In-hospital versus after-discharge complete revascularization in patients with ST segment elevation myocardial infarction and multivessel disease. REVIVA-ST trial

INTRODUCTION

Complete revascularization (CR) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), is associated with a reduction in major adverse cardiovascular events (MACE). However, there is uncertainty about whether nonculprit-lesion revascularization should be performed, during index hospitalization or delayed, especially regarding health care resources utilization. In this study, we aimed to evaluate the impact of in-hospital nonculprit-lesion revascularization vs. delayed (after discharge) revascularization on the length of index hospitalization.

METHODS

In this single-center study, we randomly assigned patients with STEMI and MVD who underwent successful culprit-lesion PCI to a strategy of either CR during in-hospital admission or a delayed CR after discharge. The first primary endpoint was the length of hospital stay. The second endpoint was the composite of cardiovascular death, myocardial infarction or ischemia-driven revascularization at 12 months (MACE).

RESULTS

From January 2018 to December 2022, we enrolled 258 patients (131 allocated to CR during in-hospital admission and 127 to an after-discharge CR). We found a significant reduction in the length of hospital stay in those assigned to after-discharge CR strategy [4 days (3-5) versus 7 days (5-9); p = 0.001]. At 12-month of follow-up, no differences were found in the occurrence of MACE, 7 (5.34%) patients in in-hospital CR and 4 (3.15%) in after-discharge CR strategy; (hazard ratio, 0.59; 95% confidence interval, 0.17 to 2.02; p = 0.397).

CONCLUSIONS

In STEMI patients with MVD, an after-discharge CR strategy reduces the length of index hospitalization without an increased risk of MACE after 12 months of follow-up.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT04743154.

Proteomic Profiling Identifies Candidate Diagnostic Biomarkers of Hydrosalpinx in Endometrial Fluid: A Pilot Study

Hydrosalpinx is a fluid occlusion and distension of the fallopian tubes, often resulting from pelvic inflammatory disease, which reduces the success of artificial reproductive technologies (ARTs) by 50%. Tubal factors account for approximately 25% of infertility cases, but their underlying molecular mechanisms and functional impact on other reproductive tissues remain poorly understood. This proteomic profiling study applied sequential window acquisition of all theoretical fragment ion spectra mass spectrometry (SWATH-MS) to study hydrosalpinx cyst fluid and pre- and post-salpingectomy endometrial fluid. Among the 967 proteins identified, we found 19 and 17 candidate biomarkers for hydrosalpinx in pre- and post-salpingectomy endometrial fluid, respectively. Salpingectomy significantly affected 76 endometrial proteins, providing insights into the enhanced immune response and inflammation present prior to intervention, and enhanced coagulation cascades and wound healing processes occurring one month after intervention. These findings confirmed that salpingectomy reverses the hydrosalpinx-related functional impairments in the endometrium and set a foundation for further biomarker validation and the development of less-invasive diagnostic strategies for hydrosalpinx.

Periodontal Effects of the Reversible Dipeptidyl Peptidase 1 Inhibitor Brensocatib in Bronchiectasis

AIMS

Brensocatib is a reversible inhibitor of dipeptidyl peptidase 1 (cathepsin C), in development to treat chronic non-cystic fibrosis bronchiectasis. The phase 2, randomized, placebo-controlled WILLOW trial (NCT03218917) was conducted to examine whether brensocatib reduced the incidence of pulmonary exacerbations. Brensocatib prolonged the time to the first exacerbation and led to fewer exacerbations than placebo. Because brensocatib potentially affects oral tissues due to its action on neutrophil-mediated inflammation, we analyzed periodontal outcomes in the trial participants.

MATERIALS AND METHODS

Patients with bronchiectasis were randomized 1:1:1 to receive once-daily oral brensocatib 10 or 25 mg or placebo. Periodontal status was monitored throughout the 24-week trial in a prespecified safety analysis. Periodontal pocket depth (PPD) at screening, week 8, and week 24 was evaluated. Gingival inflammation was evaluated by a combination of assessing bleeding upon probing and monitoring the Löe-Silness Gingival Index on 3 facial surfaces and the mid-lingual surface.

RESULTS

At week 24, mean ± SE PPD reductions were similar across treatment groups: -0.07 ± 0.007, -0.06 ± 0.007, and -0.15 ± 0.007 mm with brensocatib 10 mg, brensocatib 25 mg, and placebo, respectively. The distribution of changes in PPD and the number of patients with multiple increased PPD sites were similar across treatment groups at weeks 8 and 24. The frequencies of gingival index values were generally similar across treatment groups at each assessment. An increase in index values 0-1 and a decrease in index values 2-3 over time and at the end of the study were observed in all groups, indicating improved oral health.

CONCLUSIONS

In patients with non-cystic fibrosis bronchiectasis, brensocatib 10 or 25 mg had an acceptable safety profile after 6 months' treatment, with no changes in periodontal status noted. Improvement in oral health at end of the study may be due to regular dental care during the trial and independent of brensocatib treatment.

KNOWLEDGE TRANSFER STATEMENT

The results of this study suggest that 24 weeks of treatment with brensocatib does not affect periodontal disease progression. This information can be used by clinicians when considering treatment approaches for bronchiectasis and suggests that the use of brensocatib will not be limited by periodontal disease risks. Nevertheless, routine dental/periodontal care should be provided to patients irrespective of brensocatib treatment.

[Medication reconciliation and hospital-community transition securisation: Survey of community pharmacists]

OBJECTIVE

To collect the community pharmacists' perception on their role in the medication reconciliation's process.

METHODS

We did an observational transverse study thanks to a survey of community pharmacists working in France, conducted in 2020. A digital questionnaire was submitted to Parisian community pharmacists before being shared on two Facebook groups. The responses were analysed with Microsoft Excel® software. We calculated percentages, used Chi2 or Fisher's exact tests and did qualitative analyses.

RESULTS

We collected the perception of 135 community pharmacists, the majority was women (80%), relatively young (69.6% of 40 years old or less). They were 63.7% to claim knowing the medication reconciliation, but they could not define it properly. The subject's knowledge was statistically related to age (P-value<0.001) and previous contacts of the health care facilities (P-value<0.001). The majority of interviewed pharmacist considered the transmission of information to those health facilities as relevant and feasible and they expressed their willingness to get involved. However, they were limited by some obstacles such as the non-exhaustiveness of the medicinal record, the unsecured mail and the lack of feedbacks.

CONCLUSIONS

Although the community pharmacists expressed interest for the medication reconciliation process and willingness to get involved, their role remained limited. Therefore, this process needs an improvement of its organisation and a generalisation of its practice to really benefit the hospital-community transition's safety.

Long-term recurrent events in ST-elevation myocardial infarction and multivessel disease. The impact of different revascularization strategies

INTRODUCTION

The benefit of complete revascularization (CR) on long-term total event reduction in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), still remains unclear. We assessed the efficacy of three different revascularization strategies on long-term total recurrent events.

METHODS

We retrospectively analyzed 414 consecutive patients admitted with STEMI and MVD who were categorized according to the revascularization strategy used: culprit-vessel-only percutaneous coronary intervention (PCI) (n=163); in-hospital CR (n=136); and delayed CR (n=115). The combined endpoint assessed was all-cause mortality, the total number of myocardial infarctions, ischemia-driven revascularizations or strokes. Negative binomial regression was used to assess the association between the revascularization strategy and total events; risk estimates were expressed as an incidence rates ratio (IRR).

RESULTS

At a median follow-up of four years (1.2-6), rates of the combined endpoint per 10 patient-years were 18, 0.8, and 0.6 in culprit-vessel-only PCI, in-hospital CR, and delayed CR strategies, respectively (p<0.001). After multivariable adjustment and when compared with culprit-vessel-only PCI, both in-hospital and delayed CR strategies were significantly associated with a reduction in the combined endpoint (IRR=0.40: 95% confidence interval (CI), 0.25-0.64; p<0.001; and IRR 0.40: 95% CI, 0.24-0.62; p<0.001, respectively). No differences were observed across in-hospital and delayed CR strategies.

CONCLUSIONS

Complete revascularization of non-culprit lesions in patients with STEMI and MVD reduces the risk of total recurrent events during long-term follow-up. No differences between in-hospital and delayed CR strategies were found.

Effect on mortality and hospitalization of real-world implementation of transitional care heart failure programmes in patients with heart failure: a population-based study in 77,554 patients

Background

The efficacy of heart failure programs has been demonstrated in clinical trials but their applicability in the real-world practice setting is more controversial.

Purpose

This study evaluates the efficacy of a comprehensive, transitional-care nurse-based HF programme integrating hospital and primary care resources in a healthcare area covering a population of 209,255 (implementation area).

