Acute calcific periarthritis in a proximal interphalangeal joint of the hand after acute trauma: a rare case

Acute calcific periarthritis (ACP) in the interphalangeal joints of the hand is rare, with less than 100 cases reported. A rare case of ACP in a proximal interphalangeal (PIP) joint of the hand, in a young black woman, after acute trauma, is presented. She experienced severe pain and limited range of motion, and was medicated with an oral corticoid, which was followed by a rapid resolution of the symptoms. At six months, there were no signs of clinical or radiographic recurrence. Recognition of ACP allows for avoiding unnecessary treatments. In this case, treatment with corticoids might have played a role in a faster recovery.

"Help Me Control My Impulses!": Adolescent Impulsivity and Its Negative Individual, Family, Peer, and Community Explanatory Factors

The literature shows that impulsivity, prevalent in adolescence, is negatively linked with a variety of psychosocial factors (e.g., positive interpersonal relationships, emotion regulation); however, there is limited research examining the relative contribution of multiple factors for this trait nor exploring how these factors influence the associations between impulsivity and risk-related outcomes. Drawing on multiple components of the unified theory of development (i.e., psychological variables, peers subsystem, community subsystem, family processes subsystem), this cross-sectional study aims to identify explanatory psychosocial variables (i.e., early memories of warmth and safeness, rational decision-making style, resilience, emotion regulation, coping, parental attachment, social group attachment, satisfaction with school and family-related variables) that are negatively related with impulsivity, in younger (13-15) and older (16-19 years) adolescents, and explore their moderating role in the associations between this trait and some risk-related outcomes (i.e., verbal aggression, anger, self-harm, other high-risk behaviors). A representative sample of 6894 adolescents (52.9% female) living in the Azores (Portugal), with ages ranging from 13 to 19 (M = 15.4), was used. Two stepwise multiple regressions, one for each age group, revealed that only emotion regulation, parental attachment, and social group attachment had a negative effect on impulsivity in both age groups; additionally, satisfaction with teachers also had this effect in younger adolescents. The first three variables weakened the positive associations between impulsivity and the risk-related outcomes. These results suggest that the psychological system and all subsystems of the social context measured play a relevant role in explaining adolescent impulsivity and that it may be reduced by promoting emotion regulation, positive parenting practices, healthier relationships with peers, and healthier relationships with teachers.

Effective VTE prophylaxis with enoxaparin after elective THR or TKR: a retrospective observational study

Background

Orthopedic patients are at the highest risk for venous thromboembolism (VTE). Nowadays, with VTE prophylaxis as a routine in patients undergoing total hip replacement (THR) and total knee replacement (TKR), fatal pulmonary embolism (PE) is rare and the rates of symptomatic VTE within 3 months dropped to 1.3%-10%, compared with the rates of 50%-70% before VTE prophylaxis implementation. In this study, we aim to evaluate the VTE prophylaxis and incidence in patients who underwent THR and TKR in Centro Hospitalar Universitário de Santo António (CHUdSA).

Methods

We included 483 patients who underwent elective THR or TKR in CHUdSA from March 2019 to February 2020 and who were under enoxaparin as a VTE prophylaxis drug. All data related to prescribed enoxaparin were collected from the nationwide common electronic drug prescription system (PEM).

Results

Of the 483 eligible patients, 192 (39.75%) underwent elective THR and 291 (60.25%) underwent TKR. Enoxaparin was prescribed for 31.86 ± 5.98 and 30.28 ± 5.97 days, on average, for the THR and TKR groups, respectively (P = .005). Patients completed, on average, 29.38 ± 8.12 days and 28.20 ± 7.32 days of VTE prophylaxis with enoxaparin in the THR and TKR groups, respectively (P = .098). The incidence of VTE was approximately 3.13% and 0.69% in the THR and TKR groups, respectively (P = .064).

Conclusion

In CHUdSA, we usually prescribe enoxaparin 40 mg once daily for up to 35 days for VTE prophylaxis after THR or TKR. High therapeutic compliance rates resulted in very few events.

The Enhancing Role of Emotion Regulation in the Links between Early Positive Memories and Self-harm and Suicidal Ideation in Adolescence

Adolescence is a critical developmental period associated with an increased variety of interrelated risks and vulnerabilities. Previous studies have found associations between early memories of warmth and safeness, as well as emotion regulation, and self-harm and suicidal ideation in adolescence. Additionally, these early emotional memories have been found to be positively linked with some indicators of emotion regulation during this period. The present cross-sectional study extends prior research by exploring the moderating role of emotion regulation in the relationships between early memories of warmth and safeness, as well as each of the following risk-related outcomes in adolescence, in younger (i.e., 13-15) and older (i.e., 16-19) adolescents: suicidal ideation and self-harm and its associated functions (i.e., automatic and social reinforcement. Three self-report measures of these early emotional memories, emotion regulation, and risk-related outcomes, and a sample of 7918 Portuguese adolescents (53.3% females), with ages ranging from 13 to 19 (M_age = 15.5), were used. In both age groups, at high levels of emotion regulation, early memories of warmth and safeness had a greater (negative) effect on suicidal ideation and the automatic reinforcement function of self-harm, compared to at average and low levels of emotion regulation. These findings highlight the enhancing role of emotion regulation on the associations between early memories of warmth and safeness and some risk-related outcomes in adolescents, both younger and older, which reveals the relevance of targeting emotion regulation when preventing or tackling these outcomes, regardless of adolescents' levels of early memories of warmth and safeness.

Lumbosacral transitional vertebrae: prevalence in a southern European population and its association with low back pain

PURPOSE

Lumbosacral transitional vertebra (LSTV) is a congenital anomaly of the lumbosacral junction. Its prevalence is variable in the literature such as its association with low back pain. The aim of this study was to identify the prevalence of LSTV in a southern European population, and its correlation with low back pain.

