Early Initiation of Sacubitril/Valsartan in Patients With Acute Heart Failure and Renal Dysfunction: An Analysis of the TRANSITION Study

BACKGROUND

Treatment of patients with heart failure with reduced ejection fraction (HFrEF) and renal dysfunction (RD) is challenging owing to the risk of further deterioration in renal function, especially after acute decompensated HF (ADHF).

METHODS AND RESULTS

We assessed the effect of RD (estimated glomerular filtration rate of ≥30 to <60 mL/min/1.73 m2) on initiation, up-titration, and tolerability of sacubitril/valsartan in hemodynamically stabilized patients with HFrEF admitted for ADHF (RD, n = 476; non-RD, n = 483). At week 10, the target dose of sacubitril/valsartan (97/103 mg twice daily) was achieved by 42% patients in RD subgroup vs 54% in non-RD patients (P < .001). Sacubitril/valsartan was associated with greater estimated glomerular filtration rate improvements in RD subgroup than non-RD (change from baseline least squares mean 4.1 mL/min/1.73 m2, 95% confidence interval 2.2-6.1, P < .001). Cardiac biomarkers improved significantly in both subgroups; however, compared with the RD subgroup, the improvement was greater in those without RD (N-terminal pro-brain natriuretic peptide, -28.6% vs -44.8%, high-sensitivity troponin T -20.3% vs -33.9%) (P < .001). Patients in the RD subgroup compared with those without RD experienced higher rates of hyperkalemia (16.3% vs 6.5%, P < .001), investigator-reported cardiac failure (9.7% vs 5.6%, P = .029), and renal impairment (6.4% vs 2.1%, P = .002).

CONCLUSIONS

Most patients with HFrEF and concomitant RD hospitalized for ADHF tolerated early initiation of sacubitril/valsartan and showed significant improvements in estimated glomerular filtration rate and cardiac biomarkers.

CLINICAL TRIAL REGISTRATION

NCT02661217.

Intranasal irbesartan reverts cognitive decline and activates the PI3K/AKT pathway in an LPS-induced neuroinflammation mice model

BACKGROUND

New strategies are urgently needed to manage and delay the development of Alzheimer's disease (AD). Neuroinflammation is a significant contributor to cognitive decline in neurodegenerative diseases, including AD. Angiotensin receptor blockers (ARBs) and angiotensin converting enzyme inhibitors (ACEIs) protect hypertensive patients against AD, but the cellular and molecular mechanisms underlying these effects remain unknown. In light of this, the protective effects of three ARBs and three ACEIs against neuroinflammation and cognitive decline were investigated through comprehensive pharmacologicalin vitro/in vivoscreening.

METHODS

BV-2 microglia cells were exposed tolipopolysaccharide (LPS) and treated with ARBs and ACEIs to provide initial insights into the anti-inflammatory properties of the drugs. Subsequently, irbesartan was selected, and its efficacy was evaluated inC57/BL6 male miceintranasally administered with irbesartan and injected with LPS. Long-term memory and depressive-like behavior were evaluated; dendritic spines were measured as well as neuroinflammation, neurodegeneration and cognitive decline biomarkers.

RESULTS

Irbesartan mitigated memory loss and depressive-like behavior in mice treated with LPS, probably because itincreased spine density, ameliorated synapsis dysfunction and activated the PI3K/AKT pathway. Irbesartan elevated the levels of hippocampalsuperoxide dismutase2 andglutathione peroxidaseandsuppressed LPS-induced astrogliosis.

CONCLUSIONS

Overall, this study provides compelling evidence that multiple intranasal administrations of irbesartan can effectively prevent LPS-induced cognitive decline by activating pathways involved in neuroprotection and anti-inflammatory events. These findings underscore the potential of irbesartan as a preventive strategy against the development of AD and other neurodegenerative conditions associated with neuroinflammation.

Intranasal administration of sertraline ensures sustained brain delivery and antidepressant effect in a mouse model of depression

The pursuit of more potent and efficacious antidepressant therapies is of utmost significance. Herein, the intranasal (IN) route was investigated for sertraline brain delivery, encompassing a comparative pharmacokinetic study after a single-dose administration to mice by IN, intravenous (IV) (4.87 mg/kg) and oral (10 mg/kg) routes, and an efficacy/toxicity study to explore the therapeutic effect in mice subjected to the unpredictable chronic mild stress (UCMS) protocol. Neurotransmitters and melatonin were quantified in prefrontal cortex and plasma, respectively. A different drug biodistribution behavior was unveiled for a CNS-acting drug administered by means of the IN route. For the first time, IN administration of sertraline exhibited heightened systemic exposure (bioavailability = 166 %), and a sustained drug release into the brain, in opposition to IV and oral routes, avoiding drug fluctuation. The lower lung exposition (given by normalized area under the curve) observed after IN instillation envisions the reduction of sertraline pulmonary side effects and similarly other peripheral side effects. IN sertraline treatment displayed significant efficacy in ameliorating anhedonia after one week of administration while the 14-day IN treatment regimen translated into decreased immobility time and increased swimming time in the forced swimming test, suggesting an improvement of the depressive-like behavior displayed by the animal depressive-model. Remarkably, these effects were absent with oral sertraline, despite the higher used dose. Noteworthy neurotransmitter alterations were observed, with IN sertraline markedly reducing adrenaline in the prefrontal cortex, while serotonin and melatonin increased following both administration routes. With its sustained brain delivery and serotonin- and melatonin-enhancing potential, the innovative strategy of IN sertraline holds the potential not only to effectively address depressive symptoms but also to mitigate challenges inherent to classic treatments.

Under the umbrella of depression and Alzheimer's disease physiopathology: Can cannabinoids be a dual-pleiotropic therapy?

Depression and Alzheimer´s disease (AD) are two disorders highly prevalent worldwide. Depression affects more than 300 million people worldwide while AD affects 60-80% of the 55 million cases of dementia. Both diseases are affected by aging with high prevalence in elderly and share not only the main brain affected areas but also several physiopathological mechanisms. Depression disease is already ascribed as a risk factor to the development of AD. Despite the wide diversity of pharmacological treatments currently available in clinical practice for depression management, they remain associated to a slow recovery process and to treatment-resistant depression. On the other hand, AD treatment is essentially based in symptomatology relieve. Thus, the need for new multi-target treatments arises. Herein, we discuss the current state-of-art regarding the contribution of the endocannabinoid system (ECS) in synaptic transmission processes, synapses plasticity and neurogenesis and consequently the use of exogenous cannabinoids in the treatment of depression and on delaying the progression of AD. Besides the well-known imbalance of neurotransmitter levels, including serotonin, noradrenaline, dopamine and glutamate, recent scientific evidence highlights aberrant spine density, neuroinflammation, dysregulation of neurotrophic factor levels and formation of amyloid beta (Aβ) peptides, as the main physiopathological mechanisms compromised in depression and AD. The contribution of the ECS in these mechanisms is herein specified as well as the pleiotropic effects of phytocannabinoids. At the end, it became evident that Cannabinol, Cannabidiol, Cannabigerol, Cannabidivarin and Cannabichromene may act in novel therapeutic targets, presenting high potential in the pharmacotherapy of both diseases.

