Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

POS1290 EFFICACY AND SAFETY OF SODIUM THIOSULFATE IN CALCIFIC TENDINITIS OF THE ROTATOR CUFF – AN INTERIM ANALYSIS OF A RANDOMIZED CLINICAL TRIAL

Background

Calcific tendinitis of the rotator cuff is one of the most common causes of shoulder pain. (1) Ultrasound guided percutaneous lavage (UGPL) is indicated when conservative treatments have failed. (2) Recent reports have shown the interest of topical sodium thiosulfate (STS) in the treatment of other diseases characterizes by ectopic calcifications (3, 4, 5).

Objectives

To assess the efficacy and safety of UGPL with STS versus with saline solution (standard of care - SOC) in calcific tendinitis.

Methods

Double-blinded randomized clinical trial including adult patients with calcific tendinitis, shoulder pain for more than 3 months and at least one positive shoulder impingement test. Only dense type A calcifications (according to the Molé Classification) > 5 mm in diameter were included. Patients were randomized in two groups: STS and saline solution lavage. Informed consents were collected. Both groups were reevaluated at week 1, month 1 and month 3 after UGPL. Pain Visual Analogue Scale (VAS) at rest and during activities, shoulder range of motion and strength, impingement tests, Disabilities of the Arm, Shoulder and Hand (DASH), DASH-Work, EuroQol five-dimensional (EQ5D) and University of California at Los Angeles (UCLA) scores, ultrasound (US) and radiographic evaluations were performed on all follow up visits.

SPSS was used for statistical analysis and significance level was defined as 2-sided p<0.05.

Results

Twenty-six patients were included, where 76.9% (20) were women, with a mean age of 51.2 (SD=9.0) years old. The mean duration of pain before the procedure was 12.7 months (SD=11.3) (minimum of 3 months and a maximum of 48 months).

Fifteen patients (57.7%) were randomized to the control group (SOC) and performed a saline UGPL; the other 11 patients (42.3%) were randomized to the treatment group (STS). Demographic and baseline clinical characteristics are shown in Table 1. Since patient inclusion is dynamic, our sample met 23 patients at week 1 (SOC group = 13 and STS group = 10), 19 patients at month 1 (SOC group = 10 and STS group = 9) and 16 patients at month 3 (SOC group = 8 and STS group = 8).

Table 1.

Demographic and baseline clinical characteristics.

STS lavage(n=11)Saline solution lavage (n=15)p-valueAge (years), M (SD)52.3 (10.6)50.3 (8.0)NSSex, female % (n/N)72.7% (8/11)80% (12/15)NSDominant side, right % (n/N)100% (11/11)93.3% (14/15)NSNocturnal pain, yes % (n/N)100% (11/11)100% (15/15)NSVAS at rest (0–10), M (SD)5.7 (2.0)5.9 (2.1)NSVAS during activities (0–10), M (SD)7.1 (1.8)6.0 (2.5)NSDASH Score, M (SD)60.2 (14.0)52.6 (13.8)NSDASH-Work Score, M (SD73.4 (11.0)63.4 (22.6)NSEQ5D, M (SD)0.2897 (0.3)0.4070 (0.2)NSVAS EQ5D (0–100), M (SD)54 (15.9)58 (20.0)NSUCLA score, M (SD)18.7 (4.1)14.7 (3.3)0.014Bursitis, yes % (n/N)72.7% (8/11)66.7% (10/15)NSCalcification morphology, % (n/N)Acr-shaped18.2% (2/11)40% (6/15)0.039Fragmented18.2% (2/11)26.7% (4/15)Nodular and dense, well-defined63.6% (7/11)33.3% (5/15)Calcification size, median (IQR)12.6 (5.7)10.5 (6.3)NS

SD: Standard deviation; M: Mean; NS: non-significant; IQR: interquartile range

Overall, there were no differences between control (SOC) and treatment group (STS). Both procedures were effective improving pain at rest (p=0.024), EQ5D (p=0.019), DASH-Work (p=0.032) and UCLA scores (p=0.009) and calcification size measured by US (p=0.031) at month 3.

No adverse effects or complications were reported on both groups.

Conclusion

Although well tolerated with no side effects, STS UGPL has failed to show increased benefit for calcific tendinopathy local treatment. Further studies using STS will be needed to ascertain its interest in this disease. This on-going work will be reevaluated with a larger sample.

References

[1]Louwerens JK et al. J Shoulder Elbow Surg. 2015; 24:1588–93.

[2]De Witte PB et al. Am J Sports Med. 2013; 41:1665-73.

[3]Ossorio-García L et al. Actas Dermosifiliogr. 2016; 107:359-62. 21.

[4]Jost J et al. J Clin Endocrinol Metab. 2016; 101:2810-5. 22.

[5]Guigonis V et al. Ann Endocrinol (Paris). 2015; 76:183-4.

Disclosure of Interests

None declared

POS0162 PREDICTIVE FACTORS OF A NEW FRAGILITY FRACTURE AFTER WRIST FRAGILITY FRACTURE

Background:

Fragility fractures (FF) are fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or ‘low energy’) trauma.1 Studies have shown that history of wrist fracture increases the risk for subsequent FF.2

Objectives:

To assess predictive factors of FF occurring after a wrist fracture.

Methods:

Retrospective monocentric study that included patients with a wrist FF observed at the emergency department (ED) in a tertiary center, between 1st January 2017 and 31st December 2018. Wrist fractures were identified through the 10th International Classification of Diseases and FF were identified after revision of the clinical record. Patients with relevant missing data were excluded. Seven hundred thirty-three wrist FF were identified. After calculating a representative sample (90% confidence interval), 188 patients were included. Their clinical records until 31th December 2020 (2 to 3 years after FF) were reviewed. SPSS was used for statistical analysis and significance level was defined as 2-sided p<0.05. In multivariate analysis we included variables with a significant association in univariate analysis and those with clinical relevance (reported in others studies).

Results:

Wrist fractures represented 44.3% of the FF observed at the ED.

Most patients were woman (83.5%) with a mean age of 70.7 (SD=11.2) years-old at the time of their wrist fracture. A previous FF was seen in 22.9% of patients and 13.3% had a new FF during the follow-up period.

We found an association between the occurrence of a new FF and the number of comorbidities (p=0.012), number of visits to the ED due to falls (p<0.001), previous diagnosis of chronic pulmonary disease (p=0.029) and hematologic pathologies (p=0.047), and the need for hospitalization at time of the wrist FF (p=0.018).

No associations were found between the age at the wrist fracture time, number of drugs taken daily nor its type (anxiolytics, antiepileptics, corticoids), previous fractures (and localization), overweight/obesity and other cardiovascular risk factors, endocrinopathies, psychiatric or neurologic disease or other comorbidities.

After adjustment for age, gender, anti-osteoporotic treatment and comorbidities, the main predictors of a new FF were visits to the ED for falls (p=0.005), chronic pulmonary disease (p=0.040), hematologic pathologies (p=0.004) and need for hospitalization (p=0.040) (table 1).

Table 1.

Multivariate analyses: linear multiple regression for predictive factors of new fragility fracture.