METHODS

A retrospective review of 639 thoraco-abdomino-pelvic consecutive CT-scans between January 2019 and November 2020 was performed. The presence of LSTV was classified into type II, III, IV based on Castellvi's classification. To investigate the association with low back pain, Oswestry Low Back Disability Questionnaire (ODI) and the EuroQol-5D-3L questionnaire was applied.

RESULTS

The prevalence of LSTV was 24.9% (142 of 571). 37,3% were type IIb, 31,0% were type IIa, 13,4% were type IIIa, 9.9% were type IIIb and 8.5% were type IV. Individuals with LSTV were more likely to report low back pain and have a higher ODI score (OR:0.392, 95% CI:0.192-0.802, p = 0.010), (OR: 1050, 95% CI: 1029-1072, p < 0.01). Castellvi's type IV showed a significantly higher ODI when compared to type II (OR:1059, 95% CI:1019-1100, p = 0,04). There was no statistical difference in the EuroQol-5D-3L score between two groups (OR:1085, 95% CI: 0.459-2.560, p = 0.852).

CONCLUSION

This population-based study adds to the literature the prevalence of LSTV in a southern European population. LSTV was associated with low back pain. However, this difference did not translate into a loss of quality life. Type IV was associated with higher functional disability when compared with type II.

Motivation and anxiety during the second COVID-19 lockdown in gym exercisers: The mediating role of affects and satisfaction with life

The present study aimed to analyze the association between motivation (self-determined and non-self-determined motivation), positive and negative affect, life satisfaction and state-anxiety in a sample of gym exercisers, during the 2nd COVID-19 lockdown in Portugal. Also, we aimed to analyze the possible mediating role of positive and negative affect and life satisfaction in the relationship between motivation and levels of state-anxiety. A total of 201 gym participants (30.42 ± 11.22) were enrolled in the present study, of which 116 (57.7%) were women and 85 (42.3%) were men. The survey included sociodemographic data as well as the subsequently validated instruments: the State-Trait Anxiety Inventory, the Positive and Negative Affect Schedule, and the Satisfaction with Life Scale. The results revealed a positive association between state-anxiety and negative affect (r = .69), controlled motivation (r = .33), and autonomous motivation (r = .25). Still, state-anxiety was negatively associated with positive affect (r = -.40) and with satisfaction with life (r = -.43),. In addition, the results of mediation analysis, revealed inconsistent mediation of positive affect and life satisfaction in the relationship between autonomous motivation and state-anxiety. However, a total mediation was observed through negative affect and life satisfaction in the relationship between controlled motivation and anxiety since the indirect effect (β = .27) is higher than the direct effect (β = .06). Overall, the results reinforce that positive affect and satisfaction with life could act as a possible buffer against state-anxiety in gym exercisers and, thus, should be considered in future interventions and studies.

Postoperative impact of rod bending in the lumbar spine fusion surgery with polyaxial screws - Validation of a study

Introduction

In 2019, Moufid and Gille published a study in which they proposed certain radiological parameters that may justify the mismatch between the lordosis of the lumbar segment and the lordosis of the rod bar using polyaxial screws. The aim of this study is to reproduce the measurements performed by Moufid and Gille and try to validate their findings.

Material and methods

A retrospective study was performed including patients submitted to L3-L5 posterior fusion with or without interbody devices using polyaxial screws and titanium rods, for degenerative disease. Radiological parameters were analysed:the distance between the posterior wall and the rod for each vertebra(the standard deviation of the three distances was called Alpha); the angle between the screw and the rod for each screw(mean of the three was called Theta); the angle between screws and superior endplate for each instrumented vertebra(mean of the three was called Lambda). The difference between post-operative segmental lordosis and the lordosis of the rod was called DiffL.

Results

A total of 58 cases were included. The most frequent fusion surgery was posterolateral fusion(77.6%). The mean value of lumbar lordosis, fused segmental lordosis, pelvic incidence, Alpha, Theta, Lambda and DiffL were 48.7 ± 12.7°, 28.4 ± 9.2°, 60.7 ± 11.9°, 3.4 ± 1.6 mm, 90.5 ± 1.8°, 3.9 ± 1.8° e 9.9 ± 9.5° respectively. The mean value of rod lordosis was 20.5 ± 8.1°. DiffL varied between 0.1° (practically no mismatch) and 30.5° of mismatch. DiffL didn't correlate with gender, fusion type, age, PI and Alpha, Theta or Lambda. There was a significant positive correlation between lumbar lordosis and DiffL(ρ = 0.28; p = 0.03). No correlation was found between the radiological parameters for the cut-off point proposed by Moufid and Gille(Alpha 4.7 mm, Theta 86°, Lambda 2.8°) and the DiffL value.

Conclusion

No significant factors were identified in this study to aid in achieving an ideal match between rod and segmental spine lordosis, therefore not validating the study by Moufid and Gille.

Speckle-tracking-based global longitudinal and circumferential strain detect early signs of antibody-mediated rejection in heart transplant patients

AIMS

Acute rejection is an important cause of mortality after heart transplant (HTx), but symptoms develop only when myocardial damage is already extensive. We sought to investigate if echocardiographic parameters can detect and predict an acute cellular rejection (ACR) or antibody-mediated rejection (AMR) episode in HTx patients.