Representativeness of EXPLORER-HCM trial and prevalence of eligibility criteria for Mavacamten in a nationwide cohort

Introduction

The EXPLORER-HCM trial evaluated the safety and efficacy of Mavacamten, a cardiac myosin inhibitor, in symptomatic obstructive hypertrophic cardiomyopathy (HCM). Mavacamten improved symptoms, exercise capacity and left ventricular outflow tract (LVOT) obstruction. However, the proportion of patients eligible for this therapy in real practice remains unclear.

Purpose

To determine the prevalence of eligibility criteria for Mavacamten and to describe the profile of patients complying with EXPLORER-HCM criteria in a nationwide cohort.

Methods

Cross-sectional study including all HCM patients enrolled in a European country-based nationwide registry. Presence of EXPLORER-HCM inclusion [≥18 years, obstructive HCM (LVOT gradient ≥50 mmHg), left ventricular ejection fraction (LVEF) ≥55%, New York Heart Association (NYHA) class II–III] and exclusion criteria [syncope or sustained ventricular tachycardia with exercise] were analyzed.

Results

Of 1042 patients included in this analysis (57.8% male, mean age at diagnosis 52 years, 39.6% obstructive HCM), 45 met the EXPLORER-HCM inclusion criteria and, after applying exclusion criteria, 30 patients were eligible for therapy with Mavacamten.

Eligible patients were all Caucasian, mostly female (63.3%), with a mean age at diagnosis of 58±14 years. All patients presented with heart failure symptoms, and were mostly in NYHA class II (83.3%); 4 patients (13.3%) presented with atrial fibrillation. In the baseline echocardiogram, mean LVEF was 68±9%; mean interventricular septum thickness was 20±4 mm; most patients presented with systolic anterior motion of the mitral valve (96.7%) and mitral regurgitation (96.7%). In cardiac magnetic resonance imaging evaluation, maximal wall thickness was 22±4 mm and 76.9% had late gadolinium enhancement. A pathogenic or likely pathogenic HCM gene variant was identified in 5 patients (MYH7 and MYBPC3 gene mutations).

In this group, 86.2% of patients were treated with beta-blockers and 34.5% with calcium channel antagonists. Only 1 patient was on Disopyramide. Septal reduction techniques were used in 43.3% of patients: alcohol septal ablation and septal myectomy were performed in 7 (23.3%) and 6 (20.0%) patients, respectively. Cardioverter-defibrillators were implanted in 2 patients for primary prevention of sudden cardiac death, and 6 patients received a pacemaker for bradycardia indications.

Conclusion

Specific therapies remain an unmet need in HCM. In this large nationwide cohort, only 2.9% of patients were eligible for therapy with Mavacamten according to EXPLORER-HCM criteria. Among patients complying with the study criteria, invasive septal reduction therapies were offered to a high proportion of patients. Further real-world data are warranted to estimate the proportion of HCM patients that will benefit from Mavacamten.

Funding Acknowledgement

Type of funding sources: None.

Predictors of left ventricular dysfunction in hypertrophic cardiomyopathy: results from a nationwide registry

Introduction

Progression of hypertrophic cardiomyopathy (HCM) with incident left ventricular (LV) dysfunction (HCM-LVSD) is associated with poor prognosis and advanced heart failure (HF). Prevalence ranges from 5–10% in previous studies. Identification of predictors of adverse remodeling may improve risk stratification and prognostication in HCM.

Purpose

To identify predictors of HCM-LVSD in a nationwide cohort of HCM patients (pts).

Methods

Retrospective study including all HCM pts enrolled in a European country-based nationwide registry. HCM-LVSD group included pts with LV ejection fraction (LVEF) ≤50% at baseline and pts who developed LV dysfunction/dilated phenotype during follow-up. Multivariate logistic regression was performed to identify predictors of HCM-LVSD.

Results

1042 HCM patients (57.8% male, mean age at diagnosis 52 years) were included, of whom 81 (8%) belonged to the HCM-LVSD group. HCM-LVSD pts were mostly male (60.5%) and tended to be older at the time of diagnosis than those without LVSD (55 vs 52 years, p=0.054). HCM-LVSD pts were more often symptomatic at the index visit (84.1% vs 65.2%, p&lt;0.001), with more functional impairment (New York Heart Association class III–IV: 18.5% vs 9.2%, p=0.021). Atrial fibrillation (21.3% vs 8.6%, p&lt;0.001) and intraventricular conduction disturbances (28.6% vs 14.4%, p=0.002) were more prevalent in HCM-LVSD pts. HCM-LVSD pts had higher baseline left atrium (LA) volumes (52 vs 39 ml, p=0.001), lower LVEF (50 vs 67%, p&lt;0.001) and higher rates of mitral regurgitation (79.0% vs 65.1%, p=0.011). Prevalence of obstructive HCM was lower in the HCM-LSVD group (25.3% vs 40.9%, p=0.007). Presence of late gadolinium enhancement (92.6% vs 74.6%, p=0.035) was more common in pts with LVSD. Baseline N-terminal pro–B-type natriuretic peptide was higher in HCM-LVSD (3839 vs 1281 pg/ml, p=0.027). There were no differences in the number and type of genetic variants between groups. In HCM-LVSD pts, implantation of cardioverter-defibrillators for secondary prevention was more frequent (28.6% vs 6.4%, p=0.002), as was the use of pacemaker (16.7% vs 7.0%, p=0.002). During a mean follow-up of 5.3±6.1 years, hospitalization for HF (50.0% vs 11.3%) and all-cause mortality (12.3% vs 2.9%, p&lt;0.001) were more frequent in HCM-LVSD group.

After multivariate analysis, higher LA volume (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01–1.05, p=0.003) and nonobstructive HCM (OR 2.74, 95% CI 1.03–7.27, p=0.043) were independent predictors of HCM-LVSD.

Conclusions

In this large nationwide cohort of HCM pts, prevalence of LVSD was 8%, in line with existing literature. In this cohort, larger LA volumes and nonobstructive HCM predicted progression to HCM-LVSD.

Funding Acknowledgement

Type of funding sources: None.

Encapsulated Escitalopram and Paroxetine Intranasal Co-Administration: In Vitro/In Vivo Evaluation