DeterminantsUnstandardized CoefficientsBStandardized Coefficients Beta95.0% CIp-valueAge-0.0250.9750.924 – 1.030NSGender2.0657.8890.757 – 82.165NSNumber of comorbidities0.1861.2040.846 – 1.713NSVisits to the emergency service for falls-2.1360.1180.026 – 0.5290.005Chronic pulmonary disease-1.3260.2660.075 – 0.9400.040Hematologic pathologies-4.2960.0140.001 – 0.2550.004Need for hospitalization-2.7640.0630.004 – 0.8870.040Anti-osteoporotic treatment0.1571.1700.227 – 6.017NS

CI: Confidence Interval; NS: non-significant;

Conclusion:

Certain comorbidities seem to be associated with new FF. Patients with visits to the emergency service after falls and those who needed hospitalization due to the wrist fracture were more prone to have a new FF. There might be a substantial missed opportunity for intervention in these patients.

References:

[1]Osteoporosis: assessing the risk of fragility fracture. London: National Institute for Health and Care Excellence (UK); 2017 Feb. PMID: 32186835.

[2]Crandall CJ, Hovey KM, Cauley JA, Andrews CA, Curtis JR, Wactawski-Wende J, Wright NC, Li W, LeBoff MS. Wrist Fracture and Risk of Subsequent Fracture: Findings from the Women’s Health Initiative Study. Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research. 2015;30(11):2086–2095. doi: 10.1002/jbmr.2559.

Disclosure of Interests:

None declared

AB0799 DO WE OVERDIAGNOSE SERONEGATIVE RHEUMATOID ARTHRITIS? – THE ROLE OF MUSCULOSKELETAL ULTRASOUND IN CLARIFYING SERONEGATIVE INFLAMMATORY ARTHRITIS

Background:

Several data indicate that seronegative rheumatoid arthritis (RA-) and seropositive RA (RA+) may have different mechanisms and prognosis, being well established that rheumatoid factor (RF) and anti-citrullinated peptide antibodies (ACPA) have diagnostic and prognostic value. Several conditions, like peripheral spondyloarthritis (SpA), psoriatic arthritis or crystal-related arthropathies may mimic the presentation of RA. Mechanisms and treatment of each of these conditions differ significantly. The authors speculate that RA- may be overdiagnosed in the setting of seronegative chronic inflammatory arthritis and that musculoskeletal ultrasound (US) may help us to better classify these patients through the identification of characteristic lesions of the mentioned diseases.

Objectives:

To compare the frequency of US lesions found in joints and entheses between RA- and RA+ patients.

Methods:

Cross-sectional study: systematic US evaluation of ten joints, twelve entheses and both flexor and extensor tendons of four fingers (Table 1) in consecutive RA- patients. RA+ patients matched for sex and age were recruited. RA- patients included met every of the following criteria: history of chronic polyarthritis, RF and ACPA negativity, no extra-articular features of SpA or RA nor family history of SpA, no suspected crystal-related arthritis.

Results:

Twenty-one RA- patients were included and twenty RA+ patients were recruited as controls. No differences between groups were found in sex, age, body mass index, time of disease evolution or use of biological therapy.

RA- patients had a significantly higher number of entheseal structural and/or inflammatory lesions than RA+ patients (median 2.0 vs. 0.5, U 111.5, p=.008**), with triceps enthesitis being significantly more frequent in RA- patients (p=.036*). In total, 18.7% of RA- entheses had enthesitis lesions vs. only 8.3% of RA+ entheses. One RA- patient had ultrasonographic features of dactylitis which was not clinically evident.

As expected, considering the role of RF and ACPA in erosive RA, RA- patients had a significantly lower number of joints with erosions compared to RA+ patients (median 0.0 vs. 3.0, U 64.5, p<.001***), with significant differences in every considered joint. Erosions were found in 6.7% of RA- joints vs. 32.0% RA+ joints.

Additionally, two RA- patients had hyperechogenic foci in knee cartilage or carpal fibrocartilage suggestive of calcium pyrophosphate deposition.

Table 1.

Comparative frequency of ultrasound lesions found in joints and entheses of RA- and RA+ patients.

RA-(n=21)RA+(n=20)p-valueMdn number of ENTHESES with any lesion per patient ± IQR2.0 ± 3.00.5 ± 2.0.008**Triceps – n (%)8 (38.1%)2 (10.0%).036*Quadriceps – n (%)9 (42.9%)6 (30.0%).393Superior patellar – n (%)4 (19.0%)1 (5.0%).169Inferior patellar – n (%)---Achilles – n (%)9 (42.8%)4 (20.0%).116Plantar fascia – n (%)5 (23.8%)1 (5.0%).089DACTYLITIS – 2nd + 5th finger – n (%)1 (4.8%)--Mdn number of joints with EROSIONS per patient ± IQR0.0 ± 1.03.0 ± 3.0<.001***Ulnar styloid process – n (%)5 (23.8%)11 (55.0%).041*Metacarpophalangeal 2 – n (%)3 (14.3%)11 (55.0%).006**Metacarpophalangeal 5 – n (%)1 (4.8%)10 (50.0%).001**Metatarsophalangeal 1 – n (%)-3 (15.0%)-Metatarsophalangeal 5 – n (%)3 (14.3%)11 (55.0%).006**CHONDROCALCINOSIS – triangular fibrocartilage + knee – n (%)2 (9.5%)--DOUBLE CONTOUR – any joint – n (%)---

RA- – seronegative rheumatoid arthritis; RA+ – seropositive rheumatoid arthritis Mdn – median; IQR – interquartile range; n (%) – absolute number (percentage) of patients with the indicated lesion.

Conclusion:

We found that some patients diagnosed with RA- had, in fact, ultrasonographic features of different diseases, namely enthesitis/dactylitis and crystal deposition. These data suggest that RA- may be overdiagnosed in clinical practice. Systematic US evaluation of joints and entheses may provide valuable diagnostic information in patients with chronic inflammatory seronegative arthritis and improve patient care.

Disclosure of Interests:

None declared

POS0640 EFFECTIVENESS AND SAFETY OF ORIGINAL AND BIOSIMILAR ETANERCEPT IN bDMARD-NAÏVE PATIENTS IN A REAL-WORLD COHORT OF PORTUGAL

Background:

The patent expiration of the original etanercept in Europe has facilitated the development of biosimilar products. Non-significant differences in efficacy and safety were noted in clinical trials which are not expected to influence clinical performance. Nonetheless, daily practice data should be gathered to support the claim for biosimilarity.

Objectives:

To compare the effectiveness and safety of original and biosimilar etanercept, in biological-Disease Modifying Antirheumatic Drug (bDMARD)-naïve patients.

Methods:

A retrospective multicenter non-interventional study, using data collected prospectively from Reuma.pt (The Rheumatic Diseases Portuguese Register) was done, including patients with: age ≥ 18 years old; diagnosis of Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Spondyloarthritis (SpA) (axial or peripheral); active disease who initiated treatment with etanercept as first line of biological treatment after 2010. Kaplan-Meyer was used to calculate the persistence rate in treatment. Disease activity at baseline and follow-up data at 6, 12, 18 and 24 months of treatment was compared using the chi-square for categorical variables and t-student or Mann-Whitney tests for continuous variables. Reasons for discontinuing therapy were summarized using descriptive statistics. Statistical significance was assumed for 2-sided p-values >0.05.

Results:

We included 1694 patients (413 on biosimilar and 1280 on original etanercept) 864 with RA, 335 with PsA and 494 with SpA. The population’s baseline characteristics were not significantly different among both groups, except concomitant treatment in RA (higher use of conventional DMARDs in biosimilar group and higher use of NSAIDs in original group) and in SpA patients (higher use of corticosteroids in original group).