METHODS AND RESULTS

Data of 403 consecutive HTx recipients between 2003 and 2020 from our centre were reviewed. Patients with severe ACR (n = 10) and AMR (n = 7) were identified. Each HTx patient presenting with rejection was matched to a control HTx patient. Echocardiographic variables from the moment of rejection and 3, 6, and 12 months before were analysed and compared among groups. At acute rejection episode, patients with rejection had lower values of global longitudinal strain (GLS), global circumferential strain (GCS), and left ventricular ejection fraction (LVEF) compared to controls. HTx patients with AMR showed a progressive decline of GLS and GCS in the months preceding acute rejection, while controls and ACR patients had stable strain values except for the moment of rejection. In our cohort, a GLS cut-off lower than 15.5% and a GCS cut-off lower than 15.2% could distinguish with a sensitivity and specificity of 100.0% AMR from controls 3 months before rejection. LVEF and other conventional echo parameters could not differentiate among groups.

CONCLUSION

GLS and GCS show a progressive decrease months before AMR becomes clinically apparent. Our data suggest that global strain assessment by echocardiography allows an early detection of a developing AMR, which could improve the clinical management of HTx patients.

Left ventricular hypertrophy secondary to Fabry disease: mechanical dispersion and arrhythmic burden

Introduction

Fabry disease (FD) is an X-linked progressive and multisystemic disease, that could lead to left ventricular hypertrophy (LVH). Mechanical dispersion (MD) has been associated to risk of ventricular dysrhythmias and sudden death in several cardiomyopathies.

Purpose

To evaluate MD and arrhythmic burden in FD patients with and without LVH.

Methods

We conducted a prospective study encompassing FD patients followed in a Reference Center of Lysosomal Storage Disorders. All patients performed a complete echocardiographic evaluation, including left ventricular (LV) strain analysis by two-dimensional speckle tracking imaging. Clinical characteristics, echocardiographic parameters and 24h-holters results were analysed. FD patients were divided in two groups according to the presence or absence of LVH. Both groups were compared by Chi-square test for categorical variables and Student's T-test for continuous variables. The significance level was 0,05.

Results

A total of 91 FD patients were included, with 62,6% of female predominance and 36,3% of patients with LVH. Patients with LVH were older (63,6 vs 44,2 years-old; p&lt;0,001), were predominantly male (60,6% vs 24,1%; p=0,001), had a larger prevalence of arterial hypertension (63,6% vs 10,3%; p&lt;0,001), coronary heart disease and stroke (both 9,1% vs 0%; p=0,02). In FD patients with LVH, mean interventricular septum thickness was 16,4 mm, mean LV mass index was 157,7 g/m2, mean left atrial volume index was 34,4 ml/m2 and mean E/e' was 12,6, with 63,6% of these patients having diastolic dysfunction. Global longitudinal strain (GLS) was lower in patients with LVH (−15,6% vs −19,6%; p&lt;0,001), with a higher base-to-apex longitudinal strain gradient (9,3% vs 6,5%; p=0,013). Global radial and circumferential strains were not statistically different between both groups. Interestingly, twist was higher in patients with LVH (17,5° vs 13,8°), despite the lower GLS, but it did not reach statistical significance (p=0,077). MD was higher in patients with LVH (72,4 vs 38,3 ms; p&lt;0,001), as well as the prevalence of premature ventricular contractions (PVC) (93,8% vs 61,8%; p=0,001). Non-sustained ventricular tachycardia (NSVT) was also more prevalent in patients with LVH (18,8% vs 9,1%), although not reaching statistical significance (p=0,191).

Conclusion

FD patients with LVH present lower GLS, with a higher base-to-apex longitudinal strain gradient and higher MD, compared to FD patients without LVH. Although PVC were significantly more frequent in FD patients with LVH, NSVT were not statistically different between both groups.

Funding Acknowledgement

Type of funding sources: None.

How to distinguish between hypertrophic cardiomyopathy and left ventricular hypertrophy secondary to Fabry disease?

Introduction

Fabry disease (FD) commonly leads to left ventricular hypertrophy (LVH) that could mimic sarcomeric hypertrophic cardiomyopathy (HCM).

Purpose

To determine the differences in echocardiographic parameters between FD patients with LVH and HCM patients.

Methods

We conducted a prospective study encompassing FD patients followed in a Reference Center of Lysosomal Storage Disorders. All patients performed a complete echocardiographic evaluation, including left ventricular strain analysis by two-dimensional speckle tracking imaging. Demographic, clinical characteristics and echocardiographic parameters were analysed. FD patients with LVH were compared with HCM patients, using Chi-square test for categorical variables and Student's T-test for continuous variables. The significance level was 0,05.

Results

A total of 91 FD patients were included, with a median age of 51 years-old and 62,6% of female predominance. 16,5% of patients were under enzymatic replacement therapy with agalsidase alpha and 7,7% were treated with chaperone therapy (migalastat). 33 FD patients (36%) had LVH and were older than HCM patients (63,6 vs 59,3 years-old; p=0,106). FD patients with LVH had lower interventricular septum (IVS) thickness (16,4 vs 19,6 mm, p&lt;0,001), IVS/posterior wall ratio (1,3 vs 1,8, p&lt;0,001), and left atrial volume index (34,45 vs 42,2 ml/m2; p=0,014). Left ventricle mass index was similar between the two groups (157,7 vs 155,5 g/m2; p=0,819), with lower left ventricular ejection fraction in FD patients (64,5% vs 70,5%; p&lt;0,001). There were no significant differences in global longitudinal strain (−15,6% vs 15,9%; p=0,687), global circumferential strain (−19,9% vs −21,1%; p=0,218) and global radial strain (35,3% vs 33,7%; p=0,623). Interestingly, FD patients had lower base-to-apex circumferential strain gradient (5,7% vs 9,1%; p=0,002) and lower twist (17,5° vs 26,1°; p=0,001) than HCM patients. No significant differences were reported regarding mechanical dispersion (72,4 vs 71,2 ms; p=0,841).