Depression is a common mental disorder. Its treatment with selective serotonin reuptake inhibitors (SSRIs) is effective only in a fraction of patients, and pharmacoresistance is increasing steadily. Intranasal (IN) drug delivery to the brain stands out as a promising strategy to improve current therapeutic approaches by operating as a shuttle to overcome the blood–brain barrier. This work aimed to simultaneously administer escitalopram and paroxetine by IN route to mice. For this purpose, three nanostructured lipid carriers (NLC1, NLC2, and BorNLC) and one nanoemulsion (NE) were tested for drug loading. After their characterization, investigation of their impact on nasal cell viability and SSRI permeability assays were performed, using a human nasal RPMI 2650 cell line in air–liquid interface. In vitro assays demonstrated that NLCs, including borneol (BorNLC), significantly increased escitalopram permeability (p < 0.01) and paroxetine recovery values (p < 0.05) in relation to the other formulations and non-encapsulated drugs. IN and intravenous (IV) pharmacokinetic studies performed in vivo with a single dose of 2.38 mg/kg demonstrated similar results for escitalopram brain-to-plasma ratios. IN administrations delayed escitalopram peak concentrations in the brain for 15–60 min and no direct nose-to-brain delivery was detected. However, encapsulation with BorNLC considerably decreased escitalopram exposure in the lungs (124 μg min/g) compared with free escitalopram by IN (168 μg min/g) and IV (321 μg min/g) routes. Surprisingly, BorNLC IN instillation increased concentration levels of paroxetine in the brain by five times and accelerated brain drug delivery. Once again, lung exposure was considerably lower with BorNLC (AUC_t = 0.433 μg min/g) than that with IV administration (AUC_t = 1.01 μg min/g) and non-encapsulated IN formulation (AUC_t = 2.82 μg min/g). Direct nose-to-brain delivery was observed for paroxetine IN administration with a direct transport percentage (DTP) of 56.9%. If encapsulated, it increases to 74.2%. These results clearly emphasize that nose-to-brain delivery and lung exposure depend on the formulation and on the characteristics of the drug under investigation. NLCs seem to be an advantageous strategy for nose-to-brain delivery of lipophilic molecules, since they reduce systemic and lung exposure, thereby decreasing adverse effects. For hydrophilic compounds, NLCs are particularly important to decrease lung exposure after IN administration.

Electrocardiographic markers of incident atrial fibrillation in patients with cryptogenic stroke

Funding Acknowledgements

Type of funding sources: None.

Introduction

Prolonged screening of AF in patients (pts) with cryptogenic stroke (CS) is recommended and electrocardiographic markers of atrial remodeling, like p-wave dispersion, have been described in literature. Electrocardiographic changes in pts with CS to predict AF in the follow up are not well-established.

Purpose

To identify ECG predictors of AF in a subset of pts with cryptogenic stroke.

Methods

We prospectively included consecutive pts admitted with CS. A surface 12-lead ECG was performed at admission, recorded at 25 mm/second and 10 mV/cm with commercially available imaging system. P-wave analysis of maximum (P max) and minimum (P min) duration, p-wave dispersion (PWD, defined as the difference between the P max and P min, being abnormal if &gt; 40 msec) and amplitude were evaluated by a two independent operator. P-wave axis was determined by an automated mode available in the equipment. ROC curve was analyzed to determine the optimal cut-off values.

Results

We enrolled 105 pts (55.2% males), with mean age of 68.18 ± 8.83 years, 79% had hypertension, 18.1% had diabetes, 44.8% with dyslipidemia, 21% current smokers.

During follow up period, 18 pts (17.1%) developed AF. We found that only PWD (AUC 0.706, IC95%: 0.564-0.848, p = 0.006) and P-wave axis (AUC 0.715, IC95%: 0.870-0.860, p = 0.004) were strong predictors of AF. PWD cut-off of 47.50 presented a sensitivity of 77.8% and specificity of 59.8% and P-wave axis cut off value of 75.50 had a specificity of 95.4%. Age (p = 0.032) and current smoking (p = 0.014) were associated with occurrence of AF during the follow up.

  Conclusion: PWD and P-wave axis predicted incident AF in this subset of pts with cryptogenic stroke. The ECG may be a toll to identify pts at risk of developing AF, although larger studies are needed to confirm these results. Abstract Figure.

White matter disconnection and decreased functional connectivity between orbitofrontal cortex and the contralateral temporo-occipital cortex in adults with obsessive compulsive disorder

Introduction

Obsessive compulsive disorder (OCD) affects 2-3% of the general population. The neurobiology of OCD has been linked to dysfunction of cortico-striatal circuits connecting the orbitofrontal (OFC) to the striatum. Recently, this loop has become an approved target for non-invasive neuromodulatory treatment of OCD.

Objectives

To explore structural and functional connectivity of the OFC in OCD subjects and healthy controls.

Methods

14 OCD patients and 12 age/sex-matched controls underwent magnetic resonance imaging (MRI) (3T-Philips scanner) for diffusion tensor imaging (DTI) and resting state functional connectivity (rsFC). DTI images were brain extracted and corrected for movement and eddy currents. A diffusion tensor model was fitted to each voxel and used to generate Fractional Anisotropy (FA) maps. Voxel-wise statistical analysis of FA was performed using Tract-Based Spatial Statistics. RsFC images were preprocessed and seed-based correlation (SBC) analysis was performed using Data Processing Assistant for Resting-State fMRI.

Results

We found decreased values of FA in the body of the Corpus Callosum bilaterally (MNI_coordinates: x= 16, y= -16, z= 33 and x= -19, y= -16, z= 42) and left superior longitudinal fasciculus in OCD patients (fig 1, left), as well as decreased rsFC of the right superior orbitofrontal seed with the left inferior frontal gyrus and left middle occipital gyrus (fig 2, right).

Conclusions

Using an exploratory multimodal approach we found evidence of abnormal structural and functional long-range connectivity of the OFC in OCD. If confirmed in a larger sample these connectivity abnormalities could be explored as potential predictors of response to OFC-targeted non-invasive neuromodulatory interventions.

Disclosure

No significant relationships.

Pharmacology of lacosamide: From its molecular mechanisms and pharmacokinetics to future therapeutic applications

Epilepsy is one of the most common brain disorders, affecting more than 50 million people worldwide. Although its treatment is currently symptomatic, the last generation of anti-seizure drugs is characterized by better pharmacokinetic profiles, efficacy, tolerability and safety. Lacosamide is a third-generation anti-seizure drug that stands out due to its good efficacy and safety profile. It is used with effectiveness in the treatment of partial-onset seizures with or without secondary generalization, primary generalized tonic-clonic seizures and off-label in status epilepticus. Despite scarcely performed until today, therapeutic drug monitoring of lacosamide is proving to be advantageous by allowing the control of inter and intra-individual variability and promoting a successful personalized therapy, particularly in special populations. Herein, the pharmacology, pharmacokinetics, and clinical data of lacosamide were reviewed, giving special emphasis to the latest molecular investigations underlying its mechanism of action and therapeutic applications in pathologies besides epilepsy. In addition, the pharmacokinetic characteristics of lacosamide were updated, as well as current literature concerning the high pharmacokinetic variability observed in special patient populations and that must be considered during treatment individualization.

Is intranasal administration an opportunity for direct brain delivery of lacosamide?