Methods

We designed a pragmatic, population-based evaluation of the implementation of the program conducting a natural experiment. Study periods were: pre-implementation period (years 2015 and 2016), transition period (year 2017) and consolidation of implementation period (years 2018 and 2019). For the purposes of this study, we included all individuals consecutively admitted to hospital with at least one ICD-9-CM code for HF as the primary diagnosis and discharged alive in Catalonia between January, the 1st, 2015 and December, the 31st of 2019. Efficacy of the implementation of the program was measured at two levels: first, comparing the outcomes of patients exposed to the HF program between periods of implementation taking 2015–2016 as the reference period and, second, comparing outcomes between patients of the implementation area with patients of the remaining areas of the Catalonia at each predefined period.

Results

We included 77,554 patients in the study: 3,396 exposed to the implementation area and 74,158 exposed to the rest of healthcare areas in Catalonia. During the period of the study, 55,886 (72.1%) patients experienced at least one major adverse event. Death occurred in 37,469 (48.3%), clinically related hospitalisation in 41,709 (53.8%) and HF readmission in 29,755 (38.4%).

As shown in Table 1, multivariate Cox proportional hazards models adjusted for age, gender, previous hospitalisation, co-morbidities, socioeconomic status, and time since HF diagnosis showed there was a significant (all p-values &lt;0.001) relative risk reduction of the risk of all-cause death (5%), clinically related hospitalisation (13%) and HF hospitalisation (14%) in the consolidation period (2018–2019) compared to the pre-programme period (2015–2016). Similarly, as shown in Table 1 and Figure 1, while in the pre-programme period (2015–2016) the risk of adverse outcomes was significantly higher in patients exposed to the implementation area compared to the rest of Catalonia, this association was inverted during the consolidation period (2018–2019) where the risk of mortality, clinically-related readmission and HF re-hospitalisation was significantly reduced (all p-values &lt;0.025) by 19%, 11% and 16%, respectively, among patients exposed to the implementation area compared with patients of the remaining areas of Catalonia.

Conclusions

The implementation of multidisciplinary transitional-care nurse-based heart failure programmes integrating hospital and primary care reduce mortality and hospitalisation in vulnerable patients with heart-failure.

Funding Acknowledgement

Type of funding sources: None.

Effect of socioeconomic status in medical resource use and outcomes in patients with heart failure in integrated care settings: real-world evidence from population-based data of 77,554 patients

Background

Low socioeconomic status (SES) has a negative impact in terms of outcomes and medical resource use despite open access to care in universal health-care systems in patients with heart failure (HF). Whether the breach in outcomes determined by SES inequalities can be mitigated by intensive HF management in integrate care programs is not known.

Purpose

To analyse the effect of SES status on health outcomes before and after a pragmatic implementation of an intensive transitional care nurse-based HF management program integrating hospital and primary care and resources for patients with HF at a high risk of events in a health-care area of 209,255 inhabitants.

Methods

For the purposes of this study, we included all individuals consecutively admitted to hospital with at least one ICD-9-CM code for HF as the primary diagnosis and discharged alive in Catalonia between January, the 1st, 2015 and December, the 31st of 2019. We considered 3 distinct periods of implementation of the HF programme: pre-implementation (2015–2016), transition (2017 start of implementation) and consolidation (2018–2019). To evaluate the efficacy of the programme according to SES strata, we compared outcomes between HF patients of the implementation area and HF patients of the remaining healthcare areas of Catalonia across implementation periods and stratified according to levels of SES. SES was defined based on individual annual income.

Results

We included 77,554 patients in the study: 3,396 in the implementation area and 74, 158 in the rest of Catalonia. Distribution of patients according to SES was: 12,018 (15.5%) high or medium SES, 61,967 (79.9%) low SES and 3,535 (4.5%) very low SES. During the period of the study death occurred in 37,469 (48.3%), clinically related hospitalisation in 41,709 (53.8%) and HF readmission in 29,755 (38.4%).

Multivariate Cox proportional hazards models (Table 1) showed that low or very low SES was associated with worse outcomes compared to patients with high or medium SES. Implementation of HF programme significantly improved outcomes in patients with HF (Figure 1, left column). As shown in Figure 1 central and right columns, improvement in clinical outcomes was observed across all SES strata in patients exposed to the HF programme. The size effect for hospitalisation was more prominent among patients with medium of high SES (47% relative change) compared to patients with low or very low SES (32% relative change). Size effect for mortality did not differ between both strata (10% relative improvement in both groups).

Conclusions

The SES is an independent predictor of mortality, clinically related hospitalisation, and HF hospitalisation in vulnerable patients with HF. The implementation of an intensive transitional care nurse-based HF management program improve clinical outcomes across SES strata. However, the size effect in the prevention of hospitalisation is more pronounced among patients with medium or high SES.

Funding Acknowledgement

Type of funding sources: None.

Cutaneous larva migrans: an unusual souvenir from a Scottish holiday

Cutaneous larva migrans acquired in western Scotland. A reminder that with a warming climate, conditions conventionally restricted to the tropics may be contracted in the British Isles in the absence of foreign travel.

Interventions aux urgences d’une équipe mobile de gériatrie et articulation avec un suivi psychologique en gériatrie aiguë lors de la première vague de COVID-19

Au printemps 2020, l’Équipe mobile de gériatrie des hôpitaux universitaires de Strasbourg a fait face à un afflux majeur de patients âgés, infectés par le SARS-CoV-2, en soutien aux urgentistes. Nous allons décrire la population rencontrée, les projets de soins, exprimés par les patients, et leurs proches, ainsi que les orientations réalisées. Nous nous attacherons à décrire les enjeux et l’impact possible de l’évaluation gériatrique en contexte d’épidémie aux urgences. Enfin, nous décrirons l’articulation avec les psychologues du service de court séjour gériatrique.

OP0136 RITUXIMAB PREVENTS THE PROGRESSION OF B-CELL DRIVEN INFLAMMATORY INFILTRATE IN THE MINOR SALIVARY GLANDS OF PRIMARY SJOGREN’S SYNDROME BY DOWNREGULATING IMMUNOLOGICAL PATHWAYS KEY IN ECTOPIC GERMINAL CENTRE ORGANIZATION: RESULTS FROM THE TRACTISS TRIAL

Background:

The pathogenic role of B-cells in primary Sjögren’s Syndrome (pSS) is well established and B cell abnormalities. Because of the substantial role of B-cells, rituximab (RTX), a chimeric anti-CD20 monoclonal antibody, has been considered as a potential biologic disease modifying drug to reduce disease activity in pSS. To date, the TRial for Anti-B-Cell Therapy In patients with pSS (TRACTISS) is the largest multi-centre, placebo-controlled trial with RTX. Despite the unmet primary endpoints (30% reduction in fatigue or oral dryness, measured by visual analogue scale), RTX treated patients showed an improvement in unstimulated whole salivary flow (Bowman et al. Arthritis Rheumatol 2017;69:1440–1450).

Objectives:

To provide the first longitudinal transcriptomic and histological analysis at 3 time points over 48 weeks of labial SGs of pSS patients treated with RTX, in comparison to placebo, from the TRACTISS cohort.

Methods:

26 pSS patients randomised to RTX or placebo arm consented for labial SG biopsies at baseline, weeks 16 and 48. Patients received two 1000mg cycles of RTX or placebo at baseline and week 24. SG focus score, inflammatory aggregate area fraction, B-cells (CD20+), T-cells (CD3+), follicular dendritic cells (FDCs) (CD21+) and plasma cells (CD138+) density were assessed by H&E and immunofluorescence staining. The histological analysis was performed by digital imaging using QuPath software. RNA was extracted from matched labial SG lobules and sequenced with Illumina platform. A Principal Component Analysis (PCA) and features driving the PCA were investigated along with the most influential gene loadings. The limma-voom R pipeline was used to extract Differential Expressed Genes (DEGs) between placebo and RTX group at week 48, and gene ontology (GO) enrichment analysis performed through EnrichR to derive GO terms and pathways associated with DEGs.

Results:

Placebo-treated labial SGs showed a worsening of inflammation highlighted by the increment of B-cell density, development of new FDC networks, and a higher ectopic GC prevalence at week 48, compared to RTX-treated patients. No difference in total T-cells and plasma cell infiltration was observed. RTX downregulated genes involved in immune cell recruitment and inflammatory aggregate organisation (e.g. CCR7, CCL19, CD52, and PDCD1) and gene signature-based analysis of 64 immune cell types highlighted how RTX preferentially blocked class-switched- and memory-B-cells infiltration in SGs at week 48. Pathway analyses confirmed the downregulation of leukocyte migration, MHC class II antigen presentation, and T-cell co-stimulation immunological pathways, such as the CD40 receptor complex pathway. The analysis of placebo SGs transcriptomic at week 48 showed a higher expression of genes linked to ectopic GC organisation, such as CXCL13, CCL19, LTβ, in female compared to male subjects. Gender was confirmed as a key co-variate responsible for most of the variation in the PCA, together with the SG focus score and the foci area fraction.