Conclusion

The pattern of LVH is different between FD and HCM patients. In our study, we revealed that base-to-apex circumferential strain gradient and twist are echocardiographic parameters that could help distinguish both entities.

Funding Acknowledgement

Type of funding sources: None.

Twist, left ventricular longitudinal and circumferential strain are early markers of cardiac involvement in Fabry disease

Introduction

Fabry disease (FD) is an X-linked progressive and multisystemic disease. Cardiac involvement is common and left ventricular hypertrophy (LVH) is the main cardiac manifestation.

Purpose

To determine the differences in echocardiographic parameters between FD patients without LVH and healthy controls.

Methods

We conducted a prospective study encompassing FD patients followed in a Reference Center of Lysosomal Storage Disorders. All patients performed a complete echocardiographic evaluation, including left ventricular strain analysis by two-dimensional speckle tracking imaging. Demographic, clinical characteristics and echocardiographic parameters were analysed. FD patients without LVH were compared with healthy controls, using Chi-square test for categorical variables and Student's T-test for continuous variables. The significance level was 0,05.

Results

A total of 91 FD patients were included, with a median age of 51 years-old and 62,6% of female predominance. 16,5% of patients were under enzymatic replacement therapy with agalsidase alpha and 7,7% were treated with chaperone therapy (migalastat). 58 patients (64%) did not present LVH. FD patients without LVH were younger (44,2 vs 52,9 years-old, p&lt;0,001), had higher interventricular septum thickness (9,3 vs 8,4 mm, p=0,006) and left ventricular mass index (77,2 vs 68,4 g/m2, p=0,003) than healthy controls. Left ventricular ejection fraction was preserved in both groups (63,3% vs 65,4%; p=0,067). Global longitudinal strain (−19,6% vs −20,9%; p=0,003) and global circumferential strain (−17,9% vs −20,9%; p&lt;0,001) were significantly lower in FD patients without LVH compared to healthy controls. Global radial strain was also lower, although without statistical significance (36,4% vs 41,4%, p=0,058). FD patients without LVH presented a lower base-to-apex circumferential strain gradient (5,7% vs 7,7%; p=0,035), but a higher base-to-apex longitudinal strain gradient (7,5% vs 4,3%; p&lt;0,001), compared to controls. Left ventricular twist was also significantly lower in FD patients without LVH (13,8° vs 21,7°, p&lt;0,001).

Conclusion

Left ventricular strain and twist analysis are useful to identify subclinical myocardial impairment in FD patients without LVH.

Funding Acknowledgement

Type of funding sources: None.

QRS narrowing predicts left ventricular reverse remodelling after resynchronization therapy in patients with end-stage heart failure

Introduction

Cardiac resynchronization therapy (CRT) is an established treatment for heart failure (HF) patients, however one-third of the patients fail to benefit from CRT. The relationship between the QRS duration, severity of mechanical dyssynchrony and efficacy of CRT is not completely understood. We determined if QRS duration shortening after CRT implantation was predictive of left ventricular reverse remodelling.

Methods

We retrospectively enrolled 227 patients undergoing CRT implantation between 2013 and 2020 according to the guidelines. 88 patients were included in our analysis, from whom all data were available, and these represent our sample. Clinical, electrocardiographic and echocardiographic parameters were evaluated at baseline and after 6 months of CRT implantation. Response to CRT was defined as a reduction in left ventricular end-diastolic volume (LVEDV) &gt;15%. Linear regression models were used.

Results

88 patients were included (mean age 69±10 years, 62.5% males, 36.4% ischemic etiology). Baseline left ventricular ejection fraction (LVEF) was 27,5±5,8% and LVEDV was 181±69 ml. After 6 months of CRT, 52 patients (59.1%) were considered responders. Baseline LVEDV was superior in responders when compared with non responders (199±85 ml vs 168±53 ml, p=0.038). No significant differences were noted in male gender (p=0.823), ischemic cardiomyopathy (p=0.065), LVEF (p=0.853), atrial fibrillation (p=0.390), left bundle branch block (p=0.950) or biventricular pacing (p=0.154) between them.

QRS duration at baseline was similar between responders and non-responders (165±17 ms vs 163±17 ms, p=0.620). After 6 months of CRT, the reduction of QRS duration in responders was significantly higher than non-responders (p&lt;0.001).

QRS duration was reduced from 165±17 ms to 136±15 ms in responders vs 163±17 ms to 160±17 ms in non-responders, (p&lt;0.001). The change in QRS duration positively correlated with the change in LVEDV (0. 654; p&lt;0.001). Multi-linear regression analysis suggested that QRS duration shortening had a significant effect on LVEDV (y = 14,375 + 1.354 X, R2 0.337, p&lt;0.001)

Conclusion

QRS duration shortening after CRT implantation was predictive of LV reverse remodelling in end-stage heart failure patients. Further prospective studies should be conducted to assess the prognostic value of QRS narrowing in response to CRT.

Funding Acknowledgement

Type of funding sources: None.

Hyperdynamic Valve: A Rare Case of Ehlers-Danlos Syndrome

Ehlers-Danlos syndrome is a group of rare genetic disorders of collagen characterized by skin hyperextensibility, joint hypermobility and tissue fragility. The authors describe a rare case of a 52-year-old woman that presented to the clinic with chronic joint pain and talipes equinovarum since childhood. Large eyes, sunken cheeks, thin nose and lobeless ears were noticed on clinical examination. Beighton joint hypermotility criteria were met with a positive Walker and Steinberg sign, elbow extension superior to 10° and knee extension in genu recurvatum more than 10°. An aortic diastolic grade III/VI heart murmur was heard. The complementary study was unremarkable. Moderate aortic insufficiency was found on transthoracic echocardiogram. Genetic testing confirmed positivity for COL1A2, a gene that encodes pro-alpha2 chain type of collagen, which causes cardiac-valvular Ehlers-Danlos syndrome. Authors intend to warn to collagen-related syndromes, since severe complications are associated with a reduced life expectancy for individuals with this condition.