At baseline, a higher joint count was found in patients treated with original etanercept with a statistical difference for swollen (p=0.03) and tender (p=0.01) joints count (SJC and TJC, respectively) in RA and in TJC in SpA patients (p=0.02). In RA patients, CDAI and SDAI were higher in patients who started original (p=0.03; p=0.04, respectively). Pain measured by visual analogic scale was higher in SpA patients treated with biosimilar (p=0.03).

The 3-year PR was not significantly different between both treatment groups in RA, PsA and SpA (Figure1). In RA, PR in biosimilar was 72.6%, with a median time-on-drug (TOD) of 28.3 months; for original etanercept PR was 63.6%, with a median TOD of 27.4 months (p=0.566). In PsA patients, the PR for biosimilar was 70.6%, with a median TOD of 27.6 months, and in original drug 67.0%, with a median TOD of 28.1 months (p=0.743). In SpA patients, the PR were 78.4% for biosimilar (median TOD of 27.4 months) and 71.5% for original treatment (median TOD of 28.0 months (p=0.816)).

Figure 1.

Drug survival in biosimilar and original etanercept in Rheumatoid Arthritis, Psoriatic Arthritis and Spondyloarthritis

In RA patients, we did not find differences between the two treatment groups for the proportion of patients in remission or low disease activity by CDAI ≤10, SDAI≤11 or DAS28 <3.2 at 6, 12, 18 and 24 months of treatment. For PsA, no differences were found in the same timelines for DAPSA≤14, DAS28<3.2, BASDAI<4, ASDAS<2.1 or PsARC response. Also, in SpA patients, no differences were found in BASDAI<4, BASFI<4, ASDAS<2.1, ASDAS response and BASDAI response in all the timelines with the exception of BASDAI response at 18 months, which was achieved in fewer patients in biosimilar therapy (p=0.02).

Overall, 535 (31.6%) patients stopped etanercept (428 patients on original and 107 patients on biosimilar). Discontinuations due to inefficacy were the most frequent, but there were no significant differences between both groups as for adverse events. Discontinuations due to “other reasons” were higher for the original group, both in RA (p=0.01) and in SpA (p=0.04).

Conclusion:

Biosimilar and original used as first-line biological treatment showed similar effectiveness and safety in our long-term cohort of patients with RA, PsA, and SpA

Disclosure of Interests:

None declared

POS1010 PREDICTING CARDIOVASCULAR EVENTS IN PATIENTS WITH SPONDYLOARTHRITIS: 3 RISK ALGORITHMS

Background:

In the most recent European League Against Rheumatism (EULAR) cardiovascular risk reduction recommendations1, the use of the SCORE algorithm has been advocated as a useful tool to identify an increased 10-year cardiovascular risk of first fatal atherosclerotic event. Even though validated inflammatory disease-specific CV risk score algorithms are still lacking, the EULAR task force advocated the use of a 1.5 multiplication factor for RA, but not clear for other inflammatory diseases.

Objectives:

To assess the accuracy of several CV risk algorithms to predict an event and determine its sensibility and specificity.

Methods:

A retrospective analysis of Spondyloarthritis (SpA) patients, registered in REUMA.PT, followed in two Portuguese centres was done. We calculated risk prediction algorithms such as Framingham, the American College of Cardiology/American Heart Association (ACC/AHA) risk score and the Systematic Coronary Risk Evaluation (SCORE) for low-risk countries. The adaptation of risk algorithms was done, accordingly to EULAR recommendations. Primary outcome was the first CV event. Discriminatory ability for CV risk prediction was evaluated by the area under the ROC curves. Sensibility and specificity were calculated for low-to-intermediate and intermediate-to-high risk cut-offs. Cut-off values of high risk were defined in 5% for SCORE, 20% for Framingham and ACC/AHA.

Results:

362 patients with SpA were included, 53.9% male (195), with a mean age of 51.1 ± 12.7 years. 67.8% of the patients were HLA B27 positive. Overall, the mean BMI was 26.3± 4.4 Kg/m2 and 24.0% of the patients (87) were smokers in their lifetime. The mean of systolic blood pressure was 130± 16.4 mmHg, diastolic blood pressure of 73.5 ± 10.4 mmHg, total cholesterol of 190.1± 37.2 mg/dL and high-density lipoprotein cholesterol of 53.0 ± 14.8 mg/dL. Anti-hypertensive medication was reported in 24.3% of the patients, cholesterol medication in 19.3% and antidiabetic medications in 6.1%. Twenty-five patients (6.9%) presented a cardiovascular event. Patients with a cardiovascular event were older, with higher BMI, prescribed with medication for CV comorbidities and higher diastolic and systolic blood pressure (p<0.05).

Patients were under biologic therapy in 30.9% (112), 16.9% (61) with methotrexate; 16.3% (59) with sulfasalazine and 2.8% (10) with leflunomide; 68.5% (248) prescribed with NSAID and 10.8% (39) with corticosteroids. Area under the ROC in original and adapted scores were equal: 0.709 (95% CI 0.598 to 0.819) for SCORE, 0.805 (95% CI 0.737 to 0.872) for Framingham and 0.776 (95% CI 0.695 to 0.857) for ACC/AHA (Figure 1).

Figure 1.

ROC curves for SCORE, Framingham and ACC/AHA

SCORE>1% showed the best sensitivity (96%) but lower specificity. Framingham>20% presented the best specificity (80%) with lower sensitivity (61%). In all cases, specificity raises with higher cut-off with corresponding reduction in sensibility. (Table 1)

Table 1.

Sensibility, specificity, positive predictive value (PPV) and negative predictive value (NPV) of CV risk algorithms

Sensibility (%)Specificity (%)PPV (%)NPV (%)SCORE > 1%96291299SCORE > 5%54782094Framingham >10%78631597Framingham >20%61802196ACC/AHA >5%82551697ACC/AHA >20%32862092

Conclusion:

A good discrimination between patients with or without CV events has been demonstrated by area under the ROC curve. The adaptation of CV risk algorithms according EULAR recommendations did not provide an improvement in discriminative ability. Overall, the algorithms studied presented a low sensibility or specificity. Better algorithms are needed to correctly assess cardiovascular risk for SpA patients and they should take into consideration the risk associated with the disease.

References:

[1]Agca R, Heslinga SC, Rollefstad S, et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Annals of the Rheumatic Diseases 2017;76:17-28.

Disclosure of Interests:

None declared.

Genomics and climate change

Climate change is predicted to change the nature and distribution of global farming systems, and strategies will be needed to adapt and optimise global food-producing systems. If genomic technologies are to be useful in this scenario, there is a need for the careful definition of phenotypes and routine sample collection, as well as large-scale genotyping of animal populations. Genomic tools will greatly enhance the characterisation of available germplasm and exploration of local genetic resources, while faster and cheaper DNA sequencing is leading to an increased understanding of the underlying genetic basis of traits. The use of genomic tools to increase animal resilience, reduce methane emissions from cattle and sheep, improve disease resistance, decrease environmental impact, reduce competition for land and water and, finally, increase production may be the most feasible path for the future of livestock production. In this review, the authors discuss various genomic strategies in the light of climate change, focusing on the selection of resistant/tolerant animals, landscape genomics, metagenomics and gene editing.