Conclusion:

Treatment with RTX showed beneficial effects on labial SG inflammatory infiltration in pSS, by downregulating genes involved in immune cell recruitment, activation and organisation in ectopic GCs. Class-switched-B-cells, memory-B-cells and FDC network development were primarily affected appearing to be responsible for the lack of progression in SG B cell infiltration in the RTX compared to the placebo arm in which clear worsening of SG immunopathology over 48 weeks was detected in female patients. Although a clear association with the clinical improvement in unstimulated salivary flow observed at week 48 in RTX-treated patients could not be established given the low number of patients consenting to 3 longitudinal biopsies it is conceivable that RTX is responsible for preserving exocrine function.

Acknowledgements:

SJB receives a salary contribution from the NIHR Birmingham Biomedical Research Centre.

Disclosure of Interests:

Elena Pontarini: None declared, Farzana Chowdhury: None declared, Elisabetta Sciacca: None declared, Sofia Grigoriadou: None declared, Felice Rivellese: None declared, Davide Lucchesi: None declared, Katriona Goldmann: None declared, Liliane Fossati-Jimack: None declared, Paul Emery: None declared, Wan Fai Ng: None declared, Nurhan Sutcliffe: None declared, Colin Everett: None declared, Catherine Fernandez: None declared, Anwar Tappuni: None declared, Myles Lewis: None declared, Costantino Pitzalis: None declared, Simon J. Bowman Consultant of: SJB In 2020 I have received consultancy fees from Novartis, Abbvie and Galapagos., Michele Bombardieri: None declared

One-carbon, carnitine, and glutathione metabolism-related biomarkers in peripartal Holstein cows are altered by prepartal body condition

We investigated how prepartal body condition score (BCS) alters key hepatic enzymes associated with 1-carbon, carnitine, and glutathione metabolism and the related biomarkers in liver tissue and plasma of periparturient dairy cows. Twenty-six multiparous Holstein dairy cows were retrospectively selected according to BCS at 4 wk prepartum and divided into high (HighBCS, BCS ≥ 3.50) and normal (NormBCS, BCS ≤ 3.25) BCS groups (n = 13 each). Blood plasma samples were obtained at -30, -10, 7, 15, and 30 d relative to calving. Liver tissue biopsies were performed at -15, 7, and 30 d relative to calving, and samples were used to assess protein abundance via Western blot assay. Cows in the HighBCS group lost ∼1 unit of BCS between -4 and 4 wk around calving, while NormBCS cows lost ∼0.5 unit in the same period. Prepartal dry matter intake (DMI, kg/d) did not differ between groups. Compared with NormBCS cows, HighBCS cows had higher postpartal DMI and milk yield (+5.34 kg/d). In addition, greater overall plasma concentrations of fatty acids and activity of the neutrophil-enriched enzyme myeloperoxidase were observed in HighBCS compared with NormBCS cows. Despite similar reactive oxygen metabolite concentrations in both groups at 30 d, HighBCS cows had lower overall concentrations of β-carotene and tocopherol, explaining the lower (BCS × Time) antioxidant capacity (ferric reducing ability of plasma). The HighBCS cows also had greater liver malondialdehyde concentrations and superoxide dismutase activity at 30 d. Overall, compared with NormBCS cows, HighBCS cows had lower hepatic protein abundance of the 1-carbon metabolism enzymes cystathionine-β-synthase, betaine-homocysteine methyltransferase, and methionine adenosyltransferase 1 A (MAT1A), as well as the glutathione metabolism-related enzymes glutathione S-transferase α 4 and glutathione peroxidase 3 (GPX3). A lower protein abundance of glutathione S-transferase mu 1 (GSTM1) at -15 and 7 d was also observed. Regardless of BCS, cows had increased abundance of GSTM1 and GPX3 between -15 and 7 d around calving. A marked decrease of gamma-butyrobetaine dioxygenase 1 from -10 to 7 d in HighBCS compared with NormBCS cows suggested a decrease in de novo carnitine synthesis that was partly explained by the lower abundance of MAT1A. Overall, data suggest biologic links between BCS before calving, milk yield, immune response, and hepatic reactions encompassing 1-carbon metabolism, carnitine, and antioxidant synthesis.

Maternal body condition influences neonatal calf whole-blood innate immune molecular responses to ex vivo lipopolysaccharide challenge

Managing body condition in dairy cows during the close-up period could alter the availability of nutrients to the fetus during the final growth stages in utero. We investigated how maternal body condition score (BCS) in late pregnancy affected calf whole-blood mRNA abundance and IL-1β concentrations after ex vivo lipopolysaccharide (LPS) challenge. Thirty-eight multiparous Holstein cows and their calves from a larger cohort were retrospectively grouped by prepartal BCS as normal BCS (≤3.25; n = 22; NormBCS) and high BCS (≥3.75; n = 16; HighBCS). Calf blood samples collected at birth (before receiving colostrum, d 0) and at ages 21 and 42 d (at weaning) were used for ex vivo whole-blood challenge with 3 µg/mL of LPS before mRNA isolation. Target genes evaluated by real-time quantitative PCR were associated with immune response, antioxidant function, and 1-carbon metabolism. Plasma IL-1β concentrations were also measured. Responses in plasma IL-1β and mRNA abundance were compared between LPS-challenged and nonchallenged samples. Statistical analyses were performed at all time points using a MIXED model in SAS 9.4. Neither birth body weight (NormBCS = 43.8 ± 1.01 kg; HighBCS = 43.9 ± 1.2 kg) nor colostrum IgG concentration (NormBCS = 70 ± 5.4 mg/mL; HighBCS = 62 ± 6.5 mg/mL) differed between groups. At birth, whole blood from calves born to HighBCS cows had greater mRNA abundance of IL1B, NFKB1, and GSR and lower GPX1 and CBS abundance after LPS challenge. The longitudinal analysis of d 0, 21, and 42 data revealed a BCS × age effect for SOD2 and NOS2 due to lower mRNA abundance at 42 d in the HighBCS calves. Regardless of maternal BCS, mRNA abundance decreased over time for genes encoding cytokines (IL1B, IL6, IL10, TNF), cytokine receptors (IRAK1, CXCR1), toll-like receptor pathway (TLR4, NFKB1), adhesion and migration (CADM1, ICAM1, ITGAM), and antimicrobial function (MPO). Concentration of IL-1β after LPS challenge was also markedly lower at 21 d regardless of maternal BCS. Overall, results suggested that maternal BCS in late prepartum influences the calf immune system response to an inflammation challenge after birth. Although few genes among those studied were altered due to maternal BCS, the fact that genes related to oxidative stress and 1-carbon metabolism responded to LPS challenge in HighBCS calves underscores the potential role of methyl donors (e.g., methionine, choline, and folic acid) in the early-life innate immune response.

Training hospital inpatient nursing to know (THINK) delirium: A nursing educational program

BACKGROUND/OBJECTIVES

Recognition and documentation of delirium is a challenge in the hospital. Education programs lack standardized screening tools. The presence of dementia or depression contribute to poor recognition of delirium. Many front-line healthcare workers attribute delirium to dementia, often misidentifying or delaying a correct diagnosis and in turn, treatment. Unrecognized and untreated delirium is costly. Non-pharmacologic interventions improve patient outcomes and decrease costs. Without delirium education, nurses are vulnerable to injury and low job satisfaction when caring for delirious patients. We describe an education program improving recognition and attitudes towards patients experiencing delirium.

DESIGN

An education program about screening, documenting, and treating delirium.

SETTING

A large Veterans Health System Hospital.

PARTICIPANTS

Healthcare professionals(n = 389) participated in the education program. 355 Nurses and patient-care assistants took the pre and post-test, and 43 returned the post program follow-up survey. A delirium education program with three steps; 1) self-directed online module; 2) dementia simulation experience; and 3) a multi-station delirium skills fair. Pre and post-tests were conducted after step 2, as well as a four-month follow-up survey.

MEASUREMENTS

Changes in attitude toward patients with cognitive impairment and their abilities. Self-assessment of attitudes toward patients with delirium.

RESULTS

Statistically significant differences in pre and post-testing suggested increased understanding of the experience and abilities of people experiencing cognitive impairment . The four-month follow-up survey showed a continued understanding of the importance of recognizing, documenting, and treating delirium.