Lacosamide is well-known as an effective and safe anticonvulsant drug. Nevertheless, there is also evidence of anti-epileptogenic, neuroprotective and antinociceptive properties of lacosamide. It is currently available as oral and intravenous (IV) formulations, and its brain concentrations and therapeutic effects depend on its passage across the blood-brain barrier (BBB). Therefore, to circumvent the restrictive BBB, we herein evaluated the intranasal (IN) administration of lacosamide. Nasal thermoreversible gels were screened in vitro for their influence on the viability of human nasal septum (RPMI 2650) and lung adenocarcinoma (Calu-3) cells. According to the Alamar Blue test, the in situ gel composed of Pluronic F-127 (22.5%, w/v) and Carbopol 974P (0.2%, w/v) did not affect cell viability, which remained higher than 85%, within the concentration range of lacosamide. The in situ gel was intranasally administered to healthy male CD-1 mice (8.33 mg/kg) to describe the pharmacokinetic profiles of lacosamide in plasma, brain, lung and kidney and compare them with those obtained after IV administration of the same dose. Accordingly, IN administration allowed a fast (t_max in plasma: 5 min) and complete systemic absorption of lacosamide (absolute bioavailability: 120.46%). Interestingly, IN lacosamide demonstrated higher exposure (given by the AUC_t) in the brain (425.44 µg.min/mL versus 274.49 µg.min/mL), but lower exposure in kidneys (357.56 µg.min/mL versus 762.61 µg.min/mL), in comparison to IV administration. These findings, together with the t_max in brain of 15 min, a drug targeting efficiency (DTE) of 128.67% and a direct transport percentage of 22.28%, evidence that part of lacosamide reaches the brain directly after nasal administration, even though penetration into the brain from the systemic circulation seems to be the major determinant of brain exposure. Importantly, lacosamide concentrations found in lungs following IN administration were considerably higher than those observed after IV injection, until 30 min post-dosing (p < 0.05). Nevertheless, attained drug concentrations were lower than those tested in vitro in the Calu-3 cell line (1-100 µM), indicating that adverse effects are unlikely to occur in vivo. Hence, it seems that the proposed IN route has potential to be a suitable and valuable strategy for the brain delivery of lacosamide in emergency conditions and for the chronic treatment of epilepsy and other neurological diseases.

Death, hospitalization, emergency department visits and out-patient visits in patients with heart failure in contemporary practice: results from the prospective Europeam 9069-patient ARIADNE registry

Background

In Europe, heart failure (HF) is managed in variable settings and frequently in office-based practice. In HF with reduced ejection fraction (HFrEF) there is now extensive evidence based therapy, but implementation is inconsistent, variable and overall inadequate. The Assessment of Real lIfe cAre –Describing EuropeaN hEart failure management (ARIADNE) registry aimed to assess in detail how outpatients with HFrEF are managed in Europe in contemporary practice.

Methods

ARIADNE was a prospective non-interventional registry of patients with HFrEF (NYHA class II-IV) treated by office-based cardiologists or selected primary care physicians (recognized as HF specialists) in a real world setting. Patients were enrolled in 687 centres in 17 European countries, and studied at baseline and after 6 and 12 months. Key pre-specified outcomes were deaths, hospitalizations, emergency department visits, and office visits, and their primary reasons.

Results

Over 20 months, we enrolled 9069 patients; median age 69 (19–96) years, 24% women, with 30% older than 75 years, 61% NYHA class II, with a median EF 35% (30–40%).

Over a median follow-up of 353 (1–631) days, 382 patients (4.3%) died, with 171 cardiovascular deaths (1.9%). The rates of total hospitalizations overall, for HF, and for non-HF cardiovascular reasons were 19.3, 8.1, and 4.8 per 100 patient years, respectively; and rates of emergency department visits overall, for HF reasons, and for non-HF CV reason were 7.7, 1.6, and 1.8, respectively. The number of HF office visits were on average 1.0 per patient.

Conclusions

In this large multinational HFrEF registry with detailed data on cause-specific outcomes and health care utilization, incidence of death was low and outpatient HF visits were few, but incidence of HF and CV hospitalization and emergency department visits was high.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novartis AG, Switzerland

Treatment with sacubitril/valsartan in European outpatients with chronic heart failure in Europe: results from ARIADNE registry

Background

Recently, the angiotensin receptor neprilysin inhibitor (ARNI) sacubitril/valsartan (S/V) was introduced as a novel therapeutic option into European guidelines for the management of heart failure (HF). The Assessment of Real lIfe cAre –Describing EuropeaN hEart failure management (ARIADNE) registry provides real world information about its use and efficacy in real life in outpatients with heart failure with reduced ejection fraction (HFrEF) in Europe.

Methods

ARIADNE was a prospective registry of patients with HFrEF (NYHA II-IV, reduced EF) treated by office-based cardiologists or selected primary care physicians (recognized as HF specialists) in a real world setting. 9069 HFrEF patients were enrolled from 674 investigators in 17 European countries, and followed over 12 months. Out of 8787 patients fulfilling criteria for analysis, 52.5% of the patients received S/V treatment at baseline, whereas 47.5% continued on their previous individualized heart failure medication. Results of S/V patients are reported here.

Results

The mean age of patients prescribed S/V was 67.3 years, mainly NYHA class II or III (49.7% and 48.2%, respectively), and mean LVEF of 32.7%. Common documented comorbidities were arterial hypertension (63.7%), coronary heart disease (62.4%), dyslipidemia (50.3%), diabetes (32.5%), and chronic kidney disease (24.1%).

Of the 4143 patients in the S/V group, 89.9% received S/V at baseline, 74.8% received S/V in combination with a β-blocker; 47.8% with a β-blocker and MRA.

Within 6 months of the observational period, 693 (17.4%) of the S/V patients were hospitalized, of which 46.8% and 28.7%, had HF related and non-HF cardiovascular (CV) hospitalizations. Emergency room visits without hospitalization were documented for 3.4% of S/V patients in the same time period; stroke and myocardial infarction occurred in 22 (0.5%) and 24 (0.6%) of the S/V patients, respectively. Cardiac catheterization or coronary angiography procedures were applied to 1.7% and 2.8% of the S/V patients. Total mortality was 4.3% (S/V 3.8%; non-S/V 5.0%), cardiovascular mortality 1.9% (S/V 1.8%; non-S/V 2.2%), during the 12 month observational period.

The proportion of S/V patients in NYHA class III or IV decreased in the course of the study from 44.6% to 24.0%. After 12 months of follow up, 46.3% of patients with NYHA class III had a reported improvement to NYHA class II. Consistently, mean LVEF increased to 37.9%. The percentage of S/V patients with LVEF &lt;22.5% decreased from 11.5% to 5.8%. KCCQ overall summary score increased by 1.9 points. An improvement of ≥5 points, denoting a clinically meaningful increase, was reported for 36.2% of S/V patients.

Conclusions

Data from the ARIADNE prospective registry portray a diverse, multinational study cohort receiving sacubitril/valsartan under real-world conditions. Throughout the study, symptoms and quality of life improved with the use of S/V.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novartis AG, Switzerland

Baseline characteristics and clinical features of patients with heart failure with reduced ejection fraction: a European real-world, non-interventional registry study

Background

Heart failure (HF) is a major medical and economic burden that is often managed in office based practices. Recently, the angiotensin receptor neprilysin inhibitor (ARNI) sacubitril/valsartan (S/V) was introduced as novel therapeutic option into European guidelines for the management of HF. The ARIADNE registry aims to provide information on how outpatients with HF with reduced ejection fraction (HFrEF) are managed in Europe, in light of this novel treatment option.

Methods

ARIADNE was a prospective registry of patients with HFrEF treated by office-based cardiologists (OBC) or selected primary care physicians (recognized as HF specialists; PCP) in a real world setting. HFrEF patients were included prospectively, independently of whether treatment had been changed recently or not. 9069 patients were recruited from 687 centres in 17 European countries.