FRI0388 ARE WE OVERLOOKING OSTEOARTHRITIS? – A COMPARATIVE STUDY OF PAIN, FUNCTION AND QUALIFY OF LIFE IN PATIENTS WITH HAND OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS

Background:

Osteoarthritis (OA) is frequently regarded by patients and health care providers as a normal consequence of ageing (1). On the other hand, it is well established that rheumatoid arthritis (RA) is a pathological condition requiring prompt and efficacious treatment and in which remarkable progresses have been achieved in the last decades. Pain and physical limitations are hallmarks of both conditions. Some previous studies suggest that OA and RA may have a similar burden (2,3).

Objectives:

To compare levels of pain, physical disability and health-related quality of life in patients with primary hand osteoarthritis (hOA) and with RA: active disease (aRA) or in remission (rRA).

Methods:

Observational cross-sectional study including patients of two clinical centres with hOA and RA, either in remission or with active disease (at least two swollen and/or tender hand joints). Matching for sex and age was performed. Patients were asked to complete a survey consisting of visual analogic scale (VAS) for pain, Health Assessment Questionnaire (HAQ) and Short Form 36 (SF36). Mean values for each domain were compared between the three groups using one-way ANOVA test with significance accepted for p<.05.

Results:

Thirty patients with hOA and 93 with RA (33 with aRA and 60 with rRA) were included. All patients were caucasian females with no significant differences in age between groups. Patients with hOA reported higher levels of pain in comparison with aRA patients (mean VAS 57.3vs49.3mm, respectively, p=.265) and with rRA patients (57.3vs28.6mm, respectively, p<.001) [F(2.120)=25.907, p<.001]. Regarding physical function, patients with hOA reported levels of disability similar to rRA patients, but significantly lower disability than patients with aRA [F(2.120)=6.962, p=.001]. Patients with hOA evaluated their quality of life significantly better than patients with aRA and in similar levels to patients with rRA, as measured by mental health and general health status domains of SF36.

Conclusion:

Our results show that hOA may have similar or even higher burden of pain than RA; this is in line with previous studies, although most of them did not consider the level of inflammatory activity of RA. On the other hand, patients with hOA seem to preserve function and have better health-related quality of life despite the higher levels of pain. These results highlight OA as a cause of severe pain, which should lead us to try an optimal symptom control for these patients. These findings should also encourage rheumatologists to endeavor efforts to perform more studies in the field of OA, to better understand its pathogenesis and to eventually find disease modifying drugs.

References:

[1]Gignac MAM, Davis AM, Hawker G, Wright JG, Mahomed N, Fortin PR, et al. “What do you expect? You’re just getting older”: A comparison of perceived osteoarthritis-related and aging-related health experiences in middle- and older-age adults. Arthritis Rheum. 2006 Dec 15;55(6):905–12.

[2]El-Haddad C, Castrejon I, Gibson KA, Yazici Y, Bergman MJ, Pincus T. MDHAQ/RAPID3 scores in patients with osteoarthritis are similar to or higher than in patients with rheumatoid arthritis: a cross-sectional study from current routine rheumatology care at four sites. RMD Open. 2017 Jul;3(1):e000391.

[3]Slatkowsky-Christensen B, Mowinckel P, Kvien T. Health status and perception of pain: a comparative study between female patients with hand osteoarthritis and rheumatoid arthritis. Scand J Rheumatol. 2009 Jan;38(5):342–8.

Disclosure of Interests:

None declared

AB0192 RHEUMATOID ARTHRITIS: IS IT WORTH IT TO ADD LEFLUNOMIDE TO METHOTREXATE IN REFRACTORY DISEASE?

Background:

In refractory rheumatoid arthritis (RA), adding other classic synthetic disease-modifying antirheumatic drug (csDMARD) such as leflunomide (LFN) to methotrexate (MTX) is one suitable option [1,2]. Yet, there are safety issues to consider which may limit this strategy, but also regarding its true effectiveness in avoiding exposure to biological DMARDs (bDMARD) or target synthetic DMARDs (tsDMARD).

Objectives:

To assess the effectiveness and safety of adding LFN to MTX and to evaluate the predictors of drug retention, toxicity and inefficacy.

Methods:

A retrospective clinical record review of adult RA patients followed on our rheumatology department in whom LFN was added to MTX was done. Sociodemographic information, comorbidities, disease related information, adverse reactions and disease activity according to Disease Activity Score 28 – C reactive protein (DAS28) were recorded at baseline and after 3, 6 and 12 months of combination therapy (3_DAS28; 6_DAS28; 12_DAS28, respectively). Information regarding toxicity (need to dose adjustment/suspension) and inefficacy (add/switch to bDMARD/tsDMARD) were recorded. Follow-up was considered until last medical record available. SPSS was used for statistical analysis. Kaplan Meier and Cox-regression were used for univariate and multivariate analysis, respectively, significant level was 2-sidedp<.05.

Results:

In total, 77 patients were included, 66.20% females, with a mean age of 56±11 years old. There was a significant reduction of DAS28 only after 3 months of therapy (4.01±1.01 to 2.57±1.52,p=.003; ΔDAS28 = 1.58±1.17). However, during a median follow up time of 64 (IQR 39-83) months, 58.44% of patients needed to change treatment strategy, 66.67% due to toxicity (median time to toxicity 13 months, IQR 2-16) and 33.33% due to inefficacy (median time to inefficacy of 10 months, IQR 5.84-17.64). Gastrointestinal intolerance was the main reported toxicity (46.15%). In univariate analysis, anti-citrullinated protein antibodies (ACPA) positivity, alcohol consumption, lack of comorbidities, hepatic toxicity, higher 6_DAS28, swollen joint count and tender joint count on the 6thmonth were associated to lower retention rates.

In multivariate analysis, lack of comorbidities (HR=3.3, CI 95% 1.4-7.8,p=.006) and higher 6_DAS28 (HR=0.32, CI 95% 0.14-0.72,p=.006) were independent predictors of suspension of combination therapy. Moreover, both male gender (HR=2.87, 95%CI 1.2-6.56,p=.016) and positivity to ACPA (HR=0.1, 95%CI 0.01-0.73,p=.024) were independent predictors of toxicity. There was also higher tendency to toxicity, but without statistical significance, in alcohol consumers (p=.08). Regarding inefficacy, smoking habits (HR=0.15, 95%CI 0.04-0.52) and 3_DAS28 (HR=0.15, 95%CI 0.04-0.53) were independent predictors.

Conclusion:

Addition of LFN to MTX showed an early positive response. However, it was frequently associated to toxicity, and less than half of the patients continued with this therapeutic strategy after 5 years of follow up. Male gender, smoking habits and positivity to ACPA were predictors of worse outcome, as already reported in literature [1]. Lack of comorbidities was an independent predictor of suspension. This can be explained by the fact that physicians tend to adopt a more aggressive strategy on patients without comorbidities, switching earlier to bDMARDs/tsDMARDs.

This study also showed that early response to combination therapy is an independent predictor on drug retention, suggesting that decisions on treatment strategy should be made early after the beginning of MTX/LFN.