CONCLUSION

Nursing Education about delirium that includes instruction on a standardized screening tool, documentation, and non-pharmacologic interventions improved knowledge and recognition of delirium and may have changed attitudes surrounding delirium in the hospital.

The in vivo comparison of first versus second generation bioresorbable technologies early after implantation in the porcine coronary in stent restenosis model

Background

Second generation bioresorbable scaffold (BRS) technologies with thinner struts were developed to overcome thrombotic and restenotic events when compared to first generation

Purpose

Herein we compare vascular response and scaffold recoil of first generation BRS (Absorb, BVS, 150 micron) with second generation (Meres 100, MRS, 100 micron) in the porcine model of coronary in stent restenosis model

Methods

In total 11 BRS and 13 MRS similar scaffolds were implanted in 12 domestic swine, with 110% overstretch under Optical coherence tomography guidance. Animals were followed up for 2, 7 and 28 days (8 scaffolds for each period). At terminal follow up comprehensive evaluation with OCT was performed and tissues harvested for pathology

Results

Arterial injury expressed as overstretch was similar among groups. There were no differences at 2 and 7 days with regards to lumen area (LA), neointimal area (NA) stent areas (SA) and %AS. At 28 days SA and NA were lower in the MRS group when compared to BRS (SA: 5,1 vs. 8,8 mm2, p=0,01; NA: 1,94 vs. 3.36 mm2; p=0,01). Arterial healing was similar at 28 days between MRS and BRS as expressed by embedded and covered struts (100 vs 100%, p=1,0), however at 7 days there were more uncovered struts in the MRS (43% vs 12%, p=0,01).

Conclusions

Second generation MRS have proven improved vascular response in porcine coronary model with regard to lesser neointimal hyperplasia. Thinner struts however caused recoil when compared to thicker ones at early follow-up point. Further BRS material and design improvements are necessary to achieve metallic stent - like properties.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Center for Research and Development

Methyl donor supply to heat stress-challenged polymorphonuclear leukocytes from lactating Holstein cows enhances 1-carbon metabolism, immune response, and cytoprotective gene network abundance

Mechanisms controlling immune function of dairy cows are dysregulated during heat stress (HS). Methyl donor supply-methionine (Met) and choline (Chol)-positively modulates innate immune function, particularly antioxidant systems of polymorphonuclear leukocytes (PMN). The objective of this study was to investigate the effect of Met and Chol supply in vitro on mRNA abundance of genes related to 1-carbon metabolism, inflammation, and immune function in short-term cultures of PMN isolated from mid-lactating Holstein cows in response to heat challenge. Blood PMN were isolated from 5 Holstein cows (153 ± 5 d postpartum, 34.63 ± 2.73 kg/d of milk production; mean ± SD). The PMN were incubated for 2 h at thermal-neutral (37°C; TN) or heat stress (42°C; HS) temperatures with 3 levels of Chol (0, 400, or 800 μg/mL) or 3 ratios of Lys:Met (Met; 3.6:1, 2.9:1, or 2.4:1). Supernatant concentrations of IL-1β, IL-6, and tumor necrosis factor-α were measured via bovine-specific ELISA. Fold-changes in mRNA abundance were calculated separately for Chol and Met treatments to obtain the fold-change response at 42°C (HS) relative to 37°C (TN). Data were subjected to ANOVA using PROC MIXED in SAS (SAS Institute Inc., Cary, NC). Orthogonal contrasts were used to determine the linear or quadratic effect of Met and Chol for mRNA fold-change and supernatant cytokine concentrations. Compared with PMN receiving 0 μg of Chol/mL, heat-stressed PMN supplemented with Chol at 400 or 800 μg/mL had greater fold-change in abundance of CBS, CSAD, GSS, GSR, and GPX1. Among genes associated with inflammation and immune function, fold-change in abundance of TLR2, TLR4, IRAK1, IL1B, and IL10 increased with 400 and 800 μg of Chol/mL compared with PMN receiving 0 μg of Chol/mL. Fold-change in abundance of SAHH decreased linearly at increasing levels of Met supply. A linear effect was detected for MPO, NFKB1, and SOD1 due to greater fold-change in abundance when Met was increased to reach Lys:Met ratios of 2.9:1 and 2.4:1. Although increasing Chol supply upregulated BAX, BCL2, and HSP70, increased Met supply only upregulated BAX. Under HS conditions, enhancing PMN supply of Chol to 400 μg/mL effectively increased fold-change in abundance of genes involved in antioxidant production (conferring cellular processes protection from free radicals and reactive oxygen species), inflammatory signaling, and innate immunity. Although similar outcomes were obtained with Met supply at Lys:Met ratios of 2.9:1 and 2.4:1, the response was less pronounced. Both Chol and Met supply enhanced the cytoprotective characteristics of PMN through upregulation of heat shock proteins. Overall, the modulatory effects detected in the present experiment highlight an opportunity to use Met and particularly Chol supplementation during thermal stress.

Molecular networks of insulin signaling and amino acid metabolism in subcutaneous adipose tissue are altered by body condition in periparturient Holstein cows

Peripartal cows mobilize not only body fat but also body protein to satisfy their energy requirements. The objective of this study was to determine the effect of prepartum BCS on blood biomarkers related to energy and nitrogen metabolism, and mRNA and protein abundance associated with AA metabolism and insulin signaling in subcutaneous adipose tissue (SAT) in peripartal cows. Twenty-two multiparous Holstein cows were retrospectively classified into a high BCS (HBCS; n = 11, BCS ≥ 3.5) or normal BCS (NBCS; n = 11, BCS ≤ 3.17) group at d 28 before expected parturition. Cows were fed the same diet as a total mixed ration before parturition and were fed the same lactation diet postpartum. Blood samples collected at -10, 7, 15, and 30 d relative to parturition were used for analyses of biomarkers associated with energy and nitrogen metabolism. Biopsies of SAT harvested at -15, 7, and 30 d relative to parturition were used for mRNA (real time-PCR) and protein abundance (Western blotting) assays. Data were subjected to ANOVA using the MIXED procedure of SAS (v. 9.4; SAS Institute Inc., Cary, NC), with P ≤ 0.05 being the threshold for significance. Cows in HBCS had greater overall plasma nonesterified fatty acid concentrations, due to marked increases at 7 and 15 d postpartum. This response was similar (BCS × Day effect) to protein abundance of phosphorylated (p) protein kinase B (p-AKT), the insulin-induced glucose transporter (SLC2A4), and the sodium-coupled neutral AA transporter (SLC38A1). Abundance of these proteins was lower at -15 d compared with NBCS cows, and either increased (SLC2A4, SLC38A1) or did not change (p-AKT) at 7 d postpartum in HBCS. Unlike protein abundance, however, overall mRNA abundances of the high-affinity cationic (SLC7A1), proton-coupled (SLC36A1), and sodium-coupled amino acid transporters (SLC38A2) were greater in HBCS than NBCS cows, due to upregulation in the postpartum phase. Those responses were similar to protein abundance of p-mTOR, which increased (BCS × Day effect) at 7 d in HBCS compared with NBCS cows. mRNA abundance of argininosuccinate lyase (ASL) and arginase 1 (ARG1) also was greater overall in HBCS cows. Together, these responses suggested impaired insulin signaling, coupled with greater postpartum AA transport rate and urea cycle activity in SAT of HBCS cows. An in vitro study using adipocyte and macrophage cocultures stimulated with various concentrations of fatty acids could provide some insights into the role of immune cells in modulating adipose tissue immunometabolic status, including insulin resistance and AA metabolism.

[Elder fallers: A group at risk of readmission?]

OBJECTIVES

To describe older patients hospitalized for falls, at risk of readmission and priority for interventions to reduce this risk.

METHODS

We conducted an observational, monocentric, prospective study (from April to June 2019). The inclusion criteria were: patients aged 75 and over, admitted to the Emergency Department for falls, consenting to the study. For patients subsequently hospitalized, the geriatric scores were determined (risk of readmission [ISAR score], state of frailty, degree of autonomy [Katz score]), and when appropriate, medication treatments were listed and compliance of patients was assessed (Girerd score).

RESULTS

In three months, 154 patients were included (median age 86 years [min 75-max 103], sex ratio 0.44), of which 73 patients were hospitalized. Among these patients, 63% presented a high risk of readmission; 45.2% are likely to become frail; 72.6% were dependent. Finally, 53 of the 73 patients (72.6%) had a treatment in primary care and presented a 71.7% non-compliance or low-compliance rate. Fifty height patients (79.5%) had at least 1 drug associated with fall [min 1-max 7].

