluiu-se que a caracterização celular pode fornecer evidências indispensáveis ao entendimento da fisiologia de serpentes.

Structure and diversity of fishes in a freshwater and coastal subtropical lagoon

This study examined the fish communities of Peri Lagoon in southern Brazil to aid in the development of an effective management plan because the area is under threat from human activities. Sampling of fish fauna, ichthyoplankton and limnological data were compared between sites, differing by habitat type and characteristics such as depth, substratum composition and vegetation type. Results were significantly related to site, with the highest diversity and abundance recorded at shallow vegetated sites. A total of 14 fish species were recorded throughout the lagoon, with the most abundant being Hyphessobrycon luetkenii. Of the 14 species, half were sampled at their larval stage, suggesting a healthy and protected system. Significantly more larvae and eggs were collected during colder months (autumn to winter) and at sites closer to stream flow, possibly owing to increased food sources and habitat protection. This study highlights the importance of Peri Lagoon as a nursery ground for a wide range of fish species, providing essential information for incorporation into the future protection of fish stocks throughout Brazil.

Linac4 H⁻ ion sources

CERN's 160 MeV H(-) linear accelerator (Linac4) is a key constituent of the injector chain upgrade of the Large Hadron Collider that is being installed and commissioned. A cesiated surface ion source prototype is being tested and has delivered a beam intensity of 45 mA within an emittance of 0.3 π ⋅ mm ⋅ mrad. The optimum ratio of the co-extracted electron- to ion-current is below 1 and the best production efficiency, defined as the ratio of the beam current to the 2 MHz RF-power transmitted to the plasma, reached 1.1 mA/kW. The H(-) source prototype and the first tests of the new ion source optics, electron-dump, and front end developed to minimize the beam emittance are presented. A temperature regulated magnetron H(-) source developed by the Brookhaven National Laboratory was built at CERN. The first tests of the magnetron operated at 0.8 Hz repetition rate are described.

Allow elective ventilation to recruit more organ donors

Transplantation surgery started >50 years ago and has developed into an established medical practice in many countries. We consider it positive if our dead body could be used as an organ or tissue donor. If transplanted, our organs confer other human beings with a longer and better life. There is, however, a relative lack of organs compared with the needs, and many potential recipients die while on the waiting list for transplantation.

Noninvasive multimodal neuroimaging for Rasmussen encephalopathy surgery: simultaneous EEG-fMRI recording

Rasmussen syndrome is characterized by continuous partial seizures with progressive neurological/cognitive impairment. Currently the only effective treatment is surgery (hemispherectomy). The objective of our study is to detect the exact epileptogenic focus through the analysis of multimodal noninvasive and innocuous functional neuroimaging. The subject is a 5-year-old female patient with Rasmussen encephalopathy. Continuous and simultaneous electroencephalography-functional magnetic resonance imaging (EEG-fMRI) was recorded. The sources of background and paroxysmal activity of EEG were computed by low resolution electromagnetic tomography (LORETA). Image analysis (SPM: statistic parametric mapping) was obtained for the areas where statistically significant differences in the fMRI BOLD response were computed, and the results from both techniques were compared. The main source of paroxysmal activity by EEG analysis was found in the anterolateral left hemisphere, with a significant increase in absolute and relative energies of slow frequency bands (theta-delta): Z > or = 3. The fMRI BOLD signal (basal vs. paroxysmal activity) was significantly different in the same region (t-test > or = 2.39). The generators of propagated paroxysmal activity were found in similar areas for both techniques. In conclusion, simultaneous EEG-fMRI recording allows the analysis of two harmless functional neuroimaging techniques separately and together in the same time period. In our case, it allowed the accurate delineation of epileptogenic foci and areas of spread with high spatiotemporal resolution, which is crucial for epilepsy surgery.

Source analysis of alpha rhythm reactivity using LORETA imaging with 64-channel EEG and individual MRI

Conventional EEG and quantitative EEG visual stimuli (close-open eyes) reactivity analysis have shown their usefulness in clinical practice; however studies at the level of EEG generators are limited. The focus of the study was visual reactivity of cortical resources in healthy subjects and in a stroke patient. The 64 channel EEG and T1 magnetic resonance imaging (MRI) studies were obtained from 32 healthy subjects and a middle cerebral artery stroke patient. Low Resolution Electromagnetic Tomography (LORETA) was used to estimate EEG sources for both close eyes (CE) vs. open eyes (OE) conditions using individual MRI. The t-test was performed between source spectra of the two conditions. Thresholds for statistically significant t values were estimated by the local false discovery rate (lfdr) method. The Z transform was used to quantify the differences in cortical reactivity between the patient and healthy subjects. Closed-open eyes alpha reactivity sources were found mainly in posterior regions (occipito-parietal zones), extended in some cases to anterior and thalamic regions. Significant cortical reactivity sources were found in frequencies different from alpha (lower t-values). Significant changes at EEG reactivity sources were evident in the damaged brain hemisphere. Reactivity changes were also found in the "healthy" hemisphere when compared with the normal population. In conclusion, our study of brain sources of EEG alpha reactivity provides information that is not evident in the usual topographic analysis.