References:

[1]Smolen JS, et al. Ann Rheum Dis 2020;0:1–15. doi:10.1136/annrheumdis-2019-216655

[2]Kremer J, et al. J Rheumatol. 2004 Aug;31(8):1521-31. PMID: 15290730

Disclosure of Interests:

None declared

AB0236 DIFFERENCES AND DETERMINANTS OF PHYSICIAN’S AND PATIENT’S PERCEPTION IN GLOBAL ASSESSMENT OF RHEUMATOID ARTHRITIS

Background:

Patient’s Global Assessment of Disease Activity (PtGA) and Physician’s Global Assessment of Disease Activity (PhGA) are assessed as part of commonly used measures of disease activity in RA.1Both are important measures in treat-to-target strategies in Rheumatoid Arthritis (RA), but often provide discordant results.2,3This can provide an erroneous assessment of disease activity in patients under Biologic treatment and mislead treatment decisions, namely switches.

Objectives:

To assess differences and determinants of PtGA and PhGA in RA patients under biologic treatment.

Methods:

Cross-sectional study, including 46 patients with RA diagnosed according to the ACR/EULAR criteria, under biologic treatment, consecutively evaluated in day-care unit. Participants completed patient-reported outcomes (PROs), including PtGA, and sociodemographic characteristics. Physicians collected comorbidities and parameters of inflammatory activity (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) and completed PhGA and disease activity score 28 with ESR (DAS28). SPSS was used for statistical analysis and significance level was defined as 2-sided p<0.05.

Results:

Clinical and laboratory characteristics of patients are shown in table 1. PtGA and PhGA were significantly different (36.1±27.6 mmvs8.7±14.2 mm, p< 0.001) and a positive discordance (PtGA>PhGA, more than 25mm in visual analogue scale [VAS]) was found in 54.3% of cases.

PtGA had a correlation with PROs (Pain VAS, 36-Item Short Form Health Survey [SF-36], Health Assessment Questionnaire [HAQ], Functional Assessment of Chronic Illness Therapy [FACIT], EuroQol [EQ5D] and Hospital Anxiety and Depression Scale [HADS]), CRP, tender and swollen joint counts and an association with comorbidities like fibromyalgia or osteoarthritis (OA). No association was found between PtGA and age, sex, education level, profession, employment status, extra-articular manifestations, positivity of rheumatoid factor, ESR, years of disease evolution or number of biologic treatments. In multivariable analyse including SF-36, CRP, tender joints count and OA (R2adjusted= 0.672), the main predictors of PtGA were lower SF36, concomitant OA and higher CRP level.

PhGA had a correlation with PtGA, pain VAS, CRP, tender and swollen joints. No association was found between PhGA and patient or physician age, patient or physician sex, extra-articular manifestations, positivity of rheumatoid factor, ESR level, years of disease evolution or number of biologic treatments. In multivariable analysis including ESR, tender and swollen joints count and CRP (R2adjusted= .800), the main predictors of PhGA were swollen joint count and higher CRP level.

Conclusion:

This study showed the variability implied on global assessment of RA activity. Overall PtGA is based on function and also in subjective and emotional experience of pain, whereas the PhGA is based on more objective measures, more related to disease activity.

References:

[1]Kanekoa Y. et al, Determinants of Patient’s Global Assessment of Disease Activity and Physician’s Global Assessment of Disease Activity in patients with rheumatoid arthritis: A post hoc analysis of overall and Japanese results from phase 3 clinical trials.Modern Rheumatology2018; 28(6):960–967

[2]Furu M. et al. Discordance and accordance between patient’s and physician’s assessments in rheumatoid arthritis.Scand J Rheumatol.2014; 43(4):291-5.

Ann Rheum Dis. 2016 Sep;75(9):1661-6. doi: 10.1136/annrheumdis-2015-208251. Epub 2015 Oct 22.

[3]Portier A. et al, Patient-perceived flares in rheumatoid arthritis: A sub-analysis of the STRASS treatment tapering strategy trial.Joint Bone Spine. 2017; 84(5):577-581

Disclosure of Interests:

None declared

AB1350-HPR SOCIOECONOMIC BURDEN OF NON-ATTENDANCE IN RHEUMATOLOGY CONSULTATION

Background:

Outpatient non-attendance refers to the phenomenon of patients who have a medical appointment but do not show up at the specified date, time, and location without giving previous notice.1In addition to affecting the efficiency and thereby increasing the healthcare total costs, nonattendance might also delay access to care for users on waiting lists.1Nonattendance at health appointments is costly to services, and can risk patient health.2There is very little data on the nonattendance prevalence and impact in Portugal. This knowledge might be fundamental to improve effectiveness of outpatient care in Portugal.

Objectives:

1) describe patient’s non-attendance rate; 2) assess and characterize the sociodemographic and clinical characteristics among non-attending patients; 3) estimate the economic burden of non-attendance.

Methods:

Retrospective, cross-sectional and analytical study. We reviewed a one-month Rheumatology consultation period regarding performed medical consultations and non-attended consultations without previous notification from patients. Direct economic costs of non-attended appointments were calculated based on the “Amending Agreement to the ULSAM, EPE Program Agreement”.

Results:

982 consultations within January 2018 were included. Appointments episodes for therapeutic prescription, medical reports or programmed admissions were excluded. Fifty-seven (5.8%) of scheduled outpatient appointments were non-attended. Subsequent consultations represented 85.2% of attended appointments and 80.7% of non-attended appointments. Female gender was the most prevalent in both groups – 620 (67.0%) among attended consultations and 37 (65.0%) among non-attended consultations. Mean age was 57±15 years in the first group and 54±16 years in the second one. Among attended appointments, mean education level was 8±5 years versus 9±6 years among non-attended appointments. There were no differences between both groups in gender, age, education level, diagnosis, disease duration and activity or appointment type (first or subsequent consultation). A cost of 2,438 euros was estimated regarding non-attended appointments for this period, what could represent a burden of more than 29,000 euros yearly, in direct costs, only.

Conclusion:

Non-attendance at scheduled appointments in public hospitals seems to be influenced by other factors besides gender, age and education level. The burden of non-attended appointments is undeniable. In addition to the costs estimated in this study, further indirect costs such as poorer patients outcomes, impaired access to medical care and hospital penalties should be taken into account. Implementation of awareness strategies aiming the optimization and effectiveness of healthcare system are required.

References:

[1]Blæhr EE, Kristensen T, Væggemose U, Søgaard R. The effect of fines on nonattendance in public hospital outpatient clinics: study protocol for a randomized controlled trial.Trials. 2016;17(1):288. doi:10.1186/s13063-016-1420-3

[2]Akter S. A qualitative study of staff perspectives of patient non-attendance in a regional primary healthcare setting.Australas Med J. 2014;7(5):218-226. doi:10.4066/AMJ.2014.2056

Disclosure of Interests:

None declared

P883 Hepatocellular carcinoma presenting as a tumor thrombus extending from the inferior vena cava to the right atrium in echocardiography