CONCLUSIONS

Older patients presenting at hospital with a fall were numerous, often likely to become frail and dependent for the majority of them. As the readmission risk is also very high in this population, future studies aiming at reducing the risk of hospital readmission are needed.

Heartworm control in Grenada, West Indies: Results of a field study using imidacloprid 10% + moxidectin 2.5% and doxycycline for naturally-acquired Dirofilaria immitis infections

Canine heartworm disease (CHD) results from infection with Dirofilaria immitis and while it is of global concern, it is most prevalent in tropical climates where conditions support the parasite and vector life cycles. Melarsomine dihydrochloride is the sole treatment for CHD recommended by the American Heartworm Society. However, in cases where cost or access to melarsomine precludes treatment of an infected dog, therapeutic alternatives are warranted. This randomized, controlled field study evaluated the adulticidal efficacy of a combination therapeutic protocol using 10 % imidacloprid + 2.5 % moxidectin spot-on and a single 28-day course of doxycycline and compared with that of a 2-dose melarsomine dihydrochloride protocol. Of 37 naturally-infected domestic dogs with class 1, 2 or early class 3 CHD enrolled in the study, 30 were evaluated for a minimum of 12 months. Seven dogs were withdrawn due to canine ehrlichiosis, non-compliance, or wrongful inclusion. Dogs were randomly assigned to a control (CP, n = 15) or investigational (IVP, n = 15) treatment group. CP dogs received two injections of melarsomine dihydrochloride (2.5 mg/kg) 24 -hs apart and maintained on monthly ivermectin/pyrantel. IVP dogs were treated with oral doxycycline (10 mg/kg twice daily for 28 days) and topical 10 % imidacloprid + 2.5 % moxidectin once monthly for 9 months. Dogs were evaluated up to 18 months - monthly for the first 9 months, then every 3 months. Parasiticidal efficacy was based on antigen status using the IDEXX PetChek® 34 Heartworm-PF Antigen test. By month 18, antigen was not detected in any study dog except one from the IVP group. One other IVP dog was persistently antigenemic and treated with melarsomine at month 12 according to the initial study protocol. Mean antigen concentration (based on optical density) decreased more rapidly in the CP group and by month 15 was 0.11 for the IVP and 0.07 for CP groups, with equivalent median concentrations (0.04) in both groups. Conversion following heat-treatment of antigen-negative samples occurred frequently and at similar rates in both treatment groups. Based on the bias of diagnostic tests towards detection of female worms, we conclude that monthly application of 10 % imidacloprid + 2.5 % moxidectin for 9 months combined with a course of doxycycline twice daily for 28 days resulted in effective therapy against female adults in CHD. This therapeutic option may be particularly useful in cases where financial constraint or access to melarsomine precludes treatment of an infected individual. This study was supported by Bayer Animal Health.

Physiological wound assessment from coregistered and segmented tissue hemoglobin maps

A handheld near-infrared optical scanner (NIROS) was recently developed to map for effective changes in oxy- and deoxyhemoglobin concentration in diabetic foot ulcers (DFUs) across weeks of treatment. Herein, a coregistration and image segmentation approach was implemented to overlay hemoglobin maps onto the white light images of ulcers. Validation studies demonstrated over 97% accuracy in coregistration. Coregistration was further applied to a healing DFU across weeks of healing. The potential to predict changes in wound healing was observed when comparing the coregistered and segmented hemoglobin concentration area maps to the visual area of the wound.

Trajectories of Picky Eating in Low-Income US Children

BACKGROUND AND OBJECTIVES

Picky eating is common, yet little is known about trajectories of picky eating in childhood. Our objectives were to examine trajectories of child picky eating in low-income US children from ages 4 to 9 years and associations of those trajectories with participant characteristics, including child BMI z score (BMIz) and maternal feeding-behavior trajectories.

METHODS

Mother-child dyads (N = 317) provided anthropometry and reported on picky eating and maternal feeding behaviors via questionnaires at child ages 4, 5, 6, 8, and 9 years. At baseline, mothers reported on demographics and child emotional regulation. Trajectories of picky eating and maternal feeding behaviors were identified by using latent class analysis. Bivariate analyses examined associations of picky-eating trajectory membership with baseline characteristics and maternal feeding-behavior trajectory memberships. A linear mixed model was used to examine the association of BMIz with picky-eating trajectories.

RESULTS

Three trajectories of picky eating emerged: persistently low (n = 92; 29%), persistently medium (n = 181; 57%), and persistently high (n = 44; 14%). Membership in the high picky-eating trajectory was associated with higher child emotional lability and lower child emotional regulation. Picky eating was associated with restriction (P = .01) and demandingness (P < .001) trajectory memberships, such that low picky eating was associated with low restriction and high picky eating was associated with high demandingness. Medium and high picky-eating trajectories were associated with lower BMIz.

CONCLUSIONS

Picky eating appears to be traitlike in childhood and may be protective against higher BMIz.

P1475Impact of automatic screening and parasternal rights positions in the eligibility of patients with hypertrophic cardiomyopathy for subcutaneous automatic cardioverter defibrillator implant

Background

A high percentage of failures in the detection of QRS and T wave in patients (pts) with hypertrophic cardiomyopathy (HCM) have been reported. This finding would prevent them from being eligible for an implantable subcutaneous automatic defibrillator (S-ICD). However, recently 2 changes in the detection have been proposed, automatic screening and the use of right parasternal position of the lead. 

The aim of our work was to study if the elegibility proportion of patients  was increased with both 2 advacements.

Methods

We included 31 patients (18 male)with a diagnosis of HCM and at least 1 risk factor for sudden death, in follow-up at the outdoor clinic of of 2 cardiology centers. We performed elegibility screening test in supine position and standing using both the automatic screening (AS) obtained by Boston Scientific Zoom Latitude programmer) and the manual (MS), to simulate the detection of the 3 vectors utilized in S-ICD detection. And both screens were registered with the surface electrodes in parasternal left and right position. A pte was considered eligible if at least one vector was correct in supine position and in standing position, well in parasternal left or right position.

Results

Using MS with left parasternal position, 22 patients (71%) were eligible.  Adding the right parasternal lead, the eligibility increased by 10%,  reaching 81%. In addition, in automatic screening, eligibility in right shifts (81%) it is 7% more than in the left and, with the addition of the rights to the left, the eligibility reaches up to 84%. Figure shows the three-lead ECG factors influencing screening pass vs failure.

Conclusion

AS, right parasternal lead position and the combination of right and left parasternal lead position, increase the eligibility of sICD candidates with HCM.

Abstract Figure. ECG factors influencing screening pass

0636 Using AI To Predict Future CPAP Adherence and the Impact of Behavioral and Technical Interventions

Introduction

Clinical management of CPAP adherence remains an ongoing challenge. Behavioral and technical interventions such as patient outreach, coaching, troubleshooting, and resupply may be deployed to positively impact adherence. Previous authors have described adherence phenotypes that retrospectively categorize patients by discrete usage patterns. We design an AI model that predictively categorizes patients into previously studied adherence phenotypes and analyzes the statistical significance and effect size of several types of interventions on subsequent CPAP adherence.

Methods

We collected a cross-sectional cohort of subjects (N = 13,917) with 455 days of daily CPAP usage data acquired. Patient outreach notes and resupply data were temporally synchronized with daily CPAP usage. Each 30-days of usage was categorized into one of four adherence phenotypes as defined by Aloia et al. (2008) including Good Users, Variable Users, Occasional Attempters, and Non-Users. Cross-validation was used to train and evaluate a Recurrent Neural Network model for predicting future adherence phenotypes based on the dynamics of prior usage patterns. Two-sided 95% bootstrap confidence intervals and Cohen’s d statistic were used to analyze the significance and effect size of changes in usage behavior 30-days before and after administration of several resupply interventions.

Results

The AI model predicted the next 30-day adherence phenotype with an average of 90% sensitivity, 96% specificity, 95% accuracy, and 0.83 Cohen’s Kappa. The AI model predicted the number of days of CPAP non-use, use under 4-hours, and use over 4-hours for the next 30-days with OLS Regression R-squared values of 0.94, 0.88, and 0.95 compared to ground truth. Ten resupply interventions were associated with statistically significant increases in adherence, and ranked by adherence effect size using Cohen’s d. The most impactful were new cushions or masks, with a mean post-intervention CPAP adherence increase of 7-14% observed in Variable User, Occasional Attempter, and Non-User groups.

Conclusion

The AI model applied past CPAP usage data to predict future adherence phenotypes and usage with high sensitivity and specificity. We identified resupply interventions that were associated with significant increases in adherence for struggling patients. This work demonstrates a novel application for AI to aid clinicians in maintaining CPAP adherence.