Results

The mean age of all patients was 68.1 years (S/V: 67.3 years, Non-S/V: 68.9 years). The majority of patients were in NYHA class II (61.3%), or NYHA class III (37.1%) overall, while more patients in the S/V group showed NYHA class III (S/V: 42.8%, Non-S/V: 30.9%). Mean LVEF was slightly lower in the S/V group than in the Non-S/V group (S/V: 32.7%, Non-S/V: 35.4%, overall 34.0%). The most frequently observed signs of HF were dyspnoea upon effort, followed by fatigue, palpitations on exertion at baseline. More patients tend to have more severe symptoms in the S/V groups (e.g. for dyspnoea on effort, Non-S/V: moderate 40.8%, severe 8.6%; S/V: moderate 46.4%, severe 14.1%). 44.0% of patients from the S/V group and 39.3% of non-S/V patients reported at least one hospitalization within 12 months prior to baseline, of which 73.3% in S/V and 69.9% in non-S/V patients were due to HF., At baseline, 44.7% of the patients used a CV device, of which most were implantable cardioverter defibrillator (ICD: Non-S/V 54.2%, S/V: 52.8%), implantable cardioverter defibrillator (CRT-ICD:Non-S/V 21.9%, S/V: 27.0%), and pacemaker (Non-S/V: 13.4%, S/V: 10.5%). The mean KCCQ overall summary score was 62.6 in the S/V group and 69.5 in the Non-S/V group at baseline.

83.9% of patients were treated with ARB or ACEi in Non-S/V group, (ACEi 57.3%, ARB 26.9%). The most frequently taken drug combinations in either group were ACEi/ ARB or S/V with β -blockers (Non-S/V 69.3%, S/V 67.3%). 40.2% in the Non-S/V group and 42.9% in S/V groups used a combination of ACEi/ARB or S/V, β-blocker and MRA.

Conclusions

The ARIADNE prospective registry provides insights and reflects variations in HF treatment practices in outpatients in Europe and the way S/V was introduced by OBCs and specialized PCPs in a real-world setting. In the observed population, S/V is more often prescribed to slightly younger patients with slightly lower LVEF, there was a greater observed percentage of S/V patients NYHA class III, with lower quality of life measurements and with more severe symptoms and recent hospitalizations for heart failure.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novartis Pharma AG

Cystic fibrosis: Physiopathology and the latest pharmacological treatments

Cystic fibrosis (CF) is a lethal autosomal recessive genetic disease, caused by a mutation in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which primarily affects the lungs and digestive system. This gene encodes the CFTR protein, a distinctive membrane transporter of the ATP-binding cassette (ABC) superfamily. It functions as a chloride channel, allowing the balance and transport of chloride through the apical membrane of epithelial cells. Due to its ubiquitous location, mutations in the CFTR gene trigger multiple changes in ion transport and metabolic pathways, affecting various organs, as it will be herein explained. Pulmonary impairment is the most characteristic comorbidity of CF and respiratory failure is the main cause of death. This review presents the importance of an early diagnosis of CF to establish, as soon as possible, a primary therapy for symptomatic prevention and relief. It also mentions new therapeutic approaches that include CFTR modulators. They are correctors and/or potentiators of the deficient CFTR channel. In an attempt to overcome the disadvantages of CFTR modulators, the application of biotechnology techniques is addressed, such as gene therapy, gene editing, RNA therapy and therapeutic microRNAs. The potential of the intranasal administration route is another presented aspect.

Repairing blood-CNS barriers: Future therapeutic approaches for neuropsychiatric disorders

Central nervous system (CNS) drug development faces significant difficulties that translate into high rates of failure and lack of innovation. The pathophysiology of neurological and psychiatric disorders often results in the breakdown of blood-CNS barriers, disturbing the CNS microenvironment and worsening disease progression. Therefore, restoring the integrity of blood-CNS barriers may have a beneficial influence in several CNS disorders and improve treatment outcomes. In this review, pathways that may be modulated to protect blood-CNS barriers from neuroinflammatory and oxidative insults are featured. First, the participation of the brain endothelium and glial cells in disruption processes is discussed. Then, the relevance of regulatory systems is analysed, specifically the hypothalamic-pituitary axis, the renin-angiotensin system, sleep and circadian rhythms, and glutamate neurotransmission. Lastly, compounds of endogenous and exogenous origin that are known to mediate the repair of blood-CNS barriers are presented. We believe that enhancing the protection of blood-CNS barriers is a promising therapeutic strategy to pursue in the future.

Sexual dimorphism of physical activity on cognitive aging: Role of immune functioning

OBJECTIVE

Exercise is one of the most potent strategies available to support cognitive health with age, yet substantial variability exists. Sexual dimorphism is evident for brain and immune functioning, the latter being implicated as important pathway for exercise. We examined the moderating role of sex on the relationship between physical activity and systemic inflammatory and brain health outcomes in support of more personalized approaches to behavioral interventions.

METHODS

Our discovery cohort included 45 typically aging women matched on age (±5y) and education (±2y) to 45 men (mean age = 72.5; Clinical Dementia Rating = 0) who completed self-reported current physical activity (Physical Activity Scale for Elderly), blood draw, neuropsychological evaluation, and brain MRI. An independent sample of 45 typically aging women and 36 men who completed the same measures comprised a replication cohort. Plasma was analyzed for 11 proinflammatory cytokine and chemokine markers via MesoScale Discovery.

RESULTS

Discovery cohort: Reported physical activity did not differ between sexes (150 vs. 157, p = 0.72). There was a significant interaction between sex and physical activity on chemokine markers MDC, MIP-1b, MCP-4, and eotaxin-3 (ps < 0.03), with a similar trend for MCP-1 and INFγ (ps < 0.09). Men who reported greater activity demonstrated lower inflammatory markers, an effect attenuated-to-absent in women. An interaction between sex and physical activity was also observed for parahippocampal volumes (p = 0.02) and cognition (processing speed and visual memory; ps < 0.04). Again, the beneficial effect of physical activity on outcomes was present in men, but not women. Replication cohort analyses conferred a consistent effect of sex on the relationship between physical activity and immune markers; models examining neurobehavioral outcomes did not strongly replicate. Across cohorts, post-hoc models demonstrated an interaction between sex and activity-related inflammatory markers on total gray matter volume and visual memory. Men with higher inflammatory markers demonstrated poorer brain structure and function, whereas inflammatory markers did not strongly relate to neurobehavioral outcomes in women.

CONCLUSIONS

Greater physical activity was associated with lower markers of inflammation in clinically normal older men, but not women - an effect consistently replicated across cohorts. Additionally, men appeared disproportionately vulnerable to the adverse effects of peripheral inflammatory markers on brain structure and function compared to women. Immune activation may be a male-specific pathway through which exercise confers neurobehavioral benefit.

P773Initiation of sacubitril/valsartan and optimisation of evidence-based heart failure therapies after hospitalisation for acute decompensated heart failure: An analysis of the TRANSITION study

Background

Optimisation of chronic heart failure (HF) therapy remains the key strategy to improve outcomes after hospitalisation for acute decompensated HF (ADHF) with reduced ejection fraction (HFrEF). Initiation and uptitration of disease-modifying therapies is challenging in this vulnerable patient population. We aimed to describe the patterns of treatment optimisation including sacubitril/valsartan (S/V) in the TRANSITION study.