Case

A 74 year-old white male with COPD, type 2 Diabetes, Atrial Fibrillation and a Pacemaker presented to our hospital for a routine echocardiography follow-up for mild to moderate Aortic Stenosis. His past social history was positive for moderate alcohol consumption but negative for tattoos, recent travel, illicit drug use, blood transfusion or chemical exposure. During evaluation in the echocardiography lab the patient had symptoms of dyspnea, fatigue and abdominal distension. He was hemodynamically stable and physical examination was positive for signs os ascites and inferior limb oedema, but disclosed no scleral icterus, asterixis, spider angiomata or overt hepatomegaly. There was a recent weight gain of 10kg. Cardiac and pulmonary auscultation was unrevealing. The echocardiogram revealed moderate left ventricle dysfunction (EF ∼40%), moderate aortic stenosis and a dilated inferior vena cava (31mm) with an image of a mobile mass in the confluence of the central hepatic vein with the inferior vena cava with extension to the right atrium. Initial blood chemistry and blood count revealed macrocytic anaemia; slight increased y-GT, C-reactive protein and NT-proBNP (6210pg/mL). The patient was admitted and anticoagulation with subcutaneous enoxaparin was initiated with echocardiographic follow-up. An abdominal ultrasound was performed which a hyperecogenic mass (71x47mm) adjacent to the right and left supra-hepatic veins, highly suggestive of hepatocelullar carcinoma. A triple-phase abdominal CT confirmed a nodular lesion 70x50mm on segment VIII, compatible with hepatocellular carcinoma (Fig.1). A cardiac magnetic resonance was performed documenting the tumor extension to the inferior vena cava and right atrium, suggestive of tumor thrombus (Fig.2). Multidisciplinary meeting enrolled the patient in palliative care. The right heart failure picture was refractory to medical treatment and the patient progressed to multi organ failure and a consumptive state. He died approximately 20 days after diagnosis.

Discussion

Intravascular tumor extension, also known as Tumor thrombus (TT) is a rare complication of some forms of cancer. In the late stages of Hepatocellular carcinoma (HCC) a TT can form in the portal or hepatic vein. These are usually detected during tumor workup or during evaluation of cardiorespiratory symptoms in a patient with a known abdominal carcinoma. Tumor invasion to the portal system is quite common while invasion to the inferior vena cava (IVC) and/or heart without invasion of the portal system is rare. Tumor extension to the RA or IVC, most patients were either symptomatic, had cirrhosis, or both. Our patient presented mainly with signs of right heart failure refractory to medical treatment and had no signs of portal invasion or hypertension in the various image modalities. The prognosis for a HCC with extension to the IVC or RA is grim, with a 1 to 4 months of mean survival regardless of treatment choice.

Abstract P883 Figure.

93 A hemodynamic challenge in assessment of echocardiographic mitral regurgitation severity

DIscussion

This case illustrates the importance of assessment of hemodynamic status of the patient during echocardiographic evaluation of mitral regurgitation severity, and presents a pharmacological strategy to compensate hypotensive effects of sedative agents used during TEE.

P235 A happy ending for a dancing thrombus on the right atrium

Discussion

Large right atrial thrombus in the setting of PTE is a clinical situation in which there is no consensus regarding clinical management. In most cases, management is dictated by haemodynamic status of the patient. In the setting of a hemodynamically stable patient, systemic anticoagulation can be an option. Surgery, fibrinolysis and percutaneous aspiration have also been advocated. Successful treatment of right heart thrombus with anticoagulation alone has been reported, but there are also reports of unsuccess with that strategy. This is a case of a successful treatment with anticoagulation alone and so, we currently consider that the choice of treatment strategy based on hemodynamic status continues to be the wisest strategy to adopt.

Abstract P235 Figure. Thrombus before and after

P862 A conservative strategy for a frequently fatal post-myocardial infarction mechanical complication

Discussion

Post-myocardial infarction ventricular septal defect (VSD) is a complication that, regardless of the treatment strategy has a high mortality rate, especially when patient presents in cardiogenic shock. However, when patient is stable and especially when comorbidities imposes a high interventional risk medical treatment can be an option. So far, this is a successful case of a medically managed post-myocardial infarction VSD.

Abstract P862 Figure. Ventricular Septal Defect

P872 A case of transient atrioventricular block: the role of cardiac magnetic resonance imaging

Discussion

Transient atrioventricular block is a well-known complication of myocarditis when there is involvement of the conduction system by the inflammatory reaction. However, in rare cases it can persist or recur. CMRI plays an important role in these cases. Gadolinium-enhanced CMRI can be used to access the extent of inflammation and cellular edema and delayed-enhanced CMRI can also be used to quantify scarring which has important prognostic value. CMRI can also play a crucial role in excluding infiltrative disorders with conduction system involvement. Also, in these patients, the transient aspect of atrioventricular block poses a challenge when deciding about permanent pacemaker insertion.

Abstract P872 Figure. Magnetic Ressonance IVS

P766 Elegibility for CLOSE and REDUCE trials of real world patients with Transient Ischemic Attack (TIA) or Acute Ischemic Stroke (AIS) and Patent Foramen Ovale (PFO)

Introduction

In the last decade there has been an intense discussion in which therapeutic option is most suitable for patients with TIA or cryptogenic AIS and a PFO. Recently two randomised studies (CLOSE and REDUCE) have been published tackling this question. Both have showed preference in lower recurrence rates in the group assigned for PFO closure. The eligibility criteria of these types of studies frequently are very restricted, becoming difficult to ascertain the best therapeutic option for a large number of patients.

Goal

Analyse a real world cohort of patients with TIA or cryptogenic AIS with PFO and identify the eligibility of these patients for the inclusion in the CLOSE and REDUCE trials.

Methods

We made a retrospective observational analysis of a cohort of patients discussed in a multidisciplinary meeting (Cardiology and Neurology departments) of our Hospital in which is made the decision of PFO closure vs conservative management between November 2017 and November 2018. We included all the patients with probable TIA or AIS and PFO. Demographic, clinical, image and therapeutic data was registered. The inclusion and exclusion criteria used in CLOSE and REDUCE trial were applied.

Results

25 patients were analysed, 56.0% (n = 14) were male. Median age of 47 years. Median RoPE score 7. The commonest cardiovascular risk factors were hypertension (36.0%, n = 9) and smoking (28.0%, n = 7). Eight patients met criteria for cortical cryptogenic AIS, three had lacunar strokes, two had TIA with findings in cerebral imaging and twelve presented with TIA without findings in cerebral imaging. Transesophagic echocardiography was performed in 92.0% (n = 23) of patients, transthoracic echocardiography with bubble study was performed in two cases. At the time of data collection, six patients were waiting completion of the workup. PFO closure was performed in three cases. Closure was proposed in other two. When applying the eligibility criteria of CLOSE and REDUCE the main reasons for exclusion in the REDUCE trial were TIA without cerebral imaging (48.0%, n = 12), incomplete antiphospholipid antibody syndrome screening (36.0%, n = 9) and age greater than 59 years (28.0%, n = 7). The main reasons for exclusion in the CLOSE trial were TIA without cerebral imaging (48.0%, n = 12), age greater than 60 years (28%, n = 7) and failing to meet the designated echocardiography criteria (20.0%, n = 5).

Conclusion

2 real world patients met eligibility criteria for the REDUCE trial and 3 for CLOSE. The main reason for exclusion in both REDUCE and CLOSE was TIA without cerebral imaging (48.0% n = 12). Older patients, and patients with a prothrombotic condition were also excluded. Multidisciplinary meetings are essential to ascertain the most beneficial therapeutic option for these patients. It is our believe that the management of risk factors should be similar in a TIA and a AIS and also that the presence of a prothrombotic condition should favor the closure of PFO.