Support

 

Body condition alters glutathione and nuclear factor erythroid 2-like 2 (NFE2L2)-related antioxidant network abundance in subcutaneous adipose tissue of periparturient Holstein cows

Dairy cows with high body condition score (BCS) in late prepartum are more susceptible to oxidative stress (OS). Nuclear factor erythroid 2-like 2 (NFE2L2) is a major antioxidant transcription factor. We investigated the effect of precalving BCS on blood biomarkers associated with OS, inflammation, and liver function, along with mRNA and protein abundance of targets related to NFE2L2 and glutathione (GSH) metabolism in s.c. adipose tissue (SAT) of periparturient dairy cows. Twenty-two multiparous Holstein cows were retrospectively classified into a high BCS (HBCS; n = 11, BCS ≥3.5) or normal BCS (NBCS; n = 11, BCS ≤3.17) on d 28 before parturition. Cows were fed a corn silage- and wheat straw-based total mixed ration during late prepartum, and a corn silage- and alfalfa hay-based total mixed ration postpartum. Blood samples obtained at -10, 7, 15, and 30 d relative to parturition were used for analyses of biomarkers associated with inflammation, including albumin, ceruloplasmin, haptoglobin, and myeloperoxidase, as well as OS, including ferric reducing ability of plasma (FRAP), reactive oxygen species (ROS), and β-carotene. Adipose biopsies harvested at -15, 7, and 30 d relative to parturition were analyzed for mRNA (real-time quantitative PCR) and protein abundance (Western blotting) of targets associated with the antioxidant transcription regulator nuclear factor, NFE2L2, and GSH metabolism pathway. In addition, concentrations of GSH, ROS and malondialdehyde were measured. High BCS cows had lower prepartum dry matter intake expressed as a percentage of body weight along with greater BCS loss between -4 and 4 wk relative to parturition. Plasma concentrations of ROS and FRAP increased after parturition regardless of treatment. Compared with NBCS, HBCS cows had greater concentrations of FRAP at d 7 postpartum, which coincided with peak values in those cows. In addition, NBCS cows experienced a marked decrease in plasma ROS after d 7 postpartum, while HBCS cows maintained a constant concentration by d 30 postpartum. Overall, ROS concentrations in SAT were greater in HBCS cows. However, overall mRNA abundance of NFE2L2 was lower and cullin 3 (CUL3), a negative regulator of NFE2L2, was greater in HBCS cows. Although HBCS cows had greater overall total protein abundance of NFE2L2 in SAT, ratio of phosphorylated NFE2L2 to total NFE2L2 was lower, suggesting a decrease in the activity of this antioxidant system. Overall, mRNA abundance of the GSH metabolism-related genes glutathione reductase (GSR), glutathione peroxidase 1 (GPX1), and transaldolase 1 (TALDO1), along with protein abundance of glutathione S-transferase mu 1 (GSTM1), were greater in HBCS cows. Data suggest that HBCS cows might experience greater systemic OS after parturition, while increased abundance of mRNA and protein components of the GSH metabolism pathway in SAT might help alleviate tissue oxidant status. Data underscored the importance of antioxidant mechanisms at the tissue level. Thus, targeting these pathways in SAT during the periparturient period via nutrition might help control tissue remodeling while allowing optimal performance.

Psychiatric and physical outcomes of long-term use of lithium in older adults with bipolar disorder and major depressive disorder: A cross-sectional multicenter study

OBJECTIVE

Although lithium is widely used in current practice to treat bipolar disorder (BD) and treatment-resistant major depressive disorder (MDD) among older adults, little is known about its efficacy and tolerability in this population, which is generally excluded from randomized clinical trials. The objective of this study was to evaluate the efficacy and tolerability of long-term use of lithium among older adults with BD and MDD.

METHOD

Data from the Cohort of individuals with Schizophrenia and mood disorders Aged 55 years or more (CSA) were used. Two groups of patients with BD and MDD were compared: those who were currently receiving lithium versus those who were not. The effects of lithium on psychiatric (i.e., depressive symptoms severity, perceived clinical severity, rates of psychiatric admissions in the past-year), geriatric (overall and cognitive functioning) and physical outcomes (i.e., rates of non-psychiatric medical comorbidities and general hospital admissions in the past-year) were evaluated. All analyses were adjusted for age, sex, duration of disorder, diagnosis, smoking status, alcohol use, and use of antipsychotics, antiepileptics or antidepressants.

RESULTS

Among the 281 older participants with BD or MDD, 15.7% were taking lithium for a mean duration of 12.5(SD = 11.6) years. Lithium use was associated with lower intensity of depressive symptoms, reduced perceived clinical global severity and lower benzodiazepine use (all p < 0.05), without being linked to greater rates of medical comorbidities, except for hypothyroidism.

LIMITATIONS

Data were cross-sectional and data on lifetime history of psychotropic medications was not assessed.

CONCLUSION

Our results suggest that long-term lithium use may be efficient and relatively well-tolerated in older adults with BD or treatment-resistant MDD.

Litter traits and rainfall reduction alter microbial litter decomposers: the evidence from three Mediterranean forests

The objective of the study was to evaluate changes in microbial communities with the predicted arrival of new species to Mediterranean forests under projected intensification of water stress conditions. For that, litter from three Mediterranean forests dominated respectively by Quercus pubescens Willd., Quercus ilex L. and Pinus halepensis Mill. were collected, and placed to their 'home' forest but also to the two other forests under natural and amplified drought conditions (i.e. rainfall reduction of 30%). Quantitative PCR showed that overall, actinobacteria and total bacteria were more abundant in Q. pubescens and Q. ilex than in P. halepensis litter. However, the abundance of both groups was dependent on the forest sites: placement of allochthonous litter to Q. pubescens and P. halepensis forests (i.e. P. halepensis and Q. pubescens, respectively) increased bacterial and fungal abundances, while no effect was observed in Q. ilex forest. P. halepensis litter in Q. pubescens and Q. ilex forests significantly reduced actinobacteria (A/F) and total bacteria (B/F) to fungi ratios. The reduction of rainfall did not influence actinobacteria and bacteria but caused an increase of fungi. As a result, a reduction of A/F ratio is expected with the plant community change towards the dominance of spreading P. halepensis under amplified drought conditions.

Determination of Cry9C Protein in Corn-Based Foods by Enzyme-Linked Immunosorbent Assay: Interlaboratory Study

The performance of a commercially available enzyme-linked immunosorbent assay kit (Enviro-Logix) was assessed for the determination of Cry9C protein, which is produced by the genetically modified corn StarLink, in 8 types of corn-based foods (starch, refined oil, soft tortillas, tortilla chips, corn flakes, corn puffs, corn muffins, and corn bread) in an interlaboratory study involving 7 laboratories in the United States. The assay kit is a double antibody sandwich and is based on the specific interaction between antibody and antigen. The Cry9C protein analyte is sandwiched between 2 antibodies, one to capture the analyte and the other is conjugated to the enzyme, horseradish peroxidase. The enzyme uses tetramethylbenzidine/peroxide for color development. A strong acid stopping reagent is then used to change the color from blue to a stable yellow. The intensity of the color is proportional to the concentration of the Cry9C protein. In this study blind duplicates of control samples (blank material prepared from non- StarLink corn), spiked samples (blank material with the addition of Cry9C protein), and samples containing incurred analyte (products prepared with StarLink corn) were analyzed. Cry9C protein from 2 different sources was used to spike the food products. Cry9C protein produced and purified from a bacterial host was used to prepare spiked test samples at 2.72 and 6.8 ng/g. Cry9C protein from StarLink corn flour was used to prepare spiked samples at 1.97 ng/g. Average recoveries for samples spiked with corn flour Cry9C protein at 1.97 ng/g ranged from 73 to 122%, within-laboratory relative standard deviations (RSDr) ranged from 6 to 22%, and between-laboratories relative standard deviations (RSDR) ranged from 16 to 56%. Average recoveries for samples spiked with bacterial Cry9C protein at 2.72 and 6.8 ng/g ranged from 27 to 96% and from 32 to 113%, respectively; RSDr values ranged from 10 to 35%and from 7 to 38%, respectively; and the RSDR ranged from 28 to 84%and 15 to 75%, respectively. The incurred test samples were found to contain Cry9C protein at levels ranging from 0.8 to 3187 ng/g depending on the product, RSDr values ranged from 5 to 16% and RSDR values ranged from 11 to 71%. Results of the statistical analysis indicate that this method is applicable to the determination of Cry9C protein in the 8 types of collaboratively studied corn-based products containing Cry9C protein (from StarLink ) at levels of ≥2 ng/g.