Methods

TRANSITION (NCT02661217) was a randomised, open-label study comparing S/V initiation pre- vs. post-discharge (1–14 days) in patients admitted for ADHF after haemodynamic stabilisation. The primary endpoint was the proportion of patients achieving 97/103 mg S/V twice daily (bid) at 10 weeks post-randomisation. Up-titration of S/V was as per label. Information on dose of S/V and on the use of concomitant HF medication was collected at each study visit up to week 26.

Results

A total of 493 patients received at least one dose of S/V in the pre-discharge arm and 489 patients in the post-discharge arm. One month after randomisation, 45% of patients in the pre-d/c arm vs. 44% in the post-discharge arm used 24/26 mg bid starting dose and 42% vs. 40% were on 49/51 mg S/V bid, respectively. At week 10, 47% of patients had achieved the target dose in the pre-discharge arm vs. 51% in the post-discharge arm. At the end of the follow-up at 26 weeks, the proportion of patients on S/V target dose further increased to 53% in the pre-discharge and 61% in the post-discharge arm (Figure 1). At week 10, the mean dose of S/V was 132 mg in the pre-discharge arm and 136 mg in the post-discharge arm, and at week 26, it was 140 mg and 147 mg, respectively.

Before hospital admission, 52% and 54% of the patients received a beta-blocker (BB) in the pre-discharge and post-discharge group, respectively, and 42% in both arms received a mineralcorticoid receptor antagonist (MRA). At time of discharge, 68% and 71%% of the patients received a BB and 68% and 65% an MRA, in the pre-discharge and post-discharge groups, respectively. These proportions remained stable to week 10 and week 26.

Uptitration of sacubitril/valsartan

Conclusions

In the vulnerable post-ADHF population, initiation of S/V and up-titration to target dose was feasible within 10 weeks in half of the patients alongside with a 20% increase in the use of other disease-modifying medications that remained stable through the end of the 6-month follow-up.

Acknowledgement/Funding

The TRANSITION study was funded by Novartis

P1637Rehospitalisations during 26 weeks of follow up from initiation of sacubitril/valsartan after acute decompensated heart failure: An analysis of the TRANSITION study

Background

Patients with acute decompensated heart failure (ADHF) are at high risk of recurrent hospitalisations and death. In-hospital initiation of sacubitril/valsartan (S/V) reduced the risk for HF re-hospitalisation by 44% compared to enalapril in the PIONEER-HF study during the 8-week follow-up period. We aimed to describe the pattern of readmissions and their causes in the TRANSITION study, which randomised participants to pre-discharge or post-discharge initation of S/V.

Methods

TRANSITION (NCT02661217) was a randomised, open-label study comparing S/V initiation pre- vs. post-discharge (1–14 days) in haemodynamically stabilised patients with HF with reduced ejection fraction, admitted for ADHF. The primary endpoint was the proportion of patients achieving 97/103 mg S/V twice daily at 10 weeks post-randomisation. Information on rehospitalisation was collected throughout the study up to 26 weeks.

Results

A total of 493 patients received S/V in the pre-discharge arm and 489 patients in the post-discharge arm. Readmissions due to any cause were reported in 9.7% and 18.1% in the pre-discharge arm vs. 10.6% and 21.3% in the post-discharge arm within 30 days, and 10 weeks respectively. During the 26-weeks follow-up, all-cause readmission was reported in 34.5% of patients in the pre-discharge arm vs. 34.6% in the post-discharge arm. Median time to first rehospitalisation was 67 days in the pre-discharge arm (IQR: 26–110 days) and 50 days (IQR: 23–108 days) in the post-discharge arm. At least one HF hospitalisation was reported in 7.5% of patients in the pre-discharge arm and 7.4% in the post-discharge arm during 10 weeks and in 11.8% and 12.3% of patients, respectively, during 26 weeks of follow-up. Median duration of HF readmission was 7 days (IQR: 4–11 days) in the pre-discharge group and 6.5 days (IQR: 6.5–10 days) in the post-discharge arm. In total 2.6% and 5.5% patients in pre-discharge arm and 3.9% and 7% in the post-discharge arm visited an emergency room during 10 weeks and 26 weeks, respectively.

Conclusions

Initiation of S/V in patients hospitalised for ADHF either before or shortly after discharge, results in comparable rates of all cause and HF rehospitalisations, as well as emergency room visits without hospital admission over the 26 week follow-up period. HF re-hospitalisations rates at 10 weeks in TRANSITION are in line with the 8% in S/V arm reported in PIONEER-HF during the 8-weeks follow-up.

Acknowledgement/Funding

The TRANSITION study was funded by Novartis

A7 Co-receptor tropism determined by genotypic assay in HIV-1 non-B subtypes circulating in Cuba: Implications for pathogenesis and Maraviroc resistance

The V3 loop of the HIV-1 envelope (env) gene is involved in binding to the chemokine receptors CCR5 and CXCR4, thus determining viral tropism. With the aim of genetically characterizing the C2V3 env region of HIV-1 samples from Cuban patients, naive to Maraviroc (MVC) therapy, 115 plasma samples were taken in the period of 2014–6 and analyzed by sequencing of the C2V3 region. HIV-1 subtyping was performed using COMET V.2 and Rega subtyping toolV.3 software. Subtypes were confirmed by phylogenetic analyses using Mega-6. Prediction of co-receptor tropism was performed using the geno2pheno algorithm. The viral mutations associated to MVC resistance were analyzed, as well as the association of the subtype with clinical, epidemiological, virological, and immunological variables. The subtypes detected using the C2V3 region were CRF20, 23, 24_BG (35 patients, 30.4%); Subtype B (33 patients, 28.7%); CRF19_cpx (30 patients, 26.1%); CRF18_cpx (10 patients, 8.7%); and others (7 patients, 6.1%). Overall, 60 per cent of the viruses exhibited R5 phenotype, 14.8 per cent were R5X4 and 25.2 per cent were X4. Interestingly, CRF19_cpx virus was associated with having phenotype X4 [46.7%, P = 0.0047, odds ratio (OR): 3.96, 95% confidence interval (95% CI): 1.59–9.84], with infection in young individuals (39.1%, P = 0.025, OR: 3,548; 95% CI: 1,136–11,077) and with higher values of viral load (P ≤ 0.05). The comparison of the amino acid sequences of the V3 loop showed differences between the B and non-B subtypes (P = 0.0001). Mutations reported to be associated with MVC resistance, were detected in 75.7 per cent of the samples, in positions 11 (6.1%), 13 (49.6%), 25 (6.1%), 316 (7.0%), 323 (11.3%), and 319 (3.5%) of Gp120, particularly in the recombinant forms CRF19_cpx and CRF_BGs. HIV variants that use the CXCR4 co-receptor were associated with more than 10 years of diagnosis, with older individuals, in the AIDS stage, with low CD4 counts and higher viral load levels (P < 0.05). The results support the hypothesis previously stated that CRF19_cpx viruses could be more pathogenic and would have limitations for the use of MVC. The high rate of mutations associated to MVC among non-B Cuban subtypes should be further studied.