P875 A suspected case of extra-pulmonary tuberculosis presenting as effusive-constrictive pericarditis

Case presentation

A 33 year-old black female, born in Angola, staying in Portugal 1 week before admission presented to the emergency department of our hospital with a history of worsening but recurring pleuritic chest accompanied by dyspnea, fatigue, peripheral oedema and sweating in the past 4 years. Initial workup in Angola and more recently in Namibia was unrevealing. The patient had taken 3 months of antituberculous agents and a systemic corticosteroid and was medicated with furosemide and spironolactone. Since then the symptoms persisted and multiple admissions for decompensated heart failure followed. At presentation median blood pressure was 60mmHg, heart rate 90 beats per minute, temperature 37,6ºC. Auscultation had signs of pulmonary congestion and muffled heart sounds, the neck veins were distended. An electrocardiogram showed sinus rhythm and low-voltage complexes in limb and precordial leads. Initial transthoracic echocardiogram revealed a thickened pericardium with circunferencial effusion and marked respiratory variation (&gt;25%) of the mitral and tricuspid inflow doppler velocities. Pericardiocentesis was performed with improved dyspnea and blood pressure after drainage of 650 mL of serohematic fluid. Echocardiographic follow-up showed a mild circunferencial pericardial effusion and extensive areas of thickened crypted pericardium with fibrin strands containing heterogeneous fluid (figure 1). There were signs of constriction. A cardiac CT revealed no calcium deposition. Fluid cytology was predominant for lymphocytes and biochemistry, cultures, polymerase chain reaction and immunochemistry were inconclusive and no pathologic agent was isolated. The image findings in the transthoracic echocardiogram coupled with the demographics and past clinical history of the patient prompt the initiation of antituberculous therapy in association with systemic corticosteroids in an attempt to ameliorate the pericardial constriction. Despite initial therapeutic response, constriction was deemed irreversible and pericardiectomy was performed. The workup for definitive diagnosis is still undergoing.

Discussion

Effusive-constrictive pericarditis is defined by a pericardial effusion with signs of concurrent pericardial constriction. In these cases the scarred pericardium not only constricts cardiac volume but can also accommodate pericardial fluid under increased pressure leading to signs of cardiac tamponade. The initial approach should be the treatment of the underlying condition but if such remains ineffective, pericardiectomy is the remaining option and is reserved for patients in which constriction becomes severe and/or persistent. This condition is more prevalent with tuberculous pericarditis and when suspected presumptive treatment should be initiated in immunocompetent patients from endemic regions. Antituberculous treatment regimens in conjunction with systemic corticosteroids have shown to prevent complications from pericardial constriction.

Abstract P875 Figure.

P1366 Low-flow, low-gradient severe aortic stenosis: might mitral regurgitation be a culprit?

Introduction

According to current guidelines, given a patient with low-gradient (aortic valve maximum velocity &lt; 4m/s and/or aortic valve mean gradient &lt;40mmHg), aortic valve area (AVA) &lt; 1cm2 and low-flow (stroke volume (SV) &lt; 35mL/min/m2), with preserved left ventricle function (ejection fraction (EF) ≥50%), an integrated approach for assessment of aortic stenosis severity is proposed. We aimed to investigate whether mitral regurgitation can play a role in those cases, possibly being responsible for low antegrade systolic flow.

Methods

We retrospectively analysed 121 consecutive transthoracic echocardiograms (TTEs) of patients with severe aortic stenosis, with AVA &lt; 1.0cm2 as assessed by continuity equation. Patients with low ejection fraction (&lt; 50%) were excluded. We therefore included 84 patients (females 53,6%, mean age 79,1+-10 years). Stroke volume was assessed by Doppler at the left ventricle outflow tract (LVOT). We then compared the prevalence of more than mild mitral regurgitation among patients with low-gradient and low-flow and the other patients.

Results

15 patients had both low-gradient, low-flow and preserved ejection fraction. There was a significant association regarding the presence of more than mild mitral regurgitation among these patients (p = 0.028, OR = 4.7, CI 95% 1.1-20.1). In these patients, it was also observed a higher prevalence of atrial fibrillation (p = 0.03, OR = 6.9, CI 95% 1.74-27.1), lower longitudinal systolic function of right ventricle as measured by TAPSE (16.6 vs 21.5mm, p = 0.028), and a tendency towards higher left atrial volume (113 vs 87mL, p = 0.06).

Conclusions

Given the findings that the prevalence of more than mild mitral regurgitation is higher in patients with severe aortic stenosis as assessed by AVA with both low-gradient, low-flow and preserved ejection fraction, we suggest that the presence of more than mild mitral regurgitation should be considered on the approach of aortic stenosis classification of these patients.

P1298 A conservative strategy for an uncommon complication of endocarditis

Discussion

Infective endocarditis of mechanical prosthesis has different presentations depending on the involvement of prosthesis and periprosthetic structures, and it is associated with high morbidity and mortality. Pseudoaneurysm of the intervalvular fibrosa is an uncommon complication, furthermore when complicating with dissection to near structures such as RVOT and the PT in this case. Treatment is mainly surgical, however, in this case the surgical risk was too high due to comorbidities and a conservative strategy was adopted. It seems that it was a reasonable strategy as the patient evolution was unremarkable when regarding endocarditis. Unfortunately, he ended up dying from probably unrelated complications.

Abstract P1298 Figure. Pseudoaneurysm with fistulization

Novel laser textured surface designs for improved zirconia implants performance

The development of new surface designs to enhance the integration process between surgically placed implants and biological tissues remains a challenge for the scientific community. In this way and trying to overcome this issue, in this work, laser technology was explored to produce novel textures on the surface of green zirconia compacts produced by cold pressing technique. Two strategies regarding line design (8 and 16 lines design) and different laser parameters (laser power and number of laser passages) were explored to assess their influence on geometry and depth of created textures. The produced textures were evaluated with Scanning Electron Microscopy (SEM) and it was observed that well-defined textured surfaces with regular geometric features (cavities or pillars) were obtained by laser combining different strategies lines design and parameters. The potential of proposed textures was also evaluated regarding surface wettability, friction performance (static and dynamic coefficient of friction evolution) against bone, aging resistance and flexural strength. Results demonstrated that all the produced textures display a super hydrophilic or hydrophilic behavior. Regarding the friction behavior, it was experimentally observed a high initial static coefficient of friction (COF) for all produced textures. Concerning the aging resistance, all the textured surfaces revealed a low monoclinic content, less than 25% after 5 h of hydrothermal aging. The flexural strength results showed that the mechanical resistance of zirconia was not significantly compromised with the laser action. Based on the obtained results, it is possible to prove that the processing route used for manufacturing the new and different surface designs (cold pressing technique followed by laser texturing) showed to be particularly effective for the production of zirconia implants with customized surface designs according to the properties required in a specific application. These new surface designs besides to enhance the surface wettability and also to improve the fixation at the initial moment of the implantation, do not significantly compromise the resistance to aging and the mechanical performance of zirconia. Hence, a positive impact on the long-term performance of the zirconia implants may be expected with the proposed novel laser textured surface designs.

P1659Evolution of level of evidence c recommendations in European Society of Cardiology clinical practice guidelines on heart failure

Background

Over the past two decades, the European Society of Cardiology (ESC) Clinical Practice Guidelines (CPG) on Heart Failure has increasingly become a familiar part of Cardiology practice and are used worldwide. By creating objective standards, CPG provides a mechanism to assess decision-making and straightforward references for clinicians. Level of Evidence C recommendations are based on expert consensus and/or small retrospective studies and registries with limited and non-representative populations evaluated. The resulting directives need to be proven with better quality data to assess its true benefits.