P1515Female sex is an independent predictor of mortality in patients with STEMI in Spain: a study in 325,017 episodes over 11 years (2005–2015)

Background

Recent studies reported a decrease in the mortality of ST-elevation myocardial infarction (STEMI) patients. This favorable evolution could not extend to women. The interaction between gender and mortality in STEMI remains controversial.

Purpose

To assess the impact of female sex on mortality of patients with STEMI through of period of 11 years.

Methods

We conducted a retrospective longitudinal study using information provided by the minimal database system of the Spanish National Health System to identify all hospitalizations in patients aged 35–94 years with the principal diagnosis of STEMI from 2005–2015.

Results

A total of 325,017 STEMI were identified. Of them, 273,182 were included, and 106,277 (38.8%) were women. Women were older than men and had more comorbidities. Through the study period 53% men vs 37.2% underwent PTCA; women presented more frequently heart failure, shock and stroke than men (p<0.001, respectively). The mean crude in-hospital mortality rate for the whole study period was higher in women (OR: 2.18; 95% CI: 2.12.-2.23, p<0.0001). Female sex was independently associated with higher in-hospital mortality (adjusted OR: 1.18; 95% CI: 1.14–1.22, p<0.001) (Table 1). The risk was maintained through the whole study period (lower OR: 1.14 in 2014; higher OR: 1.28 in 2006).

Table 1. Variables independently associated with in-hospital mortality adjusted by risk in a multilevel logistic regression model, 2005–2015 STEMI In-hospital mortality Odds Ratio P 95% CI Woman 1.18 <0.001 1.14 1.22 Age 1.06 <0.001 1.06 1.06 History of PTCA 1.58 <0.001 1.40 1.77 Congestive heart failure 1.26 <0.001 1.22 1.30 Acute Myocardial Infarction 1.84 <0.001 1.54 2.20 Anterior myocardial infarction 1.47 <0.001 1.23 1.76 Cardio-respiratory failure or shock 15.25 <0.001 14.78 15.75 Hypertension 0.81 <0.001 0.79 0.84 Stroke 5.76 <0.001 5.18 6.42 Cerebrovascular disease 0.86 <0.001 0.79 0.93 Renal failure 1.95 <0.001 1.88 2.02 Vascular disease and complications 7.03 <0.001 5.72 8.63 CI, Confidence Interval.

Conclusions

Female sex is an independent predictor of mortality in patients with STEMI in Spain, maintaining through a period of the 11 years.

P3605Lower benefit of women than men with ST-elevation myocardial infarction networks system in Spain: a study of 325,017 episodes over 10 years (2005–2015)

Background

Sex differences are known to exist in the management of women presenting with ST elevation myocardial infarction (STEMI).Few studies have examined whether the clinical management and prognosis differs by sex when the STEMI network system is applied.

Purpose

To assess whether the STEMI network system improves management and prognosis both in men and women in Spain and to analyze possible differences according to sex.

Methods

We conducted a retrospective longitudinal study using information provided by the minimal database system (MDBS) of the Spanish National Health System (SNHS) to identify all hospitalizations in patients aged 35–94 years with the principal diagnosis of STEMI from 2005–2015. The risk-standardized in-hospital mortality ratio (RSMR) was defined as the ratio between predicted mortality and expected mortality, multiplied by the crude rate of mortality. The RSMR was calculated using multilevel risk adjustment models developed by the Medicare and Medicaid Services. The year of the development of organized systems of care for STEMI patients in the different Autonomous Communities was double-checked using data from the National Cardiac Catheterization and Interventional Cardiology Annual Registry. RSMR was used to compare outcomes related with gender and with the presence of regional AMI networks and the performance of PCI. Temporal trends for in-hospital mortality during the observed period were modeled using Poisson regression analysis with year as the only independent variable. In all models, incidence rate ratios (IRR) and their 95% confidence intervals (95% CI) were calculated.

Results

A total of 325,017 STEMI were identified among patients aged 35–94 years old. Of them 273,182 were selected after exclusions, and 106,277 (38.8%) were women. Women were on average 10 years older than men and had more comorbidities burden. The overall proportion of STEMI patients underwent to PCI increased, when a regional STEMI network was present from 2005–2015: (63.7% vs 48.2% in men; and 47.4% vs 32.9% in women; p<0.001). Differences in crude mortality between sexes was 15%, maintaining through 10 years, despite a higher increased of PCI (figure 1).However, women were less likely to be treated with PCI even though when STEMI network was stablished (63.7% vs 48.2% in men, 47.4% vs 32.9% in women, p<0.001) (figure 1).The mean crude in-hospital mortality rate for the whole study period was higher in women (9.3% vs 18.3%; unadjusted OR: 2.18, 95% CI: 2.12.-2.23, p<0.0001). RSMR was lower for women when STEMI network were working (17.7% vs. 19.7%; p<0.001).PCI and the presence of STEMI network were associated with a lower in-hospital mortality in STEMI women (adjusted OR, 0.48; 95% CI 0.41–0.52 and OR, 0.84; 95% CI 0.79–0.89, p<0.001, respectively).

Conclusions

Women were less likely to be treated with PCI and had higher in-hospital risk-adjusted mortality than men, despite the existence of STEMI network system.

P5488Temporal trends and prognostic impact of hospital length of three or less days in uncomplicated myocardial infarction after primary percutaneous coronary intervention in Spain

Introduction and objectives

There is scarce data on the safety of hospital stay length in uncomplicated ST- elevation myocardial infarction (STEMI). We studied the trends of the hospital stay and the safety of short (≤3 days) vs. long hospital stay, in Spain.

Methods

Using data from the Minimum Basic Data set of Spanish taxpayer-funded health system. We identified patients with uncomplicated STEMI undergoing coronary angioplasty and who were discharged alive. The mean length of stay was calculated by multilevel Poisson regression with mixed-effects, including patients from 2003–15. The effect of short stay on cardiac diseases readmissions at 30 days and 1 year was evaluated by multilevel logistic regression, including patients from 2003–14. Thirty-day and 1-year cardiac diseases risk-standardized readmissions and mortality rates (RSRRs and RSMRs), respectively, were also compared.

Results

The adjusted mean length of stay was significantly reduced (incidence rate ratio <1; p<0.001) for each year since 2003. The percentage of short stay increased from 14.3% in 2003 to 19.5% in 2015 (p<0.001). In none of the specified models short stay was statistically significant (p>0.05). The RSRRs at 30 days and 1 year as well as RSMRs at 30 days, did not differ significantly between groups. 1-year RSMRs was significantly higher in the short stay group, although probably without clinical significance (0.103% vs. 0.109%, p<0.001). See Table.

Diff mean of RSRRs and RSMRs at 30 days & 1 year Stay length N Mean Standard deviation p-value RSRRs at 30-day ≤3 days 6,486 2.541 0.74 0.20 >3 days 31,651 2.554 0.72 RSRRs at 1 year ≤3 days 6,486 5.306 1.22 0.42 >3 days 31,651 5.292 1.14 RSMRs at 30-day ≤3 days 6,486 0.109 0.04 <0.001 >3 days 31,651 0.103 0.03 RSMRs at 1 year ≤3 days 6,486 0.429 0.13 0.25 >3 days 31,651 0.427 0.13 RSRRs = risk-standardized readmission rates; RSMRs = risk-standardized readmission mortality rates.

Conclusions

In Spain, short hospital stay increased significantly from 2003 to 2015 and seems a safety option in uncomplicated STEMI patients.

5949Interleukin-6 and growth differentiation factor-15 in hypertensive heart failure

Background

Hypertension is the leading cause for the development of heart failure (HF). Increased hemodynamic load, including mechanical stretch and neurohumoral factors, is able to trigger hypertrophic growth of cardiac myocytes. Although hypertensive HF is prevalent, there is no useful biomarker to identify HF due to chronic hypertension.

Aims

To identify plasma markers associated with incidence of hypertensive HF.

Methods

Circulating levels of 149 proteins were measured by proximity extension assay at baseline examination in 4469 individuals from the Malmö Diet and Cancer study. Protein levels were compared to stretch-activated gene expression changes in cultured neonatal rat ventricular myocytes (NRVM) in response to 1, 4, 12, 24 or 48 hours of cyclic mechanical stretch. Association between plasma proteins level and HF incidence and hypertension was studied using respectively Cox proportional hazards model and binary logistic regressions.