Suicidal ideation during the first wave of COVID-19 pandemic in a child and adolescent psychiatry emergency care sample

Introduction

The COVID-19 pandemic forced many countries to apply restrictive measures. During the first wave Portugal went through a lockdown, and all the child and adolescents had to stay home and could only contact with the one’s they lived with for several months.

Objectives

This study aimed to evaluate the impact of those restrictions on suicidal ideation in the pediatric population evaluated in a child and adolescent psychiatry emergency care of a tertiary referral hospital.

Methods

We conducted an exploratory retrospective study. All the data from discharge notes were collected between March 15^th and June 15^th of 2020 (n=59), and in the homologous period of the previous year (n=178). The referral after evaluation (primary care, child and adolescent psychiatry consultation, inpatient unit) was considered a measure of severity.

Results

The demographic variables (sex, age) were homogeneous between the two groups (p ≥ 0,05). 17,4% (n=31) of the sample from 2019, and 16,9% (n=10) of the sample of 2020 had suicidal ideation, which was not statistically different between groups (p=1,000). The referral, after evaluation between groups were also not statistically different (p=0,186).

Conclusions

Even though the proportion of patients with suicidal ideation was homogenous during the two periods, the total number of patients evaluated in the emergency room were lower during the first wave of Covid-19 pandemic. We assume that the population had fear of seeking help in hospital facilities, but we also believe that the pause on school burdens and the reconnection between some families could have function as protective factors.

Disclosure

No significant relationships.

P199 Mitral valve annular disjunction prevalence and significance amongst patients with mitral valve prolapse

Background

Mitral valve prolapse (MVP) is a common and usually benign entity. Occasionally, patients with MVP present with mitral annular disjunction (MAD), whose prevalence and clinical significance are still not clearly established.

Purpose

This study aimed to define the prevalence of MAD in a population of patients with MVP and study its echocardiographic and clinical implication.

Methods

A total of 31 patients with MVP who underwent echocardiographic evaluation in our laboratory were retrospectively evaluated. Echocardiographic, demographic and clinical variables were assessed. Disjunction amplitude (DA) was measured in parasternal long axis view (PLAX) and MAD was considered present if a separation of ≥ 5mm was verified. Annular diameter was measured in PLAX and apical four chamber view (A4C) both in systole and diastole.

Results

MAD was identified in 9 patients (29%), having a mean DA of 12.3 ± 3.2 mm. The group of patients with MAD was significantly younger than the group without MAD (mean age of 54 ± 18 vs 67 ± 15 years; p = 0.001), but there were no significant differences regarding gender, height, weight or cardiovascular risk factors. DA was inversely correlated with body surface area (r=-0.8, p = 0.009). Systolic annular diameters in PLAX and A4C views were increased in patients with MAD (4.2 ± 0.6 vs 3.6 ± 0.7 mm, p= 0.04 and 4.8 ± 0.7 vs 4.1 ± 0.7 mm, p = 0.025, respectively). The difference between systolic and diastolic diameters in PLAX was also greater in MAD (0.5 ± 0.2 vs 0.1 ± 0.3 mm, p = 0.007). Posterior wall thickness (8.5 ± 1.1 vs 9.7 ± 1.4 mm, p = 0.035), indexed left ventricular mass (89.0 ± 15.8 vs 110.6 ± 40,2 g/m2, p = 0.04) and ascending aortic dimensions (28.7 ± 6.7 vs 37.4 ± 3.6 mm, p = 0.018) were notably inferior in MAD patients, as was left ventricle ejection fraction (LVEF) (57.5 ± 5.8 vs 62.6 ± 4.9 %, p = 0.0023). No differences were found in chamber volumes. Similarly, eletrocardiographic parameters were identical in both groups. Five patients (56%) in the group with MAD had documentation of events (palpitations, dizziness, syncope or sudden cardiac death), in contrast with just 3 (21%) in the group without MAD, although statistical significance was not achieved (p = 0.078).

Conclusion

This study revealed that MAD is common among patients with MVP and is associated with altered annulus dynamics during the cardiac cycle. Its association with younger individuals, lower LVEF and, apparently, more clinical events highlight the importance of this entity.

[Unmet research and developmental needs in ophthalmology : A consensus-based road map of the European Vision Institute for 2019-2025]

PURPOSE

To define unmet needs in ophthalmology which can realistically be addressed in the next years (2019-2025) and to describe potential avenues for research to address these challenges.

METHODS

Outcomes of a consensus process within the European Vision Institute (EVI, Brussels) are outlined. Disease areas which are discussed comprise glaucoma, retinal dystrophies, diabetic retinopathy, dry eye disease, corneal diseases, cataract and refractive surgery.

RESULTS

Unmet needs in the mentioned disease areas are discussed and realistically achievable research projects outlined.

CONCLUSION

Considerable progress can be made in the field of ophthalmology and patient-relevant outcomes in the near future.

Short-term prognostic effect of prior cerebrovascular and peripheral artery disease in patients with acute coronary syndrome: Can we do better?

BACKGROUND

We sought to evaluate the impact of prior cerebrovascular and/or peripheral arterial disease (PAD) on in-hospital outcomes in patients with acute coronary syndromes.