Purpose

The purpose of our study was to describe and evaluate the evolution of Level of Evidence C recommendations of ESC CPG on Heart Failure and to provide a quality assessment of its benefits in the following years.

Methods

In this retrospective observational Case-Control study, we identified and collected all Level of Evidence C recommendations in five consecutive published documents of ESC CPG in the years 2001, 2005, 2008, 2012 and 2016. Each identified recommendation was classified between two major groups: Diagnostic and Complementary Exams (group 1) and Therapeutics and Interventions (group 2) and was followed up in the following documents. Primary outcomes were classified as: (1) Upgrade to Level of Evidence A or B [Upgrade], (2) Elimination or disproven benefit/harm [Downgrade] and (3) Maintenance or minor reformulation with unchanged benefit/harm [Maintenance]. We applied a Kaplan-Meyer survival analysis to estimate the probability of Upgrade or Downgrade in each group.

Results

A total of 239 different Level of Evidence C recommendations were submitted to the final analysis, 22.6% (n=54) in group 1 and 77.4% (n=185) in group 2. On follow-up, 35.2% (n=76) of recommendations were upgraded, 29.6% (n=64) were downgraded and 35.2% (n=76) were maintained. Regarding outcomes, the downgrade of recommendations occurred predominantly in group 2 (94.4%). Considering all the eliminated recommendations, 60.9% took place on the next following published ESC CPG document. Likewise, 60.5% of upgraded recommendations also occurred on the next following published ESC CPG document. The probability of upgrade or downgrade in the next following document was 52.8%, predominantly in the Therapeutics and Interventions group (37.5% vs 57.9%, p=0.012).

Figure 1

Conclusions

Level of Evidence C recommendations constitutes an important asset of ESC CPG on Heart Failure as they are usually updated on new treatment options and are developed by experts in the specific topic. However, the probability of elimination due to disproven benefit or potential harm was high (29.6%), particularly regarding therapeutics and interventions (94%). Since a significant fraction of Level of Evidence C recommendations remains unchanged on the following document (35%), the need for high-quality data, specifically regarding therapeutic interventions, is warranted.

Energy consumption, CO2 emissions and costs related to baths water consumption depending on the temperature and the use of flow reducing valves

In the domestic segment, various appliances and processes consume great amount of water and, consequently, energy. In this context, the main aim of this study is to analyse the impact of water temperature, flow and bath duration in water and energy consumptions. The impact on CO₂ emissions and a simple costs analysis were also carried out. It included a monitoring plan of 197 baths taken under different scenarios of water temperature and flow. It was concluded that increasing water consumption leads to an increase on energy consumption and that both resources consumptions increase with bath duration. Bath temperature had influence not only on energy consumption, as expected, but also in water consumption, what may be explained by the user's satisfaction during baths with higher temperatures. The use of a flow reducing valve is not a guarantee of water saving which can also be related to the user's satisfaction patterns, given that the introduction of a flow reducing valve can lead to a bath duration increase. In what concerns to the CO₂ emissions, it was concluded, as expected, that higher values are obtained for baths with higher temperatures given their relation with higher energy consumptions patterns. A simple costs analysis revealed that having flow reducing valves, with a bath temperature of 75 °C, increased the costs with electricity and water in 119% and 32%, respectively, when compared with a temperature of 60 °C.

Which are the factors that may explain the differences in water and energy consumptions in urban and rural environments?

Rural and urban environments present significant differences between water and energy consumptions. It is important to know, in detail, which factors related to the consumption of these two resources are different in both environments, once that will be those important to manage and discuss in order to improve its use efficiency and sustainability. This research work involves a survey whose aim is to find the factors that in rural and urban environments may justify the differences found in water and energy consumptions. Besides the collection of water and energy consumption data, this survey analyzed 80 variables (socio-demographic, economic, household characterization, among others), that were chosen among the bibliography as possible factors that should influence water and energy consumptions. After the survey application in rural and urban areas and the data statistical treatment, 42 variables remained as truly differentiating factors of rural and urban environments and so as possible determinants of water and energy consumptions. In order to achieve these objectives, a descriptive data analysis and statistical inference (Mann-Whitney-Wilcoxon test and the Chi-square test of homogeneity) were performed. All the 42 differentiating variables that result from this study may be able to justify these differences, however this will not be presented in the paper and it is reserved for future work.

In situ evaluation of water and energy consumptions at the end use level: The influence of flow reducers and temperature in baths

Nowadays, water and energy consumption is intensifying every year in most of the countries. This perpetual increase will not be supportable in the long run, making urgently to manage these resources on a sustainable way. Domestic consumptions of water and electric energy usually are related and it's important to study that relation, identifying opportunities for use efficient improvement. In fact, without an understanding of water-energy relations, there are water efficiency measures that may lead to unintentional costs in the energy efficiency field. In order to take full advantage of combined effect between water and energy water management methodologies, it is necessary to collect data to ensure that the efforts are directed through the most effective paths. This paper presents a study based in the characterization, measurement and analysis of water and electricity consumption in a single family house (2months period) in order to find an interdependent relationship between consumptions at the end user level. The study was carried out on about 200 baths, divided in four different scenarios where the influence of two variables was tested: the flow reducer valve and the bath temperature. Data showed that the presence of flow reducer valve decreased electric energy consumption and water consumption, but increased the bath duration. Setting a lower temperature in water-heater, decreased electric consumption, water consumption and bath duration. Analysing the influence of the flow reducer valve and 60°C temperature simultaneously, it was concluded that it had a significant influence on electric energy consumption and on the baths duration but had no influence on water consumption.

Fano resonances in hexagonal zigzag graphene rings under external magnetic flux

We study transport properties of hexagonal zigzag graphene quantum rings connected to semi-infinite nanoribbons. Open two-fold symmetric structures support localized states that can be traced back to those existing in the isolated six-fold symmetric rings. Using a tight-binding Hamiltonian within the Green's function formalism, we show that an external magnetic field promotes these localized states to Fano resonances with robust signatures in transport. Local density of states and current distributions of the resonant states are calculated as a function of the magnetic flux intensity. For structures on corrugated substrates we analyze the effect of strain by including an out-of-plane centro-symmetric deformation in the model. We show that small strains shift the resonance positions without further modifications, while high strains introduce new ones.

Identification of molecular compartments and genetic circuitry in the developing mammalian kidney

Lengthy developmental programs generate cell diversity within an organotypic framework, enabling the later physiological actions of each organ system. Cell identity, cell diversity and cell function are determined by cell type-specific transcriptional programs; consequently, transcriptional regulatory factors are useful markers of emerging cellular complexity, and their expression patterns provide insights into the regulatory mechanisms at play. We performed a comprehensive genome-scale in situ expression screen of 921 transcriptional regulators in the developing mammalian urogenital system. Focusing on the kidney, analysis of regional-specific expression patterns identified novel markers and cell types associated with development and patterning of the urinary system. Furthermore, promoter analysis of synexpressed genes predicts transcriptional control mechanisms that regulate cell differentiation. The annotated informational resource (www.gudmap.org) will facilitate functional analysis of the mammalian kidney and provides useful information for the generation of novel genetic tools to manipulate emerging cell populations.