Results

After Bonferroni correction, 44 circulating proteins were significantly differentially expressed in individuals who developed HF during follow-up versus controls (P<3.4E-4). Out of these, 5 proteins (Interleukin-6 (IL-6), Growth Differentiation Factor-15 (GDF15), Interleukin-1 Receptor-Like-1 (ST2), Plasminogen Activator Urokinase Receptor (U-PAR), Transforming Growth Factor-α (TGF-α)), corresponding mRNA levels were upregulated by mechanical stretch in NRVM at all time points (P<0.05). Similar upregulation for the 5 proteins was shown in hypertensive versus normotensive individuals (P≤8.05E-4). In a model with all 5 proteins entered simultaneously, GDF15 and IL-6 were predictive of incident HF after adjustment for age, sex and NT-BNP levels (205 events; hazard ratio [HR] per SD increment of protein: HR=1.29, CI=1.05–1.58, P=0.013 and HR=1.16, CI=1.02–1.33, P=0.028). Using the same model, IL-6 but not GDF15 associated with hypertension (Odds ratio [OR] per SD increment of IL-6: OR=1.18, CI=1.09–1.27, P=3.3E-5). In hypertensive individuals GDF15 and IL-6 were individually predictive of future HF after adjustment for age, sex, NT-BNP levels, smoking, BMI and diabetes (183 events; HR=1.36, CI=1.16–1.60, P=1.64E-4 and HR=1.21, CI=1.05–1.40, P=0.008). Furthermore, in these hypertensive individuals, GDF15 and IL-6 were predictive of HF in a model with IL-6, GDF15, ST2 and TGF-α entered simultaneously after adjustment for age, sex and NT-BNP levels (176 events; HR=1.36, CI=1.13–1.64, P=0.001 and HR=1.16, CI=1.01–1.34, P=0.041).

Conclusions

Circulating levels of IL-6 and GDF15 might be used as NT-BNP independent biomarkers for HF development in hypertensive patients.

Acknowledgement/Funding

Påhlsson, Crafoord, Lundström, Åke Wiberg, Royal Physiographic Society and the Swedish Foundation for Strategic Research for IRC15-0067

Human Papilloma Virus Vaccination Among Adolescents in a Community Clinic Before and After Intervention

Human Papilloma Virus (HPV) is the most common sexually transmitted disease with over 14 million infections in 2008. Certain HPV types have been identified in up to 70% of cases of cervical and anal cancers. Despite being safe and effective, HPV vaccination rates remain low. Vaccination and demographic data was collected pre-and post-intervention. Among 13 thru 17-year-old cohort females were significantly more likely to be fully vaccinated. Assessment also found that patients insured by Medicaid were significantly more likely to be fully vaccinated than patients insured privately. Post-intervention vaccination rate is similar to baseline rates. There was non-significant improvement in HPV vaccination coverage after intervention. Male and privately insured patients of Creighton's Pediatric Clinic have lower HPV vaccination coverage than their counterparts. More direct efforts are needed in vaccination process and policy in the clinic to improve immunization against HPV among children and adolescents.

Dental care in children with Down syndrome: A questionnaire for Belgian dentists

Background

To date, research on the opinions of dentists on the oral health care of children with DS (Down Syndrome) is scarce.

Material and Methods

Evaluate the views and knowledge of Belgium dentists regarding dental care of children with DS. An adequate sample of dentists were invited to fill in a validated questionnaire. Results were assessed in 95% confidence interval with p< 0.05 level.

Results

A total of 356 questionnaires were returned (177 men, 179 women). Mean age of the dentists was 50.3 years (SD: 11.9) and 75% obtained their degree more than 20 years ago. 72.5% of all dentists replied that they had not been instructed in how to treat children with DS during their dental educational training, whereas this is only the case for 39% of the dentists who obtained their degree less than 10 years ago. Half of the group indicated that additional training and education would be (very) desirable (52.8%).

Conclusions

Dentists don’t seem to feel comfortable in treating children with DS and refer them to a special care dentistry centre in a hospital. It is positive that dentists are in favour of obtaining additional training and education to help them feel more confident in treating children with DS in daily practice. However we must not conclude that because students or qualified dentists received such training that they will automatically treat more patients with special needs.

Key words:Oral health care, Down syndrome, children, dentists, Belgium.

Erosive tooth Wear in special Olympic athletes with intellectual disabilities

Background

Special Olympics (SO) events represent an opportunity to obtain considerable information regarding intellectual disable (ID) patients. Studies done with SO data have shown an overview of the oral health status of these athletes; however, no information exists regarding the erosive tooth wear (ETW). Therefore, the aim of this study is to determine the presence and severity of ETW in athletes with ID who participated in the SO Belgium 2016.

Methods

The study population consisted in 232 athletes with ID who participated in the SO special smiles program, Belgium 2016. For analysis, the sample was divided in three groups: a) athletes with ID under the age of 25 not diagnosed with Down Syndrome (DS) (n = 174), b) athletes with DS under the age of 25 (n = 39) and c) athletes with DS from 25 and older ages (n = 58). Two calibrated dentists performed dental examinations using the Basic Erosive Wear Examination Index (BEWE). The BEWE sum > 0 was used to determine prevalence of ETW. Severity was determined by two- indicators: 1) By risk levels (low, medium and high risk) proposed by the BEWE index, and 2) by the highest score reached per subject in at least one tooth (BEWE1, 2 or 3). Chi-square test and Mann-Whitney U test were used to detect significant differences among different groups (p < 0.05).

Results

The prevalence of ETW for young athletes with ID was 51.14%. Within these athletes, the DS group presented a significant higher mean BEWE sum (4.67, SD 5.64) and prevalence of ETW (69.2%BEWE> 0) when compared to athletes without DS (mean BEWE sum: 1.96, SD 3.47 and 46.3% BEWE> 0; p < 0.05). Furthermore, a significantly higher percentage of athletes with DS were considered at high risk of ETW (p < 0.05).

Conclusions

As a conclusion, half of the young athletes with ID presented at least one affected surface with ETW. The recorded prevalence and severity of ETW for the younger group of athletes with DS was distinctly higher than the athletes with ID not having DS. This shows the need to generate knowledge in order to provide correct management and prevention of erosive tooth wear in populations with ID.

Plasma levels of the proprotein convertase furin and incidence of diabetes and mortality

BACKGROUND

Diabetes mellitus is linked to premature mortality of virtually all causes. Furin is a proprotein convertase broadly involved in the maintenance of cellular homeostasis; however, little is known about its role in the development of diabetes mellitus and risk of premature mortality.

OBJECTIVES

To test if fasting plasma concentration of furin is associated with the development of diabetes mellitus and mortality.

METHODS

Overnight fasted plasma furin levels were measured at baseline examination in 4678 individuals from the population-based prospective Malmö Diet and Cancer Study. We studied the relation of plasma furin levels with metabolic and hemodynamic traits. We used multivariable Cox proportional hazards models to investigate the association between baseline plasma furin levels and incidence of diabetes mellitus and mortality during 21.3-21.7 years follow-up.

RESULTS

An association was observed between quartiles of furin concentration at baseline and body mass index, blood pressure and plasma concentration of glucose, insulin, LDL and HDL cholesterol (|0.11| ≤ β ≤ |0.31|, P < 0.001). Plasma furin (hazard ratio [HR] per one standard deviation increment of furin) was predictive of future diabetes mellitus (727 events; HR = 1.24, CI = 1.14-1.36, P < 0.001) after adjustment for age, sex, body mass index, systolic and diastolic blood pressure, use of antihypertensive treatment, alcohol intake and fasting plasma level of glucose, insulin and lipoproteins cholesterol. Furin was also independently related to the risk of all-cause mortality (1229 events; HR = 1.12, CI = 1.05-1.19, P = 0.001) after full multivariable adjustment.

CONCLUSION

Individuals with high plasma furin concentration have a pronounced dysmetabolic phenotype and elevated risk of diabetes mellitus and premature mortality.

Plasma and Urinary Heparin Cofactor II Levels in Patients with Nephrotic Syndrome

Heparin cofactor II (HC II) levels were measured by electroimmunoassay in plasmas and urines from 68 patients with nephrotic syndrome. In addition, antithrombin III (AT III) and protein C (PC) activities and antigens were measured also in the same group of patients. Seven of these patients had histories of thrombosis. Plasma HC II levels (mean ± SD 105 ± 43) were not different from levels in healthy subjects (94 ± 17). Only 5 patients had low plasma levels of HC II. None of the patients with thrombosis had low HC II levels. Even though measurable amounts of HC II were found in 25 urines from 50 patients. There was a relationship in the urinary excretion between HC II and AT III and their urinary clearances were quite similar. However, no correlation was found between plasma HC II and AT III levels, and levels of AT III activity and antigen were significantly lower than in healthy subjects. Three patients with hystories of thrombosis had low AT III levels. Most patients (including those with thrombosis histories) had high plasma PC levels and increased urinary loss.

It is suggested that HC II does not play an important role in the pathogenesis of thrombosis in nephrotic syndrome.