METHODS

From 1 October 2010 to 26 February 2016, 13,904 acute coronary syndrome patients were enrolled in a national multicentre registry. They were divided into four groups: prior stroke/transient ischaemic attack (stroke/TIA); prior PAD; prior stroke/TIA and PAD; none. The endpoints included in-hospital mortality and a composite endpoint of death, re-infarction and stroke during hospitalization.

RESULTS

6.3% patients had prior stroke/TIA, 4.2% prior PAD and 1.4% prior stroke/TIA and PAD. Prior stroke/TIA and/or PAD patients were less likely to receive evidence-based medical therapies (dual antiplatelet therapy: stroke/TIA= 88.6%, PAD= 86.6%, stroke/TIA+PAD= 85.7%, none= 92.2%, p<0.001; β-blockers: stroke/TIA= 77.1%, PAD= 72.1%, stroke/TIA+PAD= 71.9%, none= 80.8%, p<0.001; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers: stroke/TIA= 86.3%, PAD= 83.6%, stroke/TIA+PAD= 83.2%, none= 87.1%, p=0.030) and to undergo percutaneous revascularization (stroke/TIA= 52.8%, PAD= 45.6%, stroke/TIA+PAD= 43.7%, none= 67.9%, p<0.001), despite more extensive coronary artery disease (three-vessel disease: stroke/TIA= 29.1%, PAD= 38.3%, stroke/TIA+PAD= 38.3%, none= 20.2%, p<0.001). In a multivariable analysis, prior stroke/TIA+PAD was a predictor of in-hospital mortality (odds ratio= 2.828, 95% confidence interval 1.001-7.990) and prior stroke/TIA (odds ratio= 1.529, 95% confidence interval 1.056-2.211), prior PAD (odds ratio= 1.618, 95% confidence interval 1.034-2.533) and both conditions (odds ratio= 3.736, 95% confidence interval 2.002-6.974) were associated with the composite endpoint.

CONCLUSION

A prior history of stroke/TIA and/or PAD was associated with lower use of medical therapy and coronary revascularization and with worst short-term prognosis. An individualized management may improve their poor prognosis.

Accuracy of a method based on atomic absorption spectrometry to determine inorganic arsenic in food: Outcome of the collaborative trial IMEP-41

A collaborative trial was conducted to determine the performance characteristics of an analytical method for the quantification of inorganic arsenic (iAs) in food. The method is based on (i) solubilisation of the protein matrix with concentrated hydrochloric acid to denature proteins and allow the release of all arsenic species into solution, and (ii) subsequent extraction of the inorganic arsenic present in the acid medium using chloroform followed by back-extraction to acidic medium. The final detection and quantification is done by flow injection hydride generation atomic absorption spectrometry (FI-HG-AAS). The seven test items used in this exercise were reference materials covering a broad range of matrices: mussels, cabbage, seaweed (hijiki), fish protein, rice, wheat, mushrooms, with concentrations ranging from 0.074 to 7.55mgkg(-1). The relative standard deviation for repeatability (RSDr) ranged from 4.1 to 10.3%, while the relative standard deviation for reproducibility (RSDR) ranged from 6.1 to 22.8%.

Determination of total cadmium, lead, arsenic, mercury and inorganic arsenic in mushrooms: outcome of IMEP-116 and IMEP-39

The Institute for Reference Materials and Measurements (IRMM) of the Joint Research Centre (JRC), a Directorate General of the European Commission, operates the International Measurement Evaluation Program (IMEP). IMEP organises inter-laboratory comparisons in support of European Union policies. This paper presents the results of two proficiency tests (PTs): IMEP-116 and IMEP-39, organised for the determination of total Cd, Pb, As, Hg and inorganic As (iAs) in mushrooms. Participation in IMEP-116 was restricted to National Reference Laboratories (NRLs) officially appointed by national authorities in European Union member states. IMEP-39 was open to all other laboratories wishing to participate. Thirty-seven participants from 25 countries reported results in IMEP-116, and 62 laboratories from 36 countries reported for the IMEP-39 study. Both PTs were organised in support to Regulation (EC) No. 1881/2006, which sets the maximum levels for certain contaminants in food. The test item used in both PTs was a blend of mushrooms of the variety shiitake (Lentinula edodes). Five laboratories, with demonstrated measurement capability in the field, provided results to establish the assigned values (Xref). The standard uncertainties associated to the assigned values (uref) were calculated by combining the uncertainty of the characterisation (uchar) with a contribution for homogeneity (ubb) and for stability (ust), whilst uchar was calculated following ISO 13528. Laboratory results were rated with z- and zeta (ζ)-scores in accordance with ISO 13528. The standard deviation for proficiency assessment, σp, ranged from 10% to 20% depending on the analyte. The percentage of satisfactory z-scores ranged from 81% (iAs) to 97% (total Cd) in IMEP-116 and from 64% (iAs) to 84% (total Hg) in IMEP-39.

Setting maximum limits for trace elements in baby food in European legislation: the outcome of International Measurement Evaluation Programme®-33

The Institute for Reference Materials and Measurements (IRMM) of the Joint Research Centre (JRC), a Directorate-General of the European Commission, operates the International Measurement Evaluation Programme® (IMEP). It organises various types of inter-laboratory comparisons in support of European Union policies. This paper presents the results of a proficiency testing exercise (PT) focusing on the determination of total cadmium (Cd) and total lead (Pb) mass fractions in baby food in support to Commission Regulation (EC) 1881/2006 of 19 December 2006 setting maximum levels for certain contaminants in foodstuffs. The test material used in this exercise was soya-based baby food formula purchased in a local pharmacy and prepared by the Reference Materials Unit of the IRMM for this exercise. Sixty-six laboratories from 23 countries registered to the exercise and 61 of them reported results. Each participant received one bottle containing approximately 15 g of test material. Participants were asked to quantify the measurands in the powder and in the reconstituted formula. Reference values independent from the participants' results were established using isotope dilution inductively coupled plasma mass spectrometry. The total Cd mass fraction was determined by IRMM and LGC Ltd (UK), while the total Pb was determined by IRMM. The standard deviation for proficiency assessment σ^ was set at 22% of the assigned value for all measurands. Laboratories were rated with z- and ζ- (zeta) scores in accordance with ISO 13528. The outcome of this exercise is clearly influenced by the very low level of Cd and Pb content in the test material which triggered: a high number of 'less than' values; overestimated values especially for Pb very likely due to contamination; and a visible method influence in the case of Pb (methods based on atomic absorption were not sensitive enough to attain such low limits of detection). The results were also evaluated with regard to the reported limit of detection and some incoherencies were observed.

Is it possible to agree on a value for inorganic arsenic in food? The outcome of IMEP-112

Two of the core tasks of the European Union Reference Laboratory for Heavy Metals in Feed and Food (EU-RL-HM) are to provide advice to the Directorate General for Health and Consumers (DG SANCO) on scientific matters and to organise proficiency tests among appointed National Reference Laboratories. This article presents the results of the 12th proficiency test organised by the EU-RL-HM (IMEP-112) that focused on the determination of total and inorganic arsenic in wheat, vegetable food and algae. The test items used in this exercise were: wheat sampled in a field with a high concentration of arsenic in the soil, spinach (SRM 1570a from NIST) and an algae candidate reference material. Participation in this exercise was open to laboratories from all around the world to be able to judge the state of the art of the determination of total and, more in particular, inorganic arsenic in several food commodities. Seventy-four laboratories from 31 countries registered to the exercise; 30 of them were European National Reference Laboratories. The assigned values for IMEP-112 were provided by a group of seven laboratories expert in the field of arsenic speciation analysis in food. Laboratory results were rated with z and ζ scores (zeta scores) in accordance with ISO 13528. Around 85 % of the participants performed satisfactorily for inorganic arsenic in vegetable food and 60 % did for inorganic arsenic in wheat, but only 20 % of the laboratories taking part in the exercise were able to report satisfactory results in the algae test material.

Laparoscopic total mesorectum excision

The main controversy of colon-rectal laparoscopic surgery comes from its use as a cancer treatment. Two points deserve special attention: the incidence of port-site tumor implantation and the possibility of performing radical cancer surgery, such as total mesorectum excision. Once these points are addressed, the laparoscopic approach will be used routinely to treat rectal cancer. To clarify these points, 32 patients with cancer of the lower rectum participated in a special protocol that included preoperative radiotherapy and laparoscopic total mesorectum excision. All data were recorded. At the same time, all data recorded from the experience of a multicenter laparoscopic group (Brazilian Colorectal Laparoscopic Surgeons - 130 patients with tumor of the lower rectum) were analyzed and compared with the data provided by our patients. Analysis of the results suggests that a laparoscopic approach allows the same effective resection as that of conventional surgery and that preoperative irradiation does not influence the incidence of intraoperative complications. The extent of lymph nodal excision is similar to that obtained with open surgery, with an average of 12.3 lymph nodes dissected per specimen. The rate of local recurrence was 3.12%. No port site implantation of tumor was noted in this series of patients with cancer of the lower rectum.

Uncertainty estimation on the quantification of major milk proteins by liquid chromatography

A detailed uncertainty budget is evaluated for the quantification of major milk proteins separated by reversed phase ion-pair high performance liquid chromatography (RP-IP HPLC). Recommendations from the International Organisation for Standardisation, Guide to the Expression of Uncertainty and the EURACHEM/CITAC Guide "Quantifying Uncertainty in Analytical Measurement" were followed resulting in the expression of combined uncertainties as an expanded uncertainty. The authors have identified the lack of a detailed description on all possible sources of uncertainty on chromatographic milk protein separations. Up to now, uncertainty has only been expressed as a random chromatographic variability, being exclusively measured by regression equations. On the contrary, the establishment of a full uncertainty budget permits a complete identification of all sources of uncertainty associated with the measurement. Thus, a better comprehension of the method is obtained. Having identified all sources of uncertainty, to the best of our knowledge, they are minimised (whenever possible) and combined. The importance of this identification is crucial, in particular, concerning previously neglected sources, in this example the combination of the interpolated injected mass of protein and its purity, having a dominant influence on the total combined uncertainty. The quality of the measurement (measured by its associated uncertainty statement, which should be based on a full uncertainty budget evaluation) is demonstrated. Moreover, due to the high precision of the proposed method, the total protein content, in addition to the group protein composition (i.e. total casein and whey protein content) is calculated with high reliability, which is an extremely useful factor regarding the establishment of milk provenance/adulteration. Combined relative standard uncertainties ranging from 3.3 up to 12.5% for individual protein concentration were found, whereas for total protein content, an overall combined relative standard uncertainty of 2.7% (liquid) and 3.3% (powdered samples) was achieved.

Antibacterial activity of Persea cordata stem barks

The antibacterial effects of extracts obtained from Persea cordata stem bark, employed in Brazil to treat infectious diseases, were studied. The ethyl acetate fraction of the hydroalcoholic extract showed activity against pathogenic bacteria which may justify the popular use of the plant.