Ménétrier's disease : a case of successful treatment using long-acting octreotide

The authors describe a 31 years old male, admitted for hematemesis, epigastric pain and lower limb edema. Laboratorial data showed haemoglobin 18.4g/dl, total proteins 2.8g/dl, albumin 1.6g/dl and hipogammaglobulinaemia. 24h urinary proteins were normal. HIV and CMV serology were negative. Upper GI endoscopy revealed markedly enlarged gastric folds covered by abundant exudative fluid. Endoscopic ultrasound showed ascites, pleural effusion and gastric wall thickening with mucosa expansion and intact submucosa. In gastric biopsies foveolar hyperplastic and regenerative mucosa were observed being suggestive of Ménétrier´s disease. Helicobacter pylori was not detected. Albumin replacement and diuretics corrected anasarca and long-acting octreotide was instituted. Nine months later, the patient was asymptomatic, serum proteins were normal (albumin 4.6g/dl and total proteins 6.5g/dl), signs of endoscopic improvement were observed with marked reduction in gastric folds and mucosal inflammation and no ultrastructural changes were detected in gastric specimens sent for electron microscopy. Ménétrier´s Disease (MD) is a rare form of hypertrophic gastropathy characterized by massive enlargement of gastric folds causing marked protein exudation. The increase in tight junction diameter is the most consistent ultraestrutural change. Octreotide is a somatostatin analogue that acts by modulating TGFαEGFR pathway, which has been associated with the pathogenic mechanisms. As well as other cases reported in literature, this case report highlights the potential of long-acting octreotide for MD treatment avoiding more expensive therapies like cetuximab and gastrectomy.

Neurohormonal modulation: The new paradigm of pharmacological treatment of heart failure

The current paradigm of medical therapy for heart failure with reduced ejection fraction (HFrEF) is triple neurohormonal blockade with an angiotensin-converting enzyme inhibitor (ACEI), a beta-blocker (BB) and a mineralocorticoid receptor antagonist (MRA). However, three-year mortality remains over 30%. Stimulation of counter-regulatory systems in addition to neurohormonal blockade constitutes a new paradigm, termed neurohormonal modulation. Sacubitril/valsartan is the first element of this new strategy. PARADIGM-HF was the largest randomized clinical trial conducted in HFrEF. It included 8442 patients and compared the efficacy and safety of sacubitril/valsartan versus enalapril. The primary endpoint was the composite of cardiovascular mortality and hospitalization due to HF, which occurred in 914 (21.8%) patients receiving sacubitril/valsartan and in 1117 (26.5%) patients receiving enalapril (HR 0.8, 95% CI 0.73-0.87, p=0.0000002; NNT 21). Sacubitril/valsartan reduced both primary endpoint components, as well as sudden cardiac death, death due to worsening HF, and death from all causes. Patients on sacubitril/valsartan reported less frequent deterioration of HF and of quality of life, and discontinued study medication less frequently because of an adverse event. PARADIGM-HF demonstrated the superiority of sacubitril/valsartan over enalapril, with a 20% greater impact on cardiovascular mortality compared to ACEIs. Accordingly, in 2016, the European (ESC) and American (ACC/AHA/HFSA) cardiology societies simultaneously issued a class I recommendation for the replacement of ACEIs by sacubitril/valsartan in patients resembling PARADIGM-HF trial participants.

Shiga toxin-producing Escherichia coli in wild ungulates

Shiga toxin-producing Escherichia coli (STEC) are zoonotic pathogens that live in the gastrointestinal tract of wildlife and cattle without causing disease. In humans, their colonization and infection lead to life-threatening disease. We investigated the occurrence of STEC in wild ungulates (wild boar, red deer and roe deer) inhabiting areas differently impacted by anthropogenic activities. STEC were detected in 9% (n = 6) of the samples and were recovered from the three species: 1 of wild boar, 4 of red deer and 1 of roe deer. All the isolates (n = 7) were non-O157 STEC encoding stx1 (n = 2; 29%) and/or stx2 genes (n = 6; 86%). O27:H30 was the most frequent serotype identified, followed by O146:H21 and O146:H28. Two STEC were O-untypable: ONT:H28 and ONT:H52. The phylo-groups identified were B1 (n = 3), E (n = 3) and F (n = 1). All the isolates recovered were susceptible to the different classes of antibiotics tested, although resistance genes were found in two strains. Apart from stx, all STEC encode many virulence factors (VF), particularly adhesins and/or other toxins. A strain with 13 VF collected from roe deer has a high enterohemorrhagic risk due to the presence of intimin, hemolysin and protease effectors genes. Enterohemorrhagic E. coli (EHEC) are implicated in the major cases of human infection and mortality, highlighting the zoonotic potential of wildlife-associated STEC. Wild ungulates are reservoirs of STEC potentially pathogenic to humans. Therefore, following the One Health concept, it is crucial to establish worldwide local monitoring programs that will benefit human, animal and environmental health.

Use of an acellular collagen-elastin matrix to support bladder regeneration in a porcine model of peritoneocystoplasty

Introduction

Bladder reconstruction without using the intestine remains a challenge to this day despite the development of new biomaterials and cell cultures. Human bladder engineering is merely anecdotic, and mostly in vitro and animal studies have been conducted.

Material and methods

In our study using a porcine model, we performed a bladder augmentation using an autologous parietal peritoneum graft (peritoneocystoplasty) and determined whether the attachment of an acellular collagen-elastin matrix (Group 1) or lack of (Group 2) had better histologic and functional results. Thus far, peritoneocystoplasty has rarely been performed or combined with a biomaterial.

Results

After 6 weeks, we observed different degrees of retraction of the new bladder wall in both groups, although the retraction was lower and the histological analysis showed more signs of regeneration (neoangiogenesis and less fibrosis) in Group 1 than when compared with Group 2. No transitional cells were found in the new bladder wall in any of the groups, and no differences were observed in the functional test results.

Conclusions

Performing a peritoneocystoplasty is an easy and safe procedure. The data supports the benefit of an acellular collagen–elastin matrix to reinforce bladder regeneration. However, in our study we observed too much retraction of the new wall and the histologic results were not acceptable to consider it an appropriate cystoplasty technique.

Human Library

Background and context: In spite of the fact that cancer is a common disease on our days, there are still a lot of myths and misconceptions concerning it. In addition, many times the strategy that community asks for is a lecture or a conference and sometimes public (if it happens in schools, specially) has no interest to be there or feels uncomfortable to speak about it with a big group of people. Human Library is a different strategy that has been applied with success and in which public may talk with different persons/books that have different perspectives about cancer. Aim: Dispelling myths and misconceptions about cancer offering an innovative approach and giving the public the possibility of actually talk about their concerns Strategy/Tactics: We have identified different perspectives about cancer and people that could impersonate them. We then had a workshop with them, presenting the “Human Library” idea, inspired in the one created in Copenhagen in the spring of 2000. What we ask them is to think about their story with cancer and to be available to answer questions about it. Afterward, as our main target was to encourage dialogue, increase knowledge about cancer and help to build positive feelings concerning fighting cancer, public is invited to talk with this volunteers/books and to ask them whatever they want/need to know. We currently have 5 types of books: survivor, volunteer, scientist, health professional and caregiver. Program/Policy process: After being publicized, the Human Library may be requested by institutions of the community (e.g., schools, associations, enterprises). We then mobilize our human books to answer this request. Once in the institution, each “book” may talk with a group of 6 people maximum. After delivering a brief description of its perspective concerning cancer, the “book” should be available for questions and the idea is that books should only talk if there are questions. After sometime, the “readers” are invited to change “books” and start all over again. Outcomes: This has been a very successful experience as far as we realized this is a strategy that engage people and allow them to really have their questions answered. In that way, we may assure that we are addressing those people myths and misconceptions, in a much more personalized approach. What was learned: Further to identifying good “books” to realize the project, engaging and empowering them, the Human Library it´s not expensive as far as the biggest resource needed is time. Otherwise, is important to stress that this kind of activity is very flexible and can be organized anywhere.