Pre-operative radiotherapy in rectal cancer: evaluation of irradiation effects on cellular undifferentiation and its influence on prognosis

BACKGROUND/AIMS

In spite of the new technology--stapler, antibiotics, anesthesia and new surgical and diagnostic procedures--the prognosis on treatment of cancer of the rectum has not changed in the last 50 years. Survival rates of 50-55% seems immutable in all published series. The main course for those results is the high incidence of recurrence, either local or widespread. Local recurrence is directly related to the number of undifferentiated cells and to the grade of wall invasion. So any kind of treatment that would diminish the number of undifferentiated cells and the size or the tumor wall penetration certainly would decrease the local recurrence rate, lengthening the interval free from cancer and, perhaps, modifying the long-term survival rate. Between 1978-1996, a total of 287 patients with rectal adenocarcinoma were treated by pre-operative RTD.

METHODOLOGY

The same RDT protocol was used in all the patients: 400 cGy, 200 cGy/day, during 4 consecutive weeks (anterior and posterior pelvic fields). Surgery was performed 7-10 days after completion of RDT.

RESULTS

Statistical analysis of the whole group showed that pre-operative RDT does decrease frequency of undifferentiated cells. Moreover, the incidence of local recurrence diminished after irradiation by 3.48%. Pre-operative RDT reduces tumor volume and wall invasion, as well as the mortality rate due to local recurrence (2.43%) and alters long-term survival rate (80.17%).

CONCLUSIONS

Pre-operative radiotherapy is really effective in reducing the number of undifferentiated cells and in diminishing the carcinomatous infiltration of the rectal wall.

[Sclerotherapy of esophageal varices in schistosomiasis patients]

To assess the therapeutic possibilities of injection sclerosis in schistosomotic portal hypertension, a 5-year prospective study was conducted in northeast Brazil, where this parasitosis is endemic. Fifty patients undergoing endoscopy for upper gastrointestinal hemorrhage from rupture of esophageal varices from July through December 1981 were chosen for the study. The 32 consenting patients were submitted to injection sclerotherapy paravariceally, using ethanolamine oleate; the 18 refusing to participate were assigned to the control group. The incidence of rebleeding was 28.1% in the former and 44.5% in the latter, a difference which was not statistically significant (Fisher's test, p = 0.375). Mortality from rupture of esophageal varices was 3.1% in the sclerotherapy group and 27.7% in the control group, a statistically significant difference (Fischer's test, p = 0.017). Since sclerotherapy markedly improved the long-term survival rate of the patients, this procedure is advocated for the treatment of esophageal varices in cases of portal hypertension due to schistosomiasis.

Open versus semi-open hemorrhoidectomy: a random trial

Three hundred patients with hemorrhoidal disease were randomly allocated to either a semi-open hemorrhoidectomy (group A) or to an open procedure (group B). The aims of the trial were to investigate the healing time in both groups, to analyse and compare the incidence of post-operative complications and the use of analgesics. A secondary aim was to investigate the period of time required to reestablish the normal bowel habit. All patients had a follow-up of at least three months. The wound was observed daily in the first week and then, twice a week, till complete healing occurred. The dosage, route and amount of analgesic demanded by each patient was noted. Any observed complication and its consequent treatment were written down. As to healing time there was a statistically significant difference between both groups: whereas for group A the average healing time was 12.38 days, for group B it was 25.22 days. The incidence of post-operative complication such as granuloma and pruritus was higher in group B; urinary disturbances were similar in both groups. The patients of group A demanded a small amount of analgesics, statistically significant (p = 0.01), in the early as well as in the late post-operative period. The normal bowel habit was re-established earlier in group A and this was also statistically significant.

Very-low dose antacid in treatment of duodenal ulcer. Comparison with cimetidine

Antacid (AA) in a very low dose (88 mmol/day) was compared to the standard 800-mg dose of cimetidine in healing duodenal ulcers. The influence of sex, age, symptom duration at entry, night pain, smoking, coffee consumption, and alcohol on ulcer healing was studied. The antacid was given in two different schedules: group I--20 ml 1 hr after breakfast and at bedtime; group II--10 ml 1 hr after breakfast and lunch and 20 ml at bedtime. Cimetidine (group III) was given in two divided doses: 400 mg 1 hr after breakfast and 400 mg at bedtime. Endoscopic control was performed after four weeks and, if necessary, after eight weeks of treatment. The healing rate after four weeks of treatment was, respectively, for groups I, II, and III, 45.5%, 55.8%, and 69.4% (group I = group II, and group III different from groups I and II). After eight weeks of treatment the healing rate was 61.5%, 80.8%, and 88.0% for groups I, II, and III, respectively (group II = group III, and group I different from groups II and III). Except for group I, smoking did not influence healing rate. Age, sex, symptoms at entry, night pain, and coffee consumption did not influence the treatment results. The authors concluded that the very low dose of magaldrate (88 mmol/day), when administered in three divided doses (10 ml after breakfast and lunch and 20 ml at bedtime) for eight weeks was as effective as 800 mg of cimetidine (400 mg twice a day) in healing duodenal ulcer.

Variceal sclerosis in schistosomotic patients: a 5-year follow-up study

To assess the therapeutic possibilities of injection sclerosis in schistosomotic portal hypertension, a 5-year prospective study was conducted in northeast Brazil, where this parasitosis is endemic. Fifty patients undergoing endoscopy for upper gastrointestinal hemorrhage from rupture of esophageal varices from July through December 1981 were chosen for the study. The 32 consenting patients were submitted to injection sclerotherapy paravariceally, using ethanolamine oleate; the 18 refusing to participate were assigned to the control group. The incidence of rebleeding was 28.1% in the former and 44.5% in the latter, a difference which was not statistically significant (Fisher's test, p = 0.375). Mortality from rupture of esophageal varices was 3.1% in the sclerotherapy group and 27.7% in the control group, a statistically significant difference (Fischer's test, p = 0.017). Since sclerotherapy markedly improved the long-term survival rate of the patients, this procedure is advocated for the treatment of esophageal varices in cases of portal hypertension due to schistosomiasis.