Super Healthy: A Healthy Diet Card Game

Background and context: The Portuguese League Against Cancer works with schools in cancer prevention for 30 years and since the very beginning tried to offer attractive strategies to get children engagement. Knowing that card games are again on the top strategies for children we develop the Super Healthy Card Game. Aim: To promote health habits in children (6-10 years old), namely in what concerns their lunch and snacks options. Strategy/Tactics: We have created a card game in which each card represents a healthy and important food (e.g., carrot, broccoli, milk, beans, fish) with specific powers like resistance or defense, for instance. There are 15 cards in total; children get the first 5 for free in the beginning of the program and then, to get the other 10, they have to eat the food defined by the card, either at lunch (school canteens have them available on predated days) or at midmorning and midafternoon snacks (children and their parents have to prepare it at home). Program/Policy process: To have success we have articulated with three main institutions on a national and governmental levels: General Health Committee; General Education Committee and National Nutrionists Association. Then, we have publicized the game in schools and asked for their registrations for the materials. Thousands of games were send to schools free of charge. The program has involved all school community because the school canteens have to cook the meals, parents have to prepare healthier snacks, teachers have to monitor the entire process and children have to play the card game. Outcomes: With this methodology many children tasted for the first time some foods and parents reflected on the importance of healthy snacks. Besides that, after getting the cards, children played with it and learned a little bit more about what they eat and its effects on their health. What was learned: This kind of strategy is very challenging because it implies the coordination of various partners. Also, nutrition is a transversal theme and different institutions stress unique aspects so it was important to assure that all partners feel their message is respected. Nevertheless, we find this strategy to be empowering and really successful.

A Pink Wave for Breast Cancer Awareness and Prevention

Background and context: Integrated in the Pink October Movement, we decided since 2014 to challenge people and institutions to use the color pink as a way to raise awareness concerning breast cancer prevention. Aim: Raise awareness and reinforce the idea that breast cancer prevention is possible, namely with screening. Strategy/Tactics: We present a list of possibilities to be done individually or in community, indoor or outdoor, in one day or several, with family, friends and colleagues or with the anonymous community. Program/Policy process: We disseminate this idea to all our partners: schools, municipalities, enterprises and, of course, mass media. Between the 15th and 31st October hundreds of institutions join us in this Pink Wave. Outcomes: Each year we raise the number of partners which develop creative and dynamic activities, engaging themselves a high number of participants. Information sessions, awareness workshops, gymnastics challenges, arts and crafts initiatives, call for partnerships throughout the rest of the year and fundraising. All of this empowers community and turns out to be totally impossible to run away from this wave and consequently from the theme of breast cancer prevention. What was learned: First, we learnt that sometimes less is more. We started to do a list of activities and we didn´t offered anything more. And the truth is people didn´t need it because the list was the trigger for their creativity and originality. Secondly, the spiral movement is reinforcement and each year we add new activities that were done successfully in the past by partners. This way people believe is possible and try it also. Finally, it´s very important to listen to the community: which kind of activities they enjoy the most and how can we help them... and of course to share with the community the good results, disseminating the best practices on social and mass media, stressing the idea that without them nothing (or nearly nothing) could be done!

Modular multipin electrodes for comfortable dry EEG

Electrode and cap concepts for continuous and ubiquitous monitoring of brain activity will open up new fields of application and contribute to increased use of electroencephalography (EEG) in clinical routine, neurosciences, brain-computer-interfacing and out-of-the-lab monitoring. However, mobile and unobtrusive applications are currently hindered by the lack of applicable convenient and reliable electrode and cap systems. We propose a novel modular electrode concept based on a flexible polymer substrate, coated with electrically conductive metallic films. The overall concept enables design adaptation to different head regions and cap designs. We describe the single modules of the system and investigate the influence of electrode pin number, coating material and adduction force on electrode-skin impedance and perceived wearing comfort. Our results contribute to rapid and comfortable multichannel dry EEG.

Polymorphism of mitochondrial DNA in the Brazilian Canindé goat breed

The success of the geographical distribution of goat populations around the world is a consequence of the adaptive potential of these breeds. Several relevant traits to the success of the species in colonizing different ecosystems (and use by man) evolved before domestication. These features were relevant for the selection of different breeds. Each breed represents a genetic heritage that may be unique and essential for maintaining the species. The objective of this study was to catalog the mtDNA haplotypes of the Brazilian autochthonous Canindé goat breed and to characterize the genetic diversity observed in subpopulations by sequencing a 481-bp fragment corresponding to the first portion of the control region in 178 individuals from 10 herds, sampled in six Brazilian states. The global population displays a total of 29 haplotypes and 56 polymorphic sites. About one-third (10) of the haplotypes were common to all subpopulations while the remaining (19) were exclusive to a single subpopulation. The population exhibited high average haplotype diversity (0.82), with maximum and minimum values of 0.90 and 0.56 in individual subpopulations, respectively. In contrast, nucleotide diversity was 0.014, with maximum and minimum values of 0.020 and 0.004, respectively. The spatial analysis of molecular variance did not detect structure within the Canindé goat breed, and analysis of molecular variance revealed that 88.4% of the variation observed in the population was due to differences among individuals in the same subpopulation. Only 11.4% of the genetic variation referred to differences among subpopulations. About one-third (33.1%) of the individuals within population shared the same haplotype, which may be due not only to the breed developing from a small number of matrilines. The Brazilian autochthonous Canindé breed was classified as haplogroup A, a haplotype predominant in the Europe region.

Demographic history, current expansion and future management challenges of wild boar populations in the Balkans and Europe

Wild boar (Sus scrofa), one of the most widespread wildlife species, has entered a stage of continuous growth in Europe, and could even be considered a pest species. We analysed microsatellite variability in 723 wild boars from across Europe, including the northern Dinaric Balkans. Our aims were: (1) to define the population structure of wild boars in the Balkans and its relation with other European populations; (2) to estimate effective populations sizes, levels of intra- and inter-population diversity, inbreeding migration and gene flow patterns; (3) to test subpopulations for bottlenecks; (4) to interpret these results in light of current knowledge about the demographic history of wild boars in Europe; and (5) to discuss the relevance of these findings for management and conservation. Strong population structuring was observed and 14 subpopulations were revealed. High genetic diversity was found, and besides the well-known identity of the Italian populations of Sardinia and Castelporziano, we bring new insights into other potential relevant, refugial populations such as Littoral Slovenia, South Portugal, North-western Iberia and an entire cluster in the Balkans. There was evidence of gene flow going from these refugial subpopulations towards less peripheral and more admixed subpopulations. Recent population bottlenecks and expansions were detected, mostly in the peninsular refuge subpopulations. The results are consistent with the fluctuations of wild boar numbers in Europe since the beginning of the twentieth century. These results should be taken into account in future conservation and management plans for wild boar populations in